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