Hoarseness

Hoarseness

Common referral Hoarseness reflects any abnormality of normal

phonation

Cartilaginous skeleton

Cricoarytenoid Joint

True synovial joint

Intrinsic Musculature

Abductors Adductors Tensors

Intrinsic Musculature

Innervation

Abduction

Adduction

Tension

Vocal Fold Anatomy

Laryngeal function

Sphincteric function Respiration Phonation Other

– Stabilizes the thorax by preventing exhalation during lifting

– Compresses abdominal cavity during coughing or straining

Phonation

Physical act of sound production by means of passive vocal fold interaction with the exhaled airstream

Pitch Quality Volume

Sound Production

– Contraction of expiratory muscles– Rise in subglottic air pressure– Escape through glottis– Closure

Bernoulli effect elasticity

Phonation

Glottal puff– Release of air as upper margins of TVC separate

Phase delay– Delay of closure between upper and lower margins

of TVC

Mucosal wave– Horizontal and vertical components

Mucosal wave/Phase delay

Body-Cover Theory

Changes to mucosal wave– Stiffness– tension

Mucosal wave

Velocity increases– Increased airflow– Increased subglottic pressure

Fundamental Frequency

Pitch (measure in Hertz) Changes in vibration frequency

– Mass– Stiffness– viscosity

Workup

“Any patient with hoarseness of two weeks duration or longer must undergo visualization of the vocal cords”

Workup

History Physical Examination Ancillary tests

History

URI– Laryngitis– Overuse with edema and inflammation– Paralyses– Granulomas from coughing

History

Trauma– Arytenoid dislocation– Nerve paralysis– Laryngeal fractures– Mucosal lacerations

History

Intubation– Arytenoid dislocations– Nerve injury– granulomas

History

Pulmonary conditions – power source– COPD– Asthma

History

Gastrointestinal– LPR

Autoimmune – RA

Endocrine – Hypothyroidism

Neurologic disorders

Surgical History

Skullbase procedures Carotid endarterectomies Thyroidectomies Aortic aneurysm repairs

Medications

Social History

Tobacco Alcohol ?Inflammation ?Drying of secretions ?malignancy

Occupational History

Voice abuse

Associated Symptoms

Physical Examination

Head & neck examination Laryngeal examination

– Physiologic position– Image quality– Magnification– Cost– Required equipment– Time/skill necessary

Laryngeal examination

Indirect mirror Flexible laryngoscopy Rigid laryngoscopy

Indirect mirror examination

Advantages– Quick– Inexpensive– Little equipment

Disadvantages– Gag– Anatomic features– nonphysiologic

Flexible laryngoscopy

Advantages– Well tolerated– Complete examination– Video documentation

Disadvantages– More time– Expensive

Rigid laryngoscopy

Advantages– Best images– Magnification– Video documentation

Disadvantages– Expensive– Nonphysiologic– Gag– Anatomic features

Videostroboscopy

Light quasi-synchronized with vocal fold vibrations– Bell microphone– Electroglottography

Video recording– Detailed review– Comparison after treatment

Videostroboscopy

Synchronous = motionless Asynchronous = slow motion

Videostroboscopy

Vocal fold closure pattern Vocal fold vibratory pattern Mucosal wave of each vocal fold Symmetry

Videostroboscopy

Radiographic studies

MRI CT

Laryngeal EMG

Myopathy – normal frequency of firing but decreased amplitude

Neuropathy – decreased frequency but occasional normal amplitudes

Polyphasic reinnervation potentials indicate some loss of function but reinnervation has begun

Laryngeal EMG

Differential

Congenital Inflammatory Neoplastic Traumatic Neurologic Endocrine Iatrogenic Local factors

Vocal Cysts

Vocal Nodules

Usually bilateral Voice rest and speech therapy for 6 months Surgical removal

Vocal cord granulomas

LPR Intubation Treat medically

Vocal Cord Paralysis

Lesion at nuclear level – cadaveric Lesion above nodose ganglion – abducted Lesion below nodose ganglion - paramedian

Vocal Cord Paralysis

Superior laryngeal nerve – subtle voice changes with decreased pitch range, tilting of the larynx with a rotation of the glottis

Vocal Cord Paralysis

Children– Neurologic– Traumatic– Idiopathic

Adults– Iatrogenic– Traumatic– Neoplastic– Idiopathic– neurologic

Vocal Cord Paralysis