53 year old woman with persistent hoarseness over the past three weeks…
53 year old woman with persistent hoarseness over the past three weeks
Possible exogenous causes elicited from history
History of heavy alcohol use
Carcinoma or layngopharyngeal reflux.
Refer to "Other associated symptoms"
History of smoking or tobacco use
Upper respiratory infection (URI). Can be associated with muscle tension dysphonia. Other Sx: cough, odynophagia (painful swallowing), palpable lymph nodes, rhinorrhea, sneezing, watery eyes
Chronic laryngitis (laryngitis > 3 weeks). Other Sx: frequent throat clearing, persistent cough, dyspepsia
Leukoplakia (rare), white lesion representing thickened epithelium. Other Sx: sensitivity to heat, spicy foods and other irritants.
Reinke edema (submucosal edema, benign vocal fold lesion with swollen vocal folds). Causes husky, low-pitched voice. Could also be due to hypothyroidism or reflux.
Recent intubation/laryngeal procedure
Vocal cord paralysis
Recent head, neck, thyroid or chest surgery
Vagus nerve/RLN injury => Unilateral vocal cord paralysis. Weak and breathy voice.For RLN injury also consider aortic arch aneurysm.
Bilateral thyroid surgery => bilateral vocal cord paralysis
Other associated symptoms
Allergy. Other Sx: rhinorrhea, sneezing, watery eyes, wheezing, throat clearing
Tobacco or other irritants
Upper Respiratory Infection (URI) or chronic laryngitis.
Refer to "History of smoking or tobacco use"
Carcinoma = constant hoarseness. Other Sx: hemoptysis, palpable lymph nodes, dysphagia, heart burn, odynophagia, stridor (harsh vibrating sound when breathing) or airway obstruction
Laryngeal cancer, mostly SCC. Other Sx: cough, blood-stained sputum, lymphadenopathy, dyspnoea
Lung cancer can cause unilateral vocal cord paralysis.
Inflammatory arthritis. Other Sx: odynophagia, possibly rheumatoid nodules on true vocal folds
Laryngopharyngeal reflux (may not present with hart burn) or GERD. May cause chronic laryngitis. Hoarseness worst in morning. Other Sx: throat clearing, persistent cough, dysphagia
Possible airway obstruction with stridor, e.g. bilateral vocal cord paralysis
Laryngeal papillomatosis (benign neoplasm, HPV associated). Benign vocal cord lesions = constant hoarseness
Parkinson's disease => Hypophonic (soft speech) monotone. Other Sx: tremor, hypomimia (reduced facial expression)
Myasthenia gravis (fluctuating, fatigable hoarseness). Hoarseness worsens throughout day. Other Sx: dysphagia
Upper motor neuron, e.g. medullary infarct. Other Sx: dysphagia, aspiration
Laryngeal amyloidosis (rare). Other Sx: dyspnea, cough, odynophagia, rarely hemoptysis
Inhaled corticosteroids. Other Sx: throat clearing
Adjacent infection, e.g. peritonsillar abscess. Other Sx: odynophagia, trismus (reduced opening of jaws), pyrexia (fever), 'hot potato' voice (muffled)
Other causes based on timing of hoarseness
Hoarseness progressively worsens throughout the day, fluctuates daily, improves with rest => vocal abuse. Other Sx: nodules (edematous to thickened/fibrotic)
Voice deteriorates towards end of day
Muscle tension dysphonia. Other Sx: neck tenderness, stress/anxiety
Glottic insufficiency. Other Sx: Risk of aspiration with thin liquids, pain/discomfort with prolonged speech
Voice worse on phone or when public speaking => spasmodic dysphonia. Reaction to stress.