53yo woman. persistent hoarseness for 3 weeks
Acute Laryngitis (<2 weeks)
self-limiting, improves with rest
Infection
Acute vocal strain
URTI
Screaming, protracted coughing
Chronic laryngitis (>2 weeks)
Chronic irritant exposure: inhaled toxins, GERD, chronic sinusitis with postnasal drip, chronic alcohol use, chronic vocal strain, tobacco smoke (keratosis, polypoid corditis)
Laryngopharyngeal reflux
retrograde movement of gastric contents beyond UES #
S/S: throat clearing, persistent cough, heartburn/dyspepsia, globus sensation (lump in throat feeling), sore throat, dysphagia, laryngospasm/choking sensation
Scope: interarytenoid hypertrophy & contact ulceration
Commonly by: M. catarrhalis, H. influenza, S. pneumonia
Benign vocal fold lesions
Breathy, raspy or harsh voice
Causes: chronic irritation, vocal abuse/coughing, reflux
Polyps - does not improve on rest. unilateral + sometimes a contralateral smaller 'contact lesion'. present in anterior 1/3 of vocal fold
Polypoid corditis - Low-pitched voice. diffuse polyps in Reinke's space. vocal folds appear swollen & 'floppy'
Singer's/Screamer's nodes - hoarseness fluctuates day-day, improves on rest. bilateral, symmetrical, edematous -> thickened & fibrotic
Neoplastic
Laryngeal cancer (squamous cell carcinoma)
persistent, progressive, non-fluctuating hoarseness. persistent cough, hemoptysis, referred otalgia, unilateral ear/throat pain, lymphadenopathy, cachexia, dyspnoea, dysphagia, unexplained weight loss
Early lesions (white (leukoplakic) plaques) V.S. advanced malignant lesions (large, exophytic/deeply ulcerative)
Risk: chronic smoking, alcohol,
Neurological
Unilateral paralysis of recurrent laryngeal nerve
Weak breathy voice (due to inadequate glottic closure)
Affected vocal fold rest in paramedian position --> rare airway complains
Causes:
- extra-laryngeal malignancy invading vagus/RLN. presence of thyroid nodule raise possibility of invasive thyroid cancer
- Iatrogenic injury (e..g thyroid/PTH/thorax/carotid surgery, endotracheal intubation
- neck/chest trauma
- degenerative neural disorders e.g. bulbar palsies
Spasmodic dysphonia
Halting, strained, strangled voice (from uncoordinated forceful adduction during phonation)
Symptoms improve with whispering, laughing, or singing
Parkinson
Hypophonic, soft-breathy & monotone quality
Resting vocal fold tremor (rhythmic, oscillatory movement)/vocal fold paralysis
Motor neuron disease
Progressive degeneration of UM/LMN (e.g. ALS) --> dysphagia, aspiration, dysphonia, vocal fold paralysis
Stiff muscles, muscle twitching, gradually worsening asymmetric muscle weakness (muscle atrophy)
Mysathenia Gravis
Fluctuating hoarseness, sometimes with dysphagia & stridor
Voice fatigues with use (hence later in the day), recovers with rest
Fluctuating weakness & fatigue of specific muscle groups (commonly worse in evening/after excercise)
Functional voice disorders:
Normal physical structure, mechanism being used improperly/inefficiently
Functional dysphonia - no identifiable organic lesion. affects people in occupation that cause vocal stress
Laryngeal conversion disorder/psychogenic - patients with psychological issues. intermittent episodes of respiratory distress, stridor, hoarseness or aphonia. may be triggered by URTI/asthma
Paradoxical vocal chord motion - vocal fold adduction with inspiration, abduction with expiration --> inspiratory stridor/wheezing
Comorbidities: asthma, exercise, postextubation, irritants, laryngopharyngeal reflux, neurologic injury, psychogenic
Others
Laryngeal amyloidosis
progressive dysphonia, dyspnea, cough, stridor, odynophagia, hemoptysis (rare)
Scope: firm orange-yellow to grey epithelial nodule
Acromegaly
Thick, deep voice and slowed speech
Enlargement of jaw, hands & feets, coarse facial features, enlargement of nose & frontal bones . CVD, sleep apnoea, TIIDM, problems related to pituitary tumor size
Rhinorrhea, cough, mild sore throat
Peritonsillar abscess - muffled, thickened voice with odynophagia, trismus, pyrexia
Rheumatoid arthritis
Cricoarytenoid joint fixation --> breathy voice
Rheumatoid nodules may be seen on true vocal folds