Hoarseness

Hoarseness is any undesirable alteration of the voice. A rough sound of the voice, change in pitch, or increased effort of speaking can all be considered as hoarseness. “Acute” refers to hoarseness of sudden onset and/or a duration of fewer than 2 weeks. “Chronic” implies duration more than 2 weeks.

Differential Diagnosis

Acute (<2 weeks)

• Infections: Laryngitis, tracheitis, epiglottitis (accompanied by stridor and “thumb sign” on lateral neck X-ray), croup, upper respiratory infections, deep space face and neck infections (e.g., peritonsillar abscess, retropharyngeal abscess, parapharyngeal abscess)
• Voice abuse: Shouting, speaking, or singing loudly; may also cause chronic hoarseness if the abuse is recurrent
• Foreign body
• Trauma: Laryngeal trauma secondary to MVA, strangulation, assault, sporting injuries, intubation, arytenoid cartilage dislocation, or surgery (e.g., damage to recurrent laryngeal nerve following thyroid surgery)
• Irritants: Vomiting, chemical inhalation
• Anaphylaxis
  Chronic (>2 weeks)
• Allergic rhinitis
• Irritants: Tobacco smoke, occupational
• GERD
• Chronic sinusitis
• Endocrine: Puberty, menopause, hypothyroidism
• Foreign body
• Aging
• Vocal cord problems: Polyps, nodules (“singer's nodules”), neoplasm (primary or metastatic), papilloma (infants and children), corditis (Reinke's edema or edema of vocal cords), vocal cord paralysis
• Malignancy: Laryngeal, esophageal, lung, and head and neck (e.g., tonsillar, tongue) cancers
• Iatrogenic: Medication side effect (e.g., pioglitazone, aerosolized steroids), postsurgical recurrent laryngeal nerve damage with vocal cord paralysis, radiation therapy
• Neurologic: Multiple sclerosis, amyotrophic lateral sclerosis, Parkinson's disease, muscular dystrophy
• Less common etiologies (“zebras”) include hemorrhage into vocal folds, psychogenic (laryngeal conversion disorders), rheumatoid arthritis, sarcoidosis, and amyloidosis

Workup and Diagnosis

• History and physical exam
  –Assess prior history, onset, and duration; exposure to irritants, allergens, tobacco and/or alcohol, medications; voice use/abuse; trauma; associated symptoms (e.g., cold symptoms, heartburn, vomiting, weight loss, dysphagia); and past medical and surgical history
  –Focus on head and neck, thyroid, lung, and cardiac examinations, including an evaluation of voice quality
• Chest X-ray
• Lateral neck X-ray if history and physical suggest epiglottitis or foreign body
• Direct or fiber optic nasolaryngoscopy is the best way to assess the larynx; if suspect epiglottitis, must be done in operating room
• Biopsy if mass seen on direct laryngoscopy (usually refer to otolaryngoscopy for biopsy, if mass is visualized)
• If indicated by history or exam, consider upper GI endoscopy (EGD), upper GI series, CT of sinuses, thyroid function tests, and/or CT scan of head and neck (if suspect laryngeal or neck tumor that is not seen on nasolaryngoscopy and/or lymphadenopathy is present)

Treatment

• Evaluate airway, breathing, and circulation
• Trauma/obstruction: Cricothyrotomy or tracheostomy may be necessary to establish an airway
• Infections: Symptomatic measures (e.g., hydration, cough suppression, decongestants), antibiotics, voice rest, surgery for abscess
• Vocal abuse: Voice rest (whispering is not voice rest); if speaking is absolutely necessary, oral steroids may be used; voice therapy may be necessary in chronic voice abuse to correct faulty vocal habits
• GERD: H2 blockers or proton pump inhibitors, diet modification
• Allergic rhinitis/chronic sinusitis: Intranasal steroids and/or antihistamines (e.g., loratadine)
• Irritants: smoking cessation, protective clothing or masks
• Masses usually require surgical intervention
• Endocrine, neurologic, and rheumatologic etiologies should be treated appropriately

Book Source Details

• Book Title: In a Page: Signs and Symptoms
• Author(s): Scott Kahan, Ellen G. Smith
• Year of Publication: 2004
• Copyright Details: In a Page: Signs and Symptoms, Copyright © 2004 Lippincott Williams & Wilkins.

Other Book Chapters Related to Speech symptoms

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Copyright Details: In a Page: Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

More About Causes of Speech symptoms

• Back to symptom: Speech symptoms: Introduction (review 802 causes)
• Next Book Extract About Speech symptoms: Hoarseness (In A Page: Pediatric Signs and Symptoms)
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More About This Book: Title: In a Page: Signs and Symptoms Authors: Scott Kahan, Ellen G. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2004 ISBN: 1-4051-0368-X

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