Week 5

C H A P T E R 2 1

Hoarseness

Hoarseness is a disturbance of the normal voice pitch by an abnormal vibration of the vocal cords. It is a term used to describe an unnaturally rough, harsh, or deep voice. Voice is the sound produced when the vocal folds are approximated and expired airflow between the cords causes them to vibrate. The sound produced by the larynx is amplified by the pharynx, oral cavity, sinuses, and nasal cavity and is modified by movements of the tongue, uvula, and soft palate. Hoarseness may be an early sign of local disease or a manifestation of a systemic illness. Hoarseness is a cardinal symptom of laryngeal disease.

The larynx is a musculocartilaginous structure lined with a mucous membrane connected superiorly to the pharynx (below the tongue and hyoid) and inferiorly to the trachea. It is the sphincter that guards the entrance into the trachea and functions secondarily as the organ of voice. Nine cartilages connected by ligaments and eight muscles form the larynx. The lower portion of the thyroarytenoid muscle forms the true vocal fold, or folds, which are highly elastic and account for the extraordinary versatility of the voice and the wide range of pitch, volume, and quality. The glottis is the triangular opening between the true vocal cords. The supraglottic area includes the ventricular folds (false vocal cords), the aryepiglottic folds, and the epiglottis (Fig. 21.1). The epiglottis is the lidlike cartilaginous structure that overhangs the entrance to the larynx and serves to prevent food from entering the larynx and trachea while swallowing.

FIGURE 21.1 View of the interior of the larynx. Source: (From Christensen B, Kockrow E: Foundations and adult health nursing, ed. 6, St. Louis, 2011, Mosby.)

Many benign conditions cause hoarseness such as functional disorders from voice overuse and upper respiratory infections (URIs). Acute laryngitis is the most common cause of hoarseness. Functional causes are unrelated to organic disease and may have a psychosocial component, such as restraint in expressing anger, crying, or a history of psychological trauma.

However, persistent hoarseness for more than 2 weeks in an adult and 1 week in a child may indicate secondary changes to the vocal cords. These changes may be caused by structural changes resulting from palsies, polyps, or cysts; laryngeal neoplasm; or congenital disorders of the larynx. Hoarseness may also be a symptom of systemic disease, such as hypothyroidism, or a symptom of inflammation caused by a variety of

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processes. Many forms of laryngitis that appear alike on physical examination have very different causes. Critical clues to the specific etiology of laryngitis depend on taking a careful history.

Diagnostic reasoning: Focused history Is the hoarseness acute or chronic? Key Questions

• How long has the symptom been present? • Has this happened before? Is it recurrent? • Is it getting better or worse? • Have you noticed other symptoms?

Duration Symptoms of less than 2 weeks’ duration are considered to be acute; the most likely cause is a viral upper respiratory tract infection. Inflammations secondary to acute viral infection or voice overuse are the most common causes of acute laryngitis. Chronic symptoms suggest structural change in the larynx or hoarseness secondary to disorders, such as gastroesophageal reflux disease (GERD), or systemic disease such as hypothyroidism. If the duration of hoarseness is longer than 2 weeks, referral to an ear, nose, and throat specialist is indicated to evaluate for possible neoplasm, most often squamous cell carcinoma because chronic laryngitis rarely has an infectious cause.

Recurrence Recurrent episodes of hoarseness may indicate allergies or sinusitis with postnasal drip, laryngeal reflux, or systemic disease.

Progression Progressive hoarseness usually indicates a lesion such as a laryngeal or hypopharyngeal cyst.

What does the onset of hoarseness tell me? Key Questions

• How did the hoarseness develop? • Is there any history of trauma to the throat? • Have you had any recent surgery around the throat or neck?

Onset Acute onset of hoarseness is usually the result of infection or trauma. The trauma can be from direct injury (foreign body, accidents) or overuse from screaming. The overuse can be gradual, resulting in progressive hoarseness and vocal cord changes. This hoarseness is worse in the afternoon or evening.

Hoarseness from birth may indicate a congenital problem, such as laryngeal web, cyst, palsy, or angioma. Newborns with aphonia, or a hoarse cry that does not resolve, may have a congenital anomaly, papilloma, or vocal cord paralysis.

Trauma External trauma to the throat is rarely a cause of hoarseness, but it can result in hematoma formation in the laryngeal soft tissues. There can also be mucosal lacerations, arytenoid cartilage dislocation, or fracture of the laryngeal cartilage. Internal trauma can occur with endotracheal intubation associated with surgery when an endotracheal tube catches on laryngeal structures and is pushed against resistance.

Surgical history

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Hoarseness or voice change is a sign of the vagus nerve (cranial nerve [CN] X). Surgery such as tonsillectomy, thyroidectomy, or rhinoplasty can alter the quality of the voice secondary to structural change and scarring. Damage to CN X can also be the result of hormone imbalance, bacterial infection, or tumor. Voice surgery undertaken by transgender persons to alter the pitch of their voice can injure the delicate tissue of the vocal fold and negatively alter normal vocal quality.

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Does the presence of risk factors help narrow the diagnosis? Key Questions

• Have you had a recent cold or upper respiratory tract infection? • Do you have allergies or asthma? • Do you smoke? How long have you been a smoker? • How much alcohol do you drink? • Can you describe your voice habits, such as singing, talking, and shouting? • Are you frequently exposed to dust, fumes, or loud noise? • Are your immunizations up to date?

Upper respiratory infection Acute laryngitis, epiglottitis, and acute laryngotracheobronchitis (croup) are sequelae from a viral URI that can result in vocal cord inflammation. Postnasal discharge that is thick and purulent may pool around the larynx and cause chronic secondary edema. Nasal congestion that leads to mouth breathing produces laryngeal dryness, with resultant hoarseness on arising in the morning.

Children who have epiglottitis are not hoarse, but as the epiglottis swells, the voice becomes muffled and drooling is observed.

Allergies and asthma Poorly controlled or undiagnosed asthma can result in a chronic cough with subsequent hoarseness. Allergies can cause chronic or recurrent irritation and swelling of both the upper and lower airways. Children who have a history of asthma or allergies can develop vocal cord edema, inflammation, and hoarseness.

Smoking Cigarette smoking is the most significant risk factor for laryngeal cancer. Smoking is also a risk factor for acute or chronic laryngitis because smoke irritates all mucous membranes and impairs ciliary function, causing pooling of secretions around the larynx.

Alcohol consumption Chronic consumption of hard liquor is a direct irritant to the throat and is associated with laryngeal cancer.

Voice habits Voice misuse occurs when the true vocal cords are forced to vibrate under undue stress and tension. Voice abuse is exuberant overuse and can lead to inflammation and edema of the larynx, hemorrhage, or vocal cord polyps. A gradual progression of hoarseness may go unnoticed by the patient. In an attempt to elevate pitch, transgender persons may voluntarily increase the tension in the vocal folds, which requires continuous muscular effort and may produce increased vocal effort and fatigue. Often a precipitating incident (e.g., shouting, excessive speaking, or singing) produces acute laryngitis. Specific questions may need to be asked to make the patient aware of conditions that lead to voice abuse, such as the following:

• Have others noticed a change in the quality of your voice? • Do you talk frequently to people who are hard of hearing? • Do you yell at children? • Do you work in an environment that is noisy or contains dust and fumes? • Have you recently attended a sporting event?

Exposures Patients who are chronically exposed to work environments that contain dust, fumes, or a high noise level that leads to chronic voice abuse are at increased risk for laryngeal cancer.

Children exposed to poor indoor air quality may be at risk for hoarseness.

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Immunizations Laryngeal diphtheria should be considered in patients who have failed to update their diphtheria immunizations. For adults, the tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination is recommended once and then tetanus and diphtheria (Td) boosters every 10 years; pregnant women are advised to have a Tdap during each pregnancy (http://www.cdc.gov/vaccines/schedules/hcp/adult.html). Laryngeal diphtheria usually develops as a downward progression of the tonsillar pharyngeal membrane.

What other clues will help narrow the diagnostic possibilities? Key Questions

• Does the hoarseness change during the day? • Is it painful? • What other symptoms are present? • Do you have a neurological disorder?

Timing Hoarseness that is altered by a position change suggests a mobile lesion, such as a pedunculated polyp. Patients with myasthenia gravis have a normal voice in the morning with progressive hoarseness throughout the day.

Pain Pain may be associated with an inflammatory process, such as a viral URI or GERD. Pain occurs late in laryngeal cancer. Neurologic and hormonal causes do not usually produce pain.

Associated symptoms The presence of cough, shortness of breath, weight loss, dysphagia, ear pain, or throat pain should raise concerns about neoplasm, systemic disease, or neurologic causes. Hormonal disorders, such as hypothyroidism, also produce signs and symptoms that vary in severity according to the duration and degree of hormone deficiency. Early symptoms of hypothyroidism include cold intolerance, heavy menses, weight gain, dry skin, fatigue, and constipation. Later signs and symptoms include hoarseness, very dry skin, hair loss of lateral eyebrows, and neurological symptoms, such as delayed deep tendon reflex recovery, depression, and mental confusion.

Neurologic disease Patients with parkinsonism, myasthenia gravis, or amyotrophic lateral sclerosis have progressive dysarthria and dysphagia. As neurologic disease progresses, patients develop a chronic cough and throat clearing caused by microaspiration of pooled secretions.

Gastroesophageal reflux disease Reflux of gastric contents causes inflammation of the posterior larynx, especially the arytenoid mucosa. The patient may also report a habit of frequent throat clearing and a sensation of a lump in the throat. Chronic cough or throat clearing further damages already irritated vocal folds. Generally patients have hoarseness in the morning and coughing at night. In children, GERD presents with dysphagia, hoarseness, vomiting, and chronic cough.

Diagnostic reasoning: Focused physical examination

Listen to the quality of the voice Acoustic evaluation criteria for voice include range (monotonic to extremely variable), loudness (soft to loud), pitch (low­pitched voice requires more effort to produce adequate volume; sudden changes in pitch), register (temporary loss of voice because of abductor spasm), and quality (roughness, breathiness, and hoarseness). Table 21.1 lists common criteria used in evaluating the voice.

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Table 21.1 Diagnostics Used in Evaluating Voice

ACOUSTIC MEASUREMENT DISORDER QUALITY

Pitch Low to high; glottal, raspy to Variable: puberty falsetto Low: male gender, overuse

Range Monotonal to extremely variable Monotonal: Parkinson disease, depression

Loudness Soft to loud Environmental, psychological, systemic disease

Register Presence of voice Vocal fatigue, overuse

Quality Breathy to resonant Vocal cord mass, paresis, bowing, atrophy

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Examine the respiratory system Assess the airway. Stridor, a high­pitched inspiratory sound caused by turbulent air passing through a narrowed glottis secondary to inflammation or tumor, indicates an immediate referral to a specialist. If the patient is able to cough and laugh but cannot speak, this indicates a functional problem because coughing and laughing require total adduction of the vocal cords. Auscultate the lungs for quality of breath sounds, asthmatic wheezing, and signs of consolidation.

Note any associated stridor in children. Inspiratory stridor may indicate an extrathoracic problem, such as supraglottic collapse or vocal fold paralysis. An intrathoracic lesion may cause an expiratory stridor.

Perform a general inspection Note hair distribution, especially signs of hair loss over lateral eyebrows and hair loss on the scalp, to assess thyroid function. Look for the placement of the trachea and thyroid gland. Bulges or asymmetry of the neck suggest a tumor. A head and neck hemangioma or lymphangioma increases the possibility of a similar laryngeal lesion as the source of hoarseness.

Examine the head and neck Examine the oral, pharyngeal, and nasal mucosa for signs of excessive dryness, inflammation, or infection. Excessive mucosal dryness, including the conjunctiva, may be secondary to use of medications such as decongestants and antidepressants or may be a symptom of an autoimmune disorder such as Sjögren syndrome.

Otoscopy may indicate otitis media with effusion contributing to hearing loss, a factor to be considered in voice abuse. Inspect the nasal mucosa for color, edema, and purulent discharge and examine the nasal septa for deviation that may cause obstruction. Hypertrophic tonsils and severe dental abnormalities (malocclusion, cleft palate) can contribute to hoarseness.

Any indication of airway obstruction associated with hoarseness is a potentially life­threatening situation. Do not perform a physical examination of the pharynx if you suspect acute epiglottitis. Examination may trigger laryngospasms and airway obstruction. Refer immediately for emergency treatment and airway support.

E VI DEN C E- B ASE D P R A CT I CE

Are Specialists More Accurate Than Primary Care Providers in Diagnosing Voice Disorders? Accurate diagnosis of a voice disorder is an essential first step in choosing appropriate treatment. The objective of this study was to examine differences in laryngeal diagnosis over time in outpatients evaluated by primary care physicians (PCPs), otolaryngologists, or both. The study retrospectively analyzed data from a large, national, administrative US claims database. Participants were patients with a laryngeal disorder diagnosis from 2004 to 2008, with at least two outpatient visits by a PCP, otolaryngologist, or both and continuously enrolled for 12 months; 29,501 individuals met the inclusion criteria. The initial and final laryngeal diagnoses were tabulated. Results showed that more than half the patients in the PCP­to­ otolaryngology group (referred), and one­third of the otolaryngology­to­otolaryngology group had different laryngeal diagnoses over time. Three­fourths of patients with an initial acute laryngitis diagnosis in the PCP –to­otolaryngology group and half of patients in the otolaryngology­to­otolaryngology group had a different final laryngeal diagnosis. Of patients with a final diagnosis of laryngeal cancer, one­fourth of the otolaryngology­to­otolaryngology group had an initial diagnosis of nonspecific dysphonia, and one­fifth of the PCP­to­otolaryngology group had an initial diagnosis of acute laryngitis.

Conclusion: Differential diagnosis of voice disorders often evolves over time, and the impacts on treatment and health care use are important areas of future study.

Reference: Cohen et al, 2014.

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Examine the larynx indirectly using a laryngeal mirror. Patient cooperation is critical. Ask the patient to open the mouth wide and extend the neck while protruding the tongue. The mirror is advanced to contact and lift the uvula while the patient breathes through the mouth. Focus the light on the mirror after the mirror is angled to visualize the larynx. Ask the patient to say “e” or “a” to observe movement. Sometimes the epiglottis obscures visualization. Direct examination of the larynx with a laryngoscope requires the skill and experience of a specialist.

Observe the larynx for the presence of secretions and evidence of ulcers, polyps, masses, edema, or redness. Observe for vocal cord motion, especially adduction and abduction of vocal cords, and the presence of spasm or tremor.

Assess cranial nerve function Most of the CNs play a part in speech and voice production, and any disease process that affects neurological function, especially vocal cord paralysis, may affect the voice. Specifically examine CNs V, VII, VIII, IX, X, XI, and XII.

Assess hearing (cranial nerve VIII) Voice or whisper testing for hearing acuity is the first level of hearing screening. An audible whisper is approximately 20 decibels (dB), and normal speech is about 50 dB. Patients with neurosensory hearing loss may speak at an abnormally loud volume.

Palpate lymph nodes Palpate the cervicofacial lymph nodes. Tender nodes indicate inflammation; nontender nodes may indicate neoplasm. Enlarged nodes in the deep cervical chain in the absence of other symptoms may indicate laryngeal cancer.

Palpate thyroid Palpate the thyroid for size, tenderness, and crepitus by moving the thyroid cartilage across the cervical spine.

Laboratory and diagnostic studies

Flexible fiberoptic laryngoscopy Laryngoscopy allows direct examination of the hypopharynx and larynx. A local anesthetic is applied to the oral or nasal mucosa, and the instrument is passed through the nose or oral cavity for excellent visualization of laryngeal structures. Laryngoscopy is also performed using a general anesthetic.

Radiography Lateral view radiographs of soft tissues of the neck are used to evaluate structures for abnormalities.

Barium esophagram This contrast radiographic technique can be used to differentiate between mechanical lesions and motility disorders, providing important information about the latter in particular. For patients with esophageal dysphagia and a suspected motility disorder, barium esophagraphy should be performed first.

Differential diagnosis

Acute laryngitis Acute laryngitis is a self­limiting condition caused by a viral infection, environmental irritants, postnasal drainage secondary to poorly controlled allergic rhinitis, or voice overuse. The loudness and quality of voice are affected, and the patient may report a sore throat. Hoarseness often progresses throughout the course of the

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day. Indirect examination of the larynx reveals redness and edema of the vocal cords. Physical pathology may be absent in mild cases.

Acute epiglottitis Adults will report severe and rapidly progressing symptoms of sore throat, dyspnea, and hoarseness. In children, there is no cough or hoarseness, but drooling with a forward leaning posture is observed. This condition is most commonly associated with Haemophilus influenzae infection. Voice quality is froglike. The patient will also have a high temperature and will be anxious, fearful, and restless with respiratory distress.

Trauma Any swelling in response to trauma, directly to the larynx or indirectly to the throat, will cause hoarseness. Swelling might be secondary to

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head and neck surgery such as dental surgery, tonsillectomy, or thyroidectomy. Postintubation trauma may be acute if secondary to inflammation, or chronic if neurological or structural damage is irreversible. Mucosal abrasion or ulcer may be caused by direct trauma to the larynx and is associated with painful phonation and a breathy voice.

Acute laryngeal edema Laryngeal edema may be one symptom in a generalized allergic response that involves the lips, tongue, and other hypopharyngeal structures. Drug reactions and food allergies, especially to seafood and nuts, often precipitate this response. This condition is a medical emergency because of the high risk of airway obstruction.

Laryngotracheobronchitis (croup) Subglottic edema is caused by a viral infection, most often parainfluenza virus 1 that can obstruct the airway. This condition is most common in children ages 3 months to 3 years and is more prevalent in the fall and winter. It is associated with a barking cough, dyspnea, wheezing, low­grade fever, and hoarseness. Inspiratory stridor occurs abruptly because of narrowing of the passage, causing negative pressures generated on inspiration. Physical examination can determine the degree of respiratory distress such as color, stridor, nasal flaring, and level of consciousness.

Chronic laryngitis This condition is associated with a combination of chronic exposure to working conditions with high levels of dust, fumes, or noise; hard liquor consumption; cigarette smoking; and a history of frequent and persistent cough. Physical examination reveals edema or nodules of the vocal cords.

Polyps Vocal cord polyps develop as a result of chronic inflammation from voice abuse, allergies, or GERD. The voice quality is breathy. With dependent polyps, the patient may report that symptoms of hoarseness change with position.

Neoplasm Laryngeal cancer usually occurs in patients who have a long history of cigarette smoking and alcohol consumption. Hoarseness is characterized by a raspy or harsh voice. Physical examination may reveal leukoplakia or a white scaly appearance of the vocal cords. Patients do not usually report pain until carcinoma is advanced. Pain secondary to ulceration is late and is often perceived as ear pain, especially when swallowing.

Gastroesophageal reflux disease Patients with GERD will report retrosternal burning (heartburn) that radiates upward. The regurgitation of gastric acid is exacerbated by consuming large meals, lying in a supine position, or bending over. Patients may describe a sour taste, experience salivary hypersecretion, have painful swallowing, or have a chronic cough or habit of throat clearing. Physical examination will be normal or epigastric tenderness may be elicited by abdominal examination. Inflammation or ulceration may be visible on the vocal cords.

Hypothyroidism One symptom of hypothyroidism is a low, gravelly voice. The degree of hoarseness depends on the severity of thyroid deficiency. Usually hypothyroidism is suspected when other symptoms are present such as cold intolerance; rough, scaly skin texture; weight gain; and signs such as bradycardia and prolonged deep tendon reflex recovery. Risk factors for hypothyroidism include increased age, postpartum status, and a family history of thyroid disease. The thyroid gland may be nonpalpable or enlarged. Examination of the larynx may reveal edema or polyps. An elevated serum thyroid­stimulating hormone level will confirm the diagnosis.

Vocal cord paralysis

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Paralysis is usually unilateral and produces a weak, breathy voice. Unilateral abductor paralysis on the left side is caused by pressure on the vagus or recurrent laryngeal nerve by a mass of malignant glands in the superior mediastinum or carcinoma of the thyroid or esophagus.

Psychogenic hoarseness Patients with psychogenic hoarseness will have a low, breathy voice caused by voluntarily abducting the vocal cords during phonation. Physical examination will reveal no abnormalities. Psychogenic hoarseness may follow a traumatic event.

Laryngeal papillomas These are the most common laryngeal lesions that occur during childhood. Most patients are between the ages of 2 and 7 years and present with hoarseness. Occasionally papillomas, caused by the human papillomavirus, are seen in newborns.

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DIFFERENTIAL DIAGNOSIS OF Common Causes of Hoarseness

CONDITION

Acute laryngitis

Acute epiglottitis

Trauma

Acute laryngeal edema

Laryngotracheobronchitis (croup)

Chronic laryngitis

Polyps

Neoplasm

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HISTORY

Voice overuse, exposure to environmental irritants, recent URI

Adults: rapid onset of sore throat, dyspnea, hoarseness

Children: drooling, forward­leaning posture

Hoarseness after intubation; direct throat trauma or foreign body

History of food or drug allergy

Children 3 mo–3 yr; recent URI

Chronic history of smoking and alcohol use; exposure to environmental irritants; chronic cough; duration of hoarseness >3 wk

History of allergy; voice abuse, GERD, smoker; duration of symptoms >3 wk; progressive hoarseness, worse at end of day, but near normal in morning; hoarseness may change with position

PHYSICAL FINDINGS

Voice quality: aphonia, cervical lymphadenopathy; pharyngitis; edema and redness of vocal cords

Voice quality froglike; fever, signs of respiratory distress; drooling

Subluxation of cricoarytenoid joint

Edema of lips, tongue, and hypopharynx; observe for respiratory distress; voice quality breathy

Barking cough, low­grade fever, wheezing, hoarseness; edema of vocal cords; observe for signs of respiratory distress

Edema of vocal cords; nodules may be present

Polyps visible on vocal cords

ENT referral for biopsy

DIAGNOSTIC STUDIES

None, if duration of hoarseness is <3 wk

Possible airway support; lateral and AP radiographic views of neck

Lateral and AP radiographic views of neck; laryngoscopy

Possible airway support

None initially, airway support may be necessary

Lateral and AP radiographic views of neck; laryngoscopy

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Smoking, airborne exposure, chronic alcohol use, history of chronic cough, hoarseness for >3 wk

GERD History of upper GI burning; cough especially at night; chronic use of alcohol, NSAIDs, or aspirin; history of ulcer disease, smoker, age younger than 45 yr; frequent throat clearing

Neoplasm

Hypothyroidism Presence of systemic symptoms, such as cold intolerance, weight gain, fatigue; age older than 65 yr; postpartum; family history of thyroid disease

Vocal cord paralysis

Chronic cough; inspiratory or expiratory stridor with exertion

Psychogenic hoarseness

History of psychiatric illness, or psychological trauma

Laryngeal papillomas

Children 2–12 yr and may occur in infants; history of maternal human papillomavirus; may be recurrent, progressive

Faint cry, severe stridor, voice change, or complete aphonia

Refer for ENT evaluation

Tracheal deviation; pain with advanced tumor; hoarseness may be only sign

May have epigastric tenderness on palpation; vocal cord inflammation or ulcers

Normal or enlarged thyroid gland, coarse hair, very dry skin, prolonged DTR recovery

TSH, free T4 index

Refer for ENT evaluation

Breathy, weak, soft voice; abnormal movement (usually unilateral) of vocal cords; examination may suggest specific CN involvement

Breathy, low voice; larynx will appear normal

ENT referral for biopsy

Referral for endoscopy if symptoms not relieved with medication or dietary alterations

As indicated to rule out other causes (i.e., lateral and AP radiographic views of neck); laryngoscopy

AP, anteroposterior; CN, cranial nerve; DTR, deep tendon reflex; ENT, ear, nose, and throat; GERD, gastroesophageal reflux disease; GI, gastrointestinal; NSAIDs, nonsteroidal antiinflammatory drugs; T4, thyroxine; TSH, thyroid-stimulating hormone; URI, upper respiratory tract infection.

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