Hoarseness
L. Gail Curtis
Hoarseness (dysphonia) is any change in normal voice quality. It is a nonspecific term with many causes and is the most common symptom of laryngeal disease. Hoarseness occurs early in the process of laryngeal disease and can be readily diagnosed in primary care settings. For a variety of reasons, unfortunately, cancer of the larynx has usually been present for 6 months before a diagnosis is made (1).
Approach
A. Etiologic categories. In evaluating hoarseness, it is important to decide which of four possible etiologic categories best accounts for the patient’s vocal changes: diseases causing inflammation or edema of the larynx; processes affecting position or approximation of the vocal cords; disorders causing malfunction of the larynx; or systemic processes (Table 6.1) (2,3).
B. Special concerns. Laryngeal cancer is suggested by prolonged (>2 weeks) hoarseness associated with dysphagia, pain, alcoholism, or chronic cigarette smoking (3,4). Urgent largyngoscopy is indicated.
History
A. Characteristics of hoarseness. Short of direct visualization of the larynx, often little exists to distinguish one cause of hoarseness from another based on routine physical examination. Therefore, a thorough history is essential. Patients should be asked about the mode of onset, duration, and consistency of the hoarseness. The voice of patients with myasthenia gravis gets more hoarse as the day progresses. Intermittent hoarseness argues against there being a fixed lesion. Prominent morning symptoms that improve through the day suggest nocturnal gastroesophageal reflux disease (GERD) (Chapter 9.6). Is the hoarseness exacerbated by talking? Is there any pain, dysphagia, or trouble mounting an adequate respiratory force? Surprisingly, pain is a late phenomenon in carcinoma, but prominent in viral or reflux laryngitis (3).
B. Other historical information. The possible role of other medical problems also must be considered. Is there a history of indigestion, heartburn, or regurgitation suggesting reflux laryngitis? Chronic cough, sputum production, or sinus problems with chronic postnasal drainage may also play a role. A history of specific inciting events—upper respiratory infections, sore throats, fevers, myalgias, fatigue or other infectious exposures (tuberculosis)—need to be explored. Has there been exposure to dust, fire, smoke, or noxious fumes? Smoking and alcohol use are well-known laryngeal irritants as well as carcinogens, and they must be asked about in detail. Is there any history of intubation, prior neck surgery, or neck mass.
C. Voice use and abuse information. It is important to establish an individual’s pattern of voice use. Specifically, does the patient raise his or her voice over crowds or machinery, or by yelling? Does his or her profession involve voice overuse or abuse (e.g., singers, politicians, preachers)?
Physical examination
A. Voice quality. Begin the physical examination by listening to the patient’s voice while obtaining the history. No specific features of hoarseness are definitively diagnostic, but a raspy voice suggests cord thickening caused by edema or inflammation; a breathy voice indicates poor vocal cord position or approximation; and a high, shaky or soft voice is more likely caused by malfunction of the larynx (2).
B. Focused physical examination (PE). Obtain vital signs with attention to temperature and weight. Completely examine the scalp, neck, thyroid gland, cervical nodes, ears, nose, sinuses, and oral cavity. Tender neck adenopathy suggests infection, whereas painless enlargement may imply malignancy (Chapters 15.1 and 15.2). Unless a diagnosis is obvious from the history and initial PE, visualization of the larynx is required. Using one of the techniques described below (section III.C.), carefully inspect the posterior nasopharynx, tongue, lymphoid tissue, and entire larynx. Perform vocal maneuvers while directly observing vocal cord movement. Assess for mucosal and cartilagineous lesions, edema, erythema, and excess mucus—the latter finding suggesting prominent allergies. Edematous vocal cords and glottis with hyperemia suggests GERD or laryngitis.
C. Techniques for laryngeal visualization
1. Indirect laryngoscopy is performed by placing a laryngeal mirror (warmed to prevent fogging) against the soft palate while grasping the tongue with gauze. A bright light source and head mirror, or a headlight, is focused on the laryngeal mirror to reveal an image of the larynx. This technique, although simple, can prove difficult secondary to a strong tongue or gag reflex.
2. Fiberoptic laryngoscopy provides an excellent view of the larynx and avoids the problems noted above in III.C.1. The scope is placed via one nares after topical anesthesia is applied intranasally (e.g., 2% lidocaine gel). The larynx is visualized while the patient swallows and phonates. The procedure is quick and painless and allows a thorough evaluation of the larynx.
Testing
A. Clinical laboratory tests. Routine blood testing is not helpful, unless dictated by features of the history or PE.
B. Imaging. If indicated by history or PE, magnetic resonance imaging is used to assess the extent of serious laryngeal or neck disease.
Diagnostic assessment
The key to diagnosis is a thorough history combined in most cases with visualization of the larynx. Hoarseness of less than 2 weeks duration is considered acute and is usually self-limited. Chronic hoarseness (>2 weeks duration) suggests a more serious cause and a laryngeal examination is critical (2–4).
Some laryngeal lesions have a pathognomonic appearance (3). Vocal polyps are benign and result from chronic voice abuse or direct trauma. They occur on the anterior portion of one vocal cord. Vocal nodules result from poor voice use (e.g., singers, preachers) and always occur at the junction of the anterior and middle third of the vocal cords bilaterally. Contact ulcers present as bilateral ulcerations at the tips of the laryngeal cartilages and are the only common lesion other than cancer that causes throat pain. Leukoplakia presents as a raised, white plaque at the anterior extremity of one vocal cord. It is usually premalignant, related to alcohol use or smoking, and needs to be biopsied.
Although most causes of hoarseness are benign, laryngeal cancer produces early changes in voice quality and is the most serious cause of hoarseness. This cancer presents as persistent hoarseness with a lesion in the hypophyarnyx, glottis, or supraglottis. Any suspicious lesion seen on laryngoscopy needs to be referred for biopsy.
References
1. Yanagisawa E. The larynx. In: Lee KJ, ed. Essential otolaryngology—head and neck surgery, 5th ed. Norwalk: Appleton & Lange, 1995:757–800.
2. Rosen CA, Anderson D, Murry T. Evaluating hoarseness. Am Fam Physician 1998;57:2775–2782.
3. Garrett CG, Ossoff RH. Hoarseness. Med Clin North Am 1999;83:115–123.
4. Vaughan C. Glottic carcinoma. In: Gates G, ed. Current therapy in otolaryngology—head and neck surgery, 5th ed. St. Louis: Mosby, 1994:288–298.
Pictures
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
Other Book Chapters Related to Speech symptoms
Read excerpts from these other book chapters related to Speech symptoms:
Medical Books Excerpts
- DYSARTHRIA
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- HOARSENESS
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Dysarthria
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Hoarseness
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Dysarthria
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Hoarseness
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Dysarthria
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- Dysarthria
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Hoarseness
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Speech symptoms
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Hoarseness (Field Guide to Bedside Diagnosis)
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