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Basic laryngeal
anatomy
Assessing voice
dysfunction
Treating nodules,
polyps,
papillomas,
paralysis and
cancer
Case studies
Hoarseness
and voice dysfunction
The author
ASSOCIATE PROFESSOR
THOMAS E HAVAS,
otolaryngologist, Prince of Wales
Hospital and Sydney Children’s
Hospital; and conjoint associate
professor, University of NSW.
Background
INTEREST in laryngology and the
voice has increased dramatically in
recent years because of four major
developments:
■ A revolution in diagnostic technology — improved optical systems
such as fibreoptic video stroboscopy
and improved voice analysis systems
have pushed voice analysis into the
modern era.
■ A simultaneous revolution in surgical technology — the most important advance has been in endoscopic
micro-laryngeal surgery and in
laryngeoplastic phonosurgery.
■ The development of enhanced mul-
tidisciplinary communication
between otolaryngologists, speech
pathologists, voice scientists and
voice teachers.
■ A dramatic increase in demand for
treatment, with public awareness
that most voice disorders can be
treated successfully.
Voice disorders are almost commonplace so it is easy to forget they
are often associated with significant
morbidity.
It is important to remember that
the voice is not an organ but rather
the external phonatory output of a
complex mechanism — the vocal
tract. As such, an understanding of
simple laryngeal anatomy and voice
production is integral in assessing
any disorder affecting the voice.
The production of the human
voice is a complex function that
requires neuromuscular control and
co-ordination of the small muscles
in the larynx, the diaphragm, the
chest, pharynx, tongue, palate and
the accessory muscles of the neck.
Sound is generated in relation to
the:
■ Mass, tension and length of the
vocal folds or cords.
■ Elastic recoil of the laryngeal tissue.
Subglottic pressure generated by
the lungs.
All these determine the vibrations
of the vocal fold mucosa that produce the voice. Sound is modified by
the position of the larynx, tongue,
palate, jaw and lips, and the tension
in the pharynx and neck muscles.
The voice of an individual is an
expression of their personality, their
physical and emotional wellbeing and is
also vital in communication. Minor or
major changes in the anatomical structure, neuromuscular co-ordination and
psychological status can all interact to
produce a change in the voice.
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Basic laryngeal anatomy
THE larynx is a complex
neuromuscular organ (figure
1). There are two vocal folds
or cords made up of a
mucous membrane, submucosal space, vocal ligament and the vocalis muscle.
The glottis is the area in
the larynx extending from
the anterior commissure to
the arytenoid cartilage at the
level of the vocal fold.
The supra-glottis lies
above the vocal fold and the
sub-glottis extends from the
lower border of the vocal
fold to the lower border of
the cricoid cartilage.
A recess called the laryngeal
ventricle is responsible for the
production of mucus and lies
above the vocal folds.
The false vocal folds are
muscular structures lying parallel to and above the true
vocal cords and, although
they play some part in phonation, their main function is to
act as the laryngeal sphincter
to prevent aspiration during
swallowing and to regulate
expiratory airflow, hence
modulating the intensity and
quality of voice.
Figure 1: Basic laryngeal anatomy. 1: Vocal process of
arytenoid. 2: Vocal cord. 3: Tubercle of epiglottis. 4: Valleculae.
5: False vocal cord. 6: Aryepiglottic fold. 7: Piriform fossa.
8: Inter-arytenoid region.
4
3
5
Table 1: Levels of vocal usage
2
6
7
8
1
Each true and false vocal
fold is anchored to the arytenoid cartilage (which sits
on the cricoid cartilage) by
a complex synovial joint.
The arytenoid cartilages
undertake a complex range
of movements (they can
move from side to side and
rotate) and can be damaged
Level
Description
Examples
I
Elite vocal performer
Singer, actor
II
Professional voice user
Clergyman, lecturer
III
Non-vocal professional
Teacher, lawyer
IV
Non-vocal non-professional
Labourer, clerk
by trauma, most often endotracheal intubation.
The joint is subject to the
same arthritic conditions as
other synovial joints: when
affected by arthritis, patients
complain of pain that is
worse with voice use.
The epiglottis is often
referred to as ‘the hood of
the larynx’ and has a protective function for the larynx
during swallowing. It sits at
the front (see figure 1), separating the larynx from the
vallecular (a recess between
the tongue and the larynx)
at the base of the tongue.
Identifying the vocal needs
of each individual is very
important in successfully
treating patients with voice
disorders. For example, a
voice disorder may prevent
a singer from performing, a
lawyer, teacher or clergyman
from working, or impair
communication between the
elderly or spouses. Table 1
illustrates the four levels of
vocal usage commonly
described.
Most adults and older
children with laryngeal problems present with voice
abnormalities. Adults may
complain of:
■ Voice change.
■ Sore throat.
■ Persistent cough.
■ Reduced secretions.
■ Feeling
of something
caught in the throat.
■ Pain referred to the ear.
■ Pain or soreness on swallowing.
■ Difficulty swallowing.
■ Lump in the neck.
■ Coughing.
■ Choking.
■ Difficulty breathing.
■ Difficulty
in forming
jointed speech or intelligible words.
Voice complaints
HOARSENESS is such a generic
term that most clinicians tend to
use more specific, descriptive terms
such as dysphonia or aphonia. Dysphonia refers to an abnormalsounding voice, but the degree of
dysphonia does not correlate with
any specific anatomical or pathological cause.
Aphonia is a term used to
describe loss of voice to varying
extents. Patients with aphonia may
still be able to communicate in a
quiet environment, but the glottis,
that is to say, the true vocal cords,
do not participate in phonation.
The sound of the voice in a
patient with aphonia is characteristically low or non-existent or
characterised by extreme breathiness. Other specific terms pertaining to common voice complaints
and symptoms are listed in table 2.
Table 2: Common vocal
complaints and symptoms
■
Dysphonia (abnormal voice)
■
Aphonia (loss of voice)
■
Diplophonia (double-tone)
■
Dysresonance (loss of resonance)
■
Vocal fatigue (worsening of the
voice with prolonged use)
■
Vocal breaks (pitch-specific
dysphonia)
■
Reduction in vocal range
(reduced dynamic range)
■
Odynophonia (painful phonation)
Table 3: Diagnoses of 100 consecutive patients seen at the
Sydney Voice Clinic
Diagnosis
Child
Adult
Total
Reflux laryngitis
1
10
11
Vocal cord carcinoma
—
10
10
Vocal cord paralysis
—
8
8
Neuromuscular disorders
—
8
8
Papillomas
2
4
6
Laryngeal stenosis
2
3
5
Polypoidal degeneration
—
4
4
Trauma
1
1
2
Miscellaneous*
1
5
6
Total
7
53
60
Conversation aphonia
1
2
3
Postviral habituated hoarseness
—
4
4
Inappropriate falsetto
—
1
1
Vocal misuse/abuse syndromes without lesions
—
14
14
Vocal misuse/abuse syndromes with lesions**
4
10
14
Postoperative dysphonia
—
3
3
Relapsing aphonia
—
1
1
Total
5
35
40
Organic
Functional
Assessing voice dysfunction
Voice dysfunction can be categorised in several ways. The most
traditional approach has been to
divide voice disorders into organic
and functional, but the definition
of each is somewhat nebulous.
In voice disorders, the term
organic commonly refers to any
disorder related to organ dysfunction or disease, whereas functional
describes organ disorders resulting
from misuse or abuse.
For example, vocal nodules are
discrete lesions at the junction of
the anterior and middle thirds of
the vocal folds and are almost
always associated with vocal
misuse and abuse because they
result from abnormal laryngeal biomechanics. Correction with speech
therapy usually leads to resolution,
so they are considered to be in the
functional group of voice disorders.
However, functional voice disorders may cause secondary develop-
* Granulomatous disorders, hypothyroidism, inflammatory polyps
** Haemorrhages, contact ulcers, nodules
ment of histopathological changes
in the vocal folds, such as vocal
nodules, contact ulcers, vocal
process granulomas and Reinke’s
oedema (a polypoid degeneration
of the vocal folds).
Table 3 summarises the diagnosis
of 100 consecutive patients with
abnormal voice seen at the Sydney
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Voice Clinic. Using the criteria
defined above, 60% of patients had
organic disorders and 40% had
functional disorders.
The organic group of disorders
most often included:
■ Neoplastic growths such as carcinoma.
■ Papilloma.
Mucosal abnormalities such as
reflux-induced pharyngolaryngitis
and Reinke’s oedema.
■ Neuromuscular disorders such as
paralysis or paresis of the vocal
folds.
■ Vocal fold atrophy.
■ Tremor.
■ Dystonias (spasmodic dystonia).
■ Parkinsonism.
Almost all the functional group
of voice disorders are due to vocal
misuse or abuse, and the vast
majority of these can be classified
as hyperfunctional states.
Both these terms (functional and
hyperfunctional) suggest altered
laryngeal biomechanics, that is,
inappropriate or abnormal muscle
tension during voice use. Therefore,
most functional voice disorders are
considered muscle tension dysphonias.
In reality, distinguishing between
organic and functional is not particularly useful, especially as the
underlying cause of many lesions
may be a combination of organic
and functional factors.
For example, a granuloma on the
vocal process may be due to vocal
abuse, gastro-oesophageal reflux,
endotracheal intubation or a combination of these factors.
Indeed, it is well recognised that
chronic throat-clearing secondary
to foreign-body sensation may further traumatise an existing granuloma, thereby producing a vicious
cycle of foreign-body sensation
leading to chronic throat-clearing
leading to increased trauma and
swelling of the lesion, leading to
increased foreign-body sensation.
A viral lesion of the larynx (viral
laryngitis) may lead to the compensatory development of false
vocal cord speech, occurring
because it is less painful to oppose
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How to treat – hoarseness and voice dysfunction
from previous page
the false vocal folds than the
two vocal folds.
Despite improvement of
the underlying inflammatory
condition and the suboptimal quality of the voice, the
‘compensation’ may become
habitual and, if the voice
remains abnormal, the
patient will usually seek
medical attention.
In these cases the organic
disorder has evoked various
compensatory mechanisms
that have caused a secondary
functional voice disorder. So
the distinction between
organic and functional voice
disorders is not always clear.
Reinke’s oedema also
results from multiple causes,
including cigarette smoking,
hypothyroidism, gastrooesophageal reflux and voice
abuse. These factors may act
alone or in combination and
it is the clinician’s responsibility to identify and treat
each of the underlying factors.
Voice disorders in children
require a different approach.
Although paediatric dysphonias may have anatomical,
functional or mixed causes,
the role of growth and development in the causation,
treatment and resolution of
vocal fold abnormalities in
children is particularly
important.
For example, the causes of
dysphonia in the newborn
may include vocal cord
paralysis, laryngeal web and
cerebral palsy, and are quite
different from the likely
causes of dysphonia in a
teenager, such as vocal fold
abuse or puberphonia.
Puberphonia occurs particularly in males and is
characterised by the prolonged use of a fixed highpitched pre-pubescent voice.
It is a functional voice disorder that can be treated by
expert speech therapy.
Successful care of patients
with voice disorders depends
on the ability of the clinician
to:
■ Understand how the patient
uses their voice.
■ Provide an accurate diagnosis and appropriate treatment.
■ Elicit the outcome desired
by the patient.
A maximum
phonation time
of eight seconds
is pathologically
short and usually
indicates
significant
laryngeal
pathology.
History
The history of the change in
voice sometimes gives a clue
to the cause. Hoarseness
after a viral URTI causing
laryngitis is likely to last
only a few days, whereas
huskiness caused by Reinke’s
oedema may last months or
years.
The onset of hoarseness
may be sudden, for example,
when shouting causes haemorrhage of the vocal cord or
when there is damage to the
recurrent laryngeal nerve
during thyroid surgery.
A progression of symptoms over weeks or months
should cause particular concern and suggest the possibility of neoplasm.
32
| Australian Doctor | 26 May 2006
ture of generalised systemic
diseases. Hoarseness can be
caused by:
■ Rheumatoid arthritis of the
larynx affecting the cricoarytenoid joints.
■ Sarcoidosis.
■ Amyloidosis.
■ Wagner’s granulomatosis.
■ Epidermolysis bullosa.
■ Bullous pemphigoid.
■ A variety of other systemic
disorders.
Examination
It is important to ask
about exposure to any
potential environmental irritants such as cigarette
smoke, or excessive periods
in air conditioning or cool
rooms.
Variable, irregular fluctuating voice production associated with loss of intelligibility may be the first
manifestation of a neurological disorder. The most
common neurological disorders affecting voice are:
■ Vocal cord paralysis (which
may be idiopathic or secondary to a disease process
in the neck or mediastinum).
■ Multiple sclerosis.
■ Motor neurone disease.
■ Myasthenia gravis.
■ Spasmodic dysphonia.
■ Parkinson’s disease.
■ Cerebellar degeneration.
■ Pseudo bulbar palsy.
■ Various forms of dystonias.
The clinician must also be
mindful of the possibility
that laryngeal symptoms can
be the initial presenting fea-
The GP should listen to the
voice in static and jointed
speech. To evaluate static
speech, ask the patient to
phonate using a flat E sound
for as long as they can. A
maximum phonation time of
eight seconds is pathologically short and usually indicates significant laryngeal
pathology.
Then, ask the patient to
glide up on an E as high
then as low as they can, to
get some assessment of their
functional range.
To assess jointed speech,
ask the patient to speak, to
read from a prepared passage or the local newspaper,
and to sing a simple ditty
such as Happy Birthday.
The degree of communication limitation caused by the
patient’s symptoms can also
be made during history
taking.
Systematically examine the
lips, mouth, oral cavity,
oropharynx, nose and
nasopharynx. Palpate the
neck for masses such as
enlarged lymph nodes or
thyroid.
Palpate the thyroid cartilage to ensure it has normal
contour and gently rock it
from side to side: discomfort
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on gentle rocking indicates
laryngeal pathology, particularly if the cause is inflammatory.
While examining the
tongue, oral cavity and
oropharynx it is important
to look for:
■ Any mucosal changes associated with smoking, such
as dysplasia or leukoplakia.
■ Signs
consistent with
gastro-oesophageal pathology, such as excessive furring of the tongue or granular pharyngitis.
■ Any discrete masses or
lesions, such as a mass in
the tongue or floor of the
mouth.
The technique of indirect
laryngoscopy is no longer
taught to undergraduate students in most medical
schools, so most physicians
and GPs are not adequately
trained to examine the
larynx and hypopharynx
using this method.
If symptoms suggest possible pathology in the larynx
or pharynx (eg, husky voice
or difficulty swallowing
because of a lump in the
throat), the patient should
be referred to an otolaryngologist, who can:
■ Examine the upper airway,
including the nose and
nasal cavity, mouth, oral
cavity, pharynx and larynx.
■ Perform indirect laryngoscopy using a mirror.
■ Perform a direct laryngoscopy using a rigid (70°
or 90°) telescope and flexible fibreoptic naso-laryngoscopy.
In most cases, when
anatomical abnormalities are
found at the initial examination, a diagnosis can be
made on the basis of the
physical examination. However, patients with more
complex functional voice
disorders often need referral
to a voice clinic.
Voice clinics
Patients at most voice clinics are seen conjointly by an
otolaryngologist and a
speech pathologist, who take
a detailed history of general
health and specific voice
problems.
Perceptual analysis and
complex computer acoustic
analysis are used to break
down the voice into specific
acoustic parameters, which
can then be studied individually.
This type of acoustic diagnosis may be useful in
assessing some conditions
such as vocal nodules, when
there is a characteristic pattern of dysphonia called
diplophonia, in which the
vocal cords vibrate at two
discrete fundamental frequencies.
During acoustic diagnosis
patients are asked to
phonate and/or sing a series
of pre-arranged texts that
emphasise every aspect of
laryngeal muscle use.
The larynx is examined in
detail using rigid and flexible
telescopes and the images
are projected onto a computer screen and recorded to
facilitate detailed computer
analysis.
During video endostroboscopy a rapidly flashing
light is introduced through
the telescope. The light is
triggered by a stethoscope
placed on the patient’s
larynx that records the
vibration of the vocal folds.
This technique allows the
rapid vibration of the
mucosa along the free edge
of the vocal cord to be seen
in slow motion and facilitates a much more detailed
examination of any movement disorder of the
mucosa, which may arise
from either movement from
the front to the back of the
vocal cord or from the free
edge into the laryngeal ventricle.
Small mucosal or subepithelial lesions that cannot
be identified with constant
light can often be identified
using endostroboscopy.
Electro-laryngography (laryngeal EMGs) can be used
to assess cases of vocal fold
paralysis but there are
doubts about the sensitivity
and reproducibility of this
investigation. However,
when expertly performed,
information about the neuromuscular junctions in an
immobile vocal fold can be
obtained using this technique.
The presence of re-innervation potentials indicates
that an immobile vocal fold
is due to a neurological disorder and can be used to
track whether the disorder is
likely to return sooner rather
than later.
Electro-laryngography is
also a useful way to isolate
specific muscles for injection
of botulinum A in patients
with laryngeal dystonias.
Flexible transnasal oesophagoscopy is performed
under local anaesthesia and
is a useful investigation for
examining the cricopharyngeal muscle, oesophageal
mucosa and the gastrooesophageal junction in cases
of reflux-induced pharyngolaryngitis.
Conditions such as Barrett’s dysplasia, mucosal
ulceration or hyperaemia
and cricopharyngeal muscle
spasm can be identified
using this technique.
Diagnostic imaging
Diagnostic imaging is rarely
used as a first-line investigation in the management of
voice disorders but can be
used to supplement the clinical examination findings.
The investigation of choice
is a high-resolution CT scan
in the axial plane, with thin
overlapping slices, or spiral
CT with three-dimensional
reconstructions.
Imaging is most useful in
cases of laryngeal trauma
and suspected laryngeal neoplasia.
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Treatment
WHEN the reason for dysphonia has been found, treatment can be tailored to the
cause. Most functional voice
disorders are treated by expert
speech therapy and/or pharmacology.
For example, a patient who
has gastro-oesophageal reflux,
habitual throat clearing and a
vocal process granuloma is
best treated by speech therapy
to address the throat clearing,
and acid suppression to control the gastro-oesophageal
reflux. Typically, patients are
started on acid suppression for
three months and then
reassessed.
Figure 2: Parakeratosis and benign epithelial hyperplasia in a
vocal nodule.
Figure 4: A haemorrhagic vocal cord polyp.
Figure 3: Laryngeal polyp with prominent squamous epithelial
acanthosis.
Figure 5: Vocal cord papilloma.
likely to undergo dysplasia.
Overall, 1-5% of patients
develop significant or severe
atypia and/or malignancy.
Common modes of presentation are a change of voice
and/or cry in children.
Diagnosis is made by endoscopic examination of the
larynx. Treatment involves
removal of the papilloma
either by surgical dissection,
carbon dioxide laser vaporisation and/or the use of a
micro-debrider.
Papillomas tend to be recurrent, and multiple surgical
interventions are often needed.
Adjuvant therapy using
intralesional cidofovir (Vistide)
has been shown to reduce the
recurrence rate of papillomas
but it carries the risk of potential systemic side effects and/or
laryngeal scaring.
Granuloma
Granulomas are inflammatory
lesions that usually occur on
the vocal process of the arytenoid cartilages at the site of
contact during vocal fold closure. They are usually caused
by irritation associated with
voice misuse or injury. Treatment is incremental, beginning
with vocal hygiene, specifically, the avoidance of forced
throat clearing.
If necessary, proton-pump
inhibitors are added to avoid
any gastro-oesophageal or
pharyngolaryngeal reflux,
which is often the cause of the
throat clearing.
If there is no evidence of
reflux and no forced throat
clearing, conservative management involves a long course of
low-dose oral antibiotics.
If granulomas are large,
atypical or interfere with
voice or airway, surgical
removal is recommended.
This involves microlaryngoscopy, removal of the granuloma and laser to the base
of the granuloma overlying
the vocal process of the arytenoid cartilage.
In some institutions, corticosteroids are injected into the
perichondrium of the arytenoid, but there are no data
to suggest this reduces the
recurrence rate of vocal
process granulomas.
Vocal nodules
Vocal nodules are more
common in boys than girls in
childhood, but become more
common in women than men
in adulthood.
The main clinical features
are huskiness, breathiness and
vocal fatigue, particularly after
prolonged use. All these symptoms are accentuated by any
respiratory tract infection.
Certain occupational subgroups such as teachers,
entertainers, singers, travel
agents and stockbrokers are
more prone to vocal nodules
in adulthood. Essentially they
can affect anyone with a
high-pressure demanding job
in which prolonged vocal use
is required under stress.
Vocal nodules almost
always relate to abuse or
misuse of the voice — overusing conversational speech,
shouting, yelling or using an
Vocal cord paralysis
Papillomas tend to
be recurrent, and
multiple surgical
interventions are
often needed.
unnaturally low register. If
any of these qualities become
habitual, they often lead to
development of laryngeal
pathology.
Histopathological findings
include hyperplasia of the
epithelial layer and thickening
of the basement membrane,
with or without keratin formation (figure 2).
Almost all children and the
vast majority of adults with
vocal nodules can be treated
using expert speech pathology
aimed at:
■ Correcting hyperfunctional
voice usage.
■ Use of an appropriate register.
■ Teaching forward placement
(a technique that involves
anchoring, laryngeal elevation and forward placement
of the tongue base).
Vocal nodules do not continue to grow, are never premalignant, never cause airway
compromise and are in no
way a danger to life.
Surgical treatment is usually
confined to children, when
diligent speech therapy has
failed and the dysphonia is
causing personality changes
and significant embarrassment
at school. However, surgery
is rarely recommended before
age eight.
The operation involves suspension microlaryngoscopy
under general anaesthesia and
microsurgical dissection and
removal of the vocal nodule(s).
Vocal cord polyps
Vocal cord polyps (figure 3)
are the most common laryngeal pathology requiring surgical removal. They are usually unilateral, found most
often in the anterior or the
middle third of the membranous cord and are twice as
common in men as women.
They occur in adults of all
ages but most often in
patients between 20 and 60.
Overuse or abuse of the
voice, particularly in the
context of background
noise, is said to be one of the
aggravating factors, but
direct irritation from smoking or gastro-oesophageal
reflux is almost always present as well.
Polyps interfere with the
vibration of the vocal cord on
which they occur and also
cause a repeated ‘banging’
injury to the contralateral
vocal cord.
Sometimes they are caused
by an intracordal bleed (figure
4). This is most often secondary to forceful banging
together of the two vocal folds
during screaming or shouting.
Usually vocal fold haemorrhages present with painful
dysphonia of sudden onset.
Polyps are categorised histologically as oedematous,
angiomatous or fibrous.
Diagnosis is by laryngeal
endoscopy. Differentiation of
polyps from other lesions such
as nodules, granulomas and
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papillomas is usually not difficult histologically.
Polyps do not improve with
medical treatment or speech
therapy, so surgical removal
is necessary to restore the
vocal cord’s normal appearance and vibratory function.
Surgical removal involves
meticulous microdissection,
with care not to damage the
deeper structures of the vocal
cord, especially the vocal ligament. Prognosis after surgery
is usually excellent in terms of
voice restoration.
Laryngeal papillomas
Laryngeal papillomas (figure
5) are the most common
benign tumour of the larynx.
They occur in paediatric and
adult forms and are caused by
the human papilloma virus,
activated by an unknown promoter.
Two subtypes of virus (6
and 11) are found in most
laryngeal papillomata. There
are no known predisposing
risk factors.
Although it is uncommon
to find intercurrent papillomas elsewhere in the upper
digestive tract, they sometimes occur in the nasopharynx, nasal cavity,
oropharynx, trachea, bronchus, lung and tongue. Papillomas have been known to
occur in the oesophagus but
are extremely rare.
Papillomas caused by type
6 virus appear to be more
Vocal cord paralysis can occur
in infants or adults. It is the
most common laryngeal
abnormality in childhood
(accounting for about 20% of
all laryngeal disorders) after
laryngomalacia.
Paralysis of both vocal
cords is a cause of stridor in
childhood, and about 10% of
children who present with
stridor and airway obstruction
have bilateral vocal cord
paralysis. There is usually no
preceding voice pathology and
their pattern of dysphonia
and/or shortness of breath is
not diagnostic.
Bilateral vocal cord paralysis rarely occurs in an otherwise normal child. Although
the cause is probably retarded
development of the 10th cranial nerve motor pathways,
gross or specific abnormalities
are not often found.
Many infants with bilateral
vocal cord paralysis have an
anomaly of the central nervous system, such as an
Arnold-Chiari malformation
or myelomeningocele.
Bilateral vocal cord paralysis can occur with birth
trauma due to difficult or prolonged labour, forceps delivery or undue traction on the
cervical spine.
Unilateral vocal cord paralysis in adulthood is a common
cause of a weak breathy voice.
The diagnosis is usually made
clinically by direct laryngoscopy.
Electromyography can be
helpful in distinguishing
between partial and complete
denervation and/or conditions
that limit the movement of the
crico-arytenoid joints, such as
rheumatoid arthritis.
In adults, most neurological lesions causing vocal cord
paralysis are between the
medulla and the laryngeal
muscles and it is uncommon
for corticobulbar pathway
lesions to affect laryngeal
movement.
Twenty to thirty per cent of
unilateral vocal cord paralycont’d next page
26 May 2006 | Australian Doctor |
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How to treat – hoarseness and voice dysfunction
from previous page
sis in adults is postviral or idiopathic.
The remainder is usually postsurgical,
occurring particularly after thyroidectomy, cardiac bypass surgery, anterior
cervical fusion or removal of lateral
neck masses.
Malignancy in the neck or mediastinum can also cause pressure neurapraxia of the vagus and/or superior
or recurrent laryngeal nerves, leading
to cord paralysis.
Treatment of unilateral vocal cord
paralysis usually depends on the severity of the dysphonia, the patient’s voice
requirements and the presence or
absence of aspiration. The presence of
aspiration is an absolute indication for
treatment.
Conservative management includes
observation and/or speech therapy but
there is a growing trend towards early
intervention to minimise the period of
dysphonia and associated morbidity.
Early surgical intervention usually
involves peroral augmentation of the
paralysed vocal cord, usually with
autologous fat harvested from around
the umbilicus, or with gelfoam. If there
is significant atrophy of the vocal fold
and a large phonatory gap, alloplast
augmentation of the vocal cord is performed.
Figure 6: Invasive squamous cell carcinoma of the larynx.
Figure 7: Laryngeal dysplasia with keratosis (leukoplakia).
Cancer of the larynx
Cancer of the larynx (figure 6) is the
most common head and neck malignancy after cancers of the oral cavity
and tongue and occurs most often in
middle-aged men who smoke.
Although the prevalence of laryngeal
carcinoma is constant in men it is
increasing in women.
Depending on the extent of the
laryngeal cancer at the time of diagnosis, the overall five-year survival rate
averages 65-70%.
Aetiological studies have identified
three major predisposing factors to carcinoma of the larynx — tobacco, alcohol and/or previous irradiation.
Although strong evidence is lacking,
there is increasing clinical suspicion
that gastro-oesophageal reflux could
also act as a promoting agent.
In the normal larynx the vocal folds
or cords are lined by non-keratinised
squamous epithelium. The rest of the
endolarynx has a pseudo-stratified,
columnar ciliated epithelium.
Laryngeal dysplasias are a range of
conditions causing predominately
microscopic changes in cellular architecture and structure. The changes are
commonly described by the pathologist
as hyperplasia, keratosis with or without atypia, carcinoma in-situ, or microinvasive or invasive carcinoma.
Older-style descriptive terms like
leukoplakia (white patch) usually refer
to laryngeal dysplasia with keratosis
(figure 7). Only about 2% of these
lesions manifest changes of either carcinoma in-situ, micro-invasive or
frankly invasive carcinoma.
Erythroplakia (or red patch) is more
likely to be due to chronic inflammation or mild dysplasia, although about
10% show micro-invasive or invasive
carcinoma on biopsy.
Lesser degrees of dysplasia are
treated by excision biopsy or laser
vaporisation. Carcinoma in-situ and
micro-invasive carcinoma can be
totally cured by local excision or laser
vaporisation.
Invasive carcinoma, depending on
its size and site, can be treated by an
incremental range of therapeutic
options, including:
■ Endoscopic removal of the affected
mucosa by laser vaporisation.
■ Cordectomy (either by opening the
larynx through the skin of the neck
or endoscopic techniques).
■ Partial laryngectomy.
■ Total laryngectomy.
■ External beam radiotherapy.
■ A combination of surgery and radiotherapy, or chemotherapy with radiation therapy.
Most laryngeal cancers occur at the
level of the true vocal cords, which
have a poor lymphatic supply. Therefore, until the cancer is very advanced,
local or regional lymph node metastases are uncommon.
Any adult — especially a male —
with symptoms of progressive hoarseness, stridor, sensation of a lump in
the throat, referred pain in the neck or
odynophagia, and who has a history
of smoking, alcohol excess, previous
radiation or untreated reflux should
raise a high index of suspicion of
laryngeal malignancy: they should be
referred to an otolaryngologist as a
matter of urgency.
Summary
Hoarseness is a common
complaint that needs to
be assessed in the clinical
context of:
·■ Interference with
communication and
social contact.
■ Interference with working
capacity and quality of life.
■ Risk factors for upper
airway/digestive tract
malignancy.
If symptoms do not
resolve within days to
weeks, early referral to
an otolaryngologist to
exclude malignancy is
recommended.
Author’s case studies
Voice change from a
thyroid lump
A 50-YEAR-old schoolteacher
presents with increasing weakness of voice and voice
fatigue. He is an experienced
teacher and is otherwise fit
and well.
There are no risk factors for
upper-airway tract malignancy. He does not smoke or
drink, there is no relevant
family history and he has
no symptoms of gastrooesophageal reflux.
At the time of consultation
he has dysphonia characterised by breathiness of the
voice. The examination of the
oral cavity and pharynx are
normal but palpation of the
neck reveals an enlarged right
hemi-thyroid.
Static voice analysis shows
a maximum phonation time
of six seconds (reduced). Gliding on an E (without showing
restriction of range) indicates
that the superior laryngeal
nerves are intact.
Indirect laryngoscopy shows
an immobile right vocal fold,
suggestive of right recurrent
34
laryngeal nerve palsy. Jointed
speech and gliding on an
ascending E reveals that the
superior laryngeal nerve is
intact but there is a right recurrent laryngeal nerve palsy.
CT scans and ultrasound of
the neck demonstrate a large
solitary nodule in the thyroid
gland in the region of the tracheo-oesophageal groove,
extending into the superior
mediastinum.
Surgical treatment is appropriate and the patient has a
right hemi-thyroidectomy
with parathyroid preservation.
At surgery, the recurrent
laryngeal nerve is inspected
and found to be attenuated
but intact.
The patient’s postoperative
recovery from thyroidectomy
is uneventful. When reassessed
six weeks after surgery the
voice is normal and the recurrent laryngeal nerve function
has returned.
Comment
This case illustrates:
■ The breathy nature of dysphonia typical of unilateral
| Australian Doctor | 26 May 2006
■
The reasonable expectation
that the neurapraxia caused
by pressure on the nerve will
fully recover.
Two lesions in the
oropharynx
vocal cord paralysis.
The importance of palpation
of the neck and investigation
of any significant mass.
■ The importance of indirect
laryngoscopy, which reveals
an immobile vocal fold. If
on the same side as the
mass, the mass has increased
clinical significance.
■ The use of appropriate
investigations, imaging and
treatment.
■
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A 55-YEAR-old man presents
with increasing voice raspiness. He is a heavy smoker
and drinker and his uncle died
of laryngeal cancer.
Examination of the oral
cavity reveals poor dental
hygiene and a right ulcerated
mass on the lateral border of
the tongue. There are no
enlarged lymph nodes or
masses on palpation of the
neck.
Direct laryngoscopy shows
an exophytic lesion on the
right vocal fold, but vocal fold
movement is full. The remainder of the ENT examination is
normal.
Examination under anaesthesia and excision biopsy of
the lesion in the tongue is performed as well as micro-laryngoscopy and laser excision of
lesion in the larynx.
Histopathology of the
tongue and laryngeal lesions
show a small squamous cell
carcinoma that has been completely excised.
Comment
This case illustrates:
■ Smoking and drinking
are risk factors of upper
airway and digestive tract
malignancy.
■ 15% of people with one
cancer in the upper digestive
tract have a second synchronous primary.
■ Another 15% go on to
develop a second metachronous primary.
■ Local excision biopsy of the
lesion in the tongue is curative.
■ Local excision biopsy of the
lesion in the larynx is curative.
■ Close and meticulous examination of the upper airway
tract, oral cavity and pharynx is mandatory for this
patient at-six monthly intervals for the rest of his life.
■ If need be, vocal quality can
be improved by secondary
surgery.
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How to treat – hoarseness and voice dysfunction
GP’s contribution
tially for speech therapy and
subsequently for botulinum
injections.
Questions for the author
Is the underlying cause of spasmodic dysphonia understood?
No. Current thinking is that
it is a neurodegenerative disorder affecting the vagus
nucleus of the brainstem.
DR JON FOGARTY
Point Clare, NSW
Case study
RL, 26, presents with a long
history of intermittent dysphonia. This first presented at
age 23 and was thought to be
a manifestation of ‘globus’ (a
sensation of tightness or a
lump in the throat).
His symptoms of huskiness
were initially intermittent and
disappeared when he was
singing or laughing. He felt
his symptoms were worse
when he was anxious.
He has never smoked and
has no history of voice abuse.
He sings in a choir and is anxious that his hoarseness will
eventually affect his singing.
RL had previously been
told that his voice changes
were related to anxiety and
had been referred for stress
management.
He was referred for ENT
examination and no abnormality was found. A diagnosis
of spasmodic dysphonia was
made and he was referred ini-
What is the role of botox
injections here? What role
does the speech therapist play
in the management of this
condition?
Usually spasmodic dysphonia can be abductor, adductor
or mixed type. In mild cases
speech therapy does have a
role to play in facilitating
meaningful communication.
Botox injections are the
treatment of choice when
there is a significant communication problem. However,
there are two potential problems with injecting botulinum
toxin type A.
One is tachyphylaxis, when
progressively increasing doses
of botulinum A are required
to get a good result. The
second problem is that there is
increasing evidence of intramuscular scarring and fibrosis from repeated injection.
What symptoms may suggest
a diagnosis of spasmodic dysphonia rather than globus or
speech fatigue?
Spasm is the pathognomonic symptom of spasmodic
dysphonia. Globus refers to a
sensation of tightness in the
neck associated with swallowing and is almost certainly due
to cricopharyngeal muscle
spasm. Speech fatigue is the
deterioration of voice after
prolonged use.
ated with a respiratory tract
infection is nearly always
viral. Appropriate management is adequate hydration,
management of associated
symptoms such as pyrexia
and limited voice use.
It is more likely than not
that maintenance of hydration does affect the clinical
course of these infections,
but there is no strong collaborative evidence.
General questions for the
author
Could you comment on the
electro-larynx and on speaking valves for post-laryngectomy patients. Are there particular issues that GPs need
to be aware of?
With regard to post-laryngectomy speech, electro-larynxes are less commonly
Is infective laryngitis associated with a respiratory tract
infection always viral? Does
any active treatment beyond
voice rest alter the course of
these infections?
Infective laryngitis associ-
How to Treat Quiz
INSTRUCTIONS
Hoarseness and voice dysfunction
— 26 May 2006
FAX BACK
Photocopy form
and fax to
(02) 9422 2844
1. Which THREE statements about the
anatomy and function of the structures
making up the larynx are correct?
❏ a) The mass, tension and length of the vocal
cords affect the quality of sound produced
by the larynx
❏ b) One of the main functions of the false
vocal cords is preventing aspiration during
swallowing
❏ c) Arthritis does not affect the larynx
❏ d) The main function of the laryngeal ventricle is to produce mucus
2. Which TWO definitions of voice
dysfunction are correct?
❏ a) Dysphonia refers to an abnormal sounding
voice
❏ b) Patients with aphonia have no voice and
cannot communicate using speech
❏ c) Odynophonia refers to painful phonation
❏ d) If a patient has vocal fatigue, their voice
symptoms improve with prolonged use
3. Harry, 45 and an auctioneer, complains of
hoarseness and vocal fatigue. If laryngeal
pathology is present, which THREE
conditions are most likely, given his
occupation?
❏ a) Reinke’s oedema of the larynx
❏ b) Vocal process granuloma
❏ c) Vocal nodules
❏ d) Vocal cord paralysis
4. What other factors in Harry’s history
would increase his risk of voice
dysfunction (choose TWO)?
❏ a) Diabetes
❏ b) Smoking
❏ c) Pancreatitis
❏ d) Gastro-oesophageal reflux
5. Denise, 37 and a non-smoker, works in a
call centre. She complains of painful
speech and a change in the sound of her
voice. She had an URTI recently and also
complains of increasing joint pain and
stiffness. Which ONE condition is least
likely to contribute to her odynophonia?
❏ a) Rheumatoid arthritis
❏ b) Cancer of the larynx
❏ c) Viral illness causing false vocal cord speech
❏ d) Vocal cord haemorrhage
used than previously.
The most common method
of communication after laryngectomy is the fashioning of
a tracheo-oesphageal fistula
(TOF) and use of a one-way
pressure valve device to facilitate air being diverted from
the trachea into the pharynx,
base of tongue and out
through the mouth.
The major issues for GPs
regarding TOFs are that the
prosthetic button put in the
fistula can become dislodged
and partly obstruct the tracheotome, or can be displaced down the trachea into
the tracho-bronchial tree.
While this does not constitute a medical emergency,
the patient should be
referred to the emergency
room sooner rather than
later for endoscopic removal.
A significant number of
these prostheses become
infected, often by fungus,
and occasionally oral antifungal therapy is required.
This is heralded by an alteration or diminution in the
quality or the volume of
speech with a tracheooesphageal device in place.
Regarding the electrolarynx, it is a simple batteryoperated vibrator with or
without an oral reed. These
devices rarely malfunction
and the main problem with
them tends to be the need
for battery change.
Voice changes frequently
occur with increasing age
and with globus. Are there
any red flag symptoms that
should suggest early referral?
The most common cause
of dysphonia with age is a
condition known as myasthenia vocalis, which is
senile atrophy of the intrinsic
laryngeal muscles.
A weak breathy voice and
an increase in voice fatigue
are characteristic of the condition. These symptoms are
not associated with pain, nor
are they associated with any
difficulty swallowing.
Any person — young or old
— with dysphonia should
have a direct examination of
the larynx to exclude any
potentially worrying lesions,
particularly if there is:
■ A history of smoking.
■ A
history of gastrooesophageal reflux.
■ A family history of upper
aerodigestive tract malignancy.
■ Associated dysphasia or
odynophagia.
■ Haemoptysis.
■ Associated pain and/or
mass in the neck.
■ Significant weight loss.
Complete this quiz to earn 2 CPD points and/or 1 PDP point by marking the correct answer(s)
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6. Which TWO tests are most important in
Denise’s investigation?
❏ a) Laryngeal EMGs
❏ b) High-resolution CT scan
❏ c) Indirect laryngoscopy using a mirror
❏ d) Direct laryngoscopy using a rigid (70° or
90°) telescope
7. Investigations show a vocal cord polyp.
What can you tell Denise about this
condition and its treatment (choose TWO)?
❏ a) The mainstay of treatment is speech
therapy
❏ b) She is likely to have gastro-oesophageal
reflux that is contributing to the formation
of polyps
❏ c) Treatment with intralesional cidofovir
(Vistide) reduces the chance of recurrence
❏ d) Her chance of voice restoration after
surgery is excellent
8. Savva, 60, presents with painless
hoarseness. Which THREE factors, if
present in his history, would increase his
risk of cancer of the larynx?
❏ a) Smoking
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❏ b) Vocal nodules
❏ c) Alcohol excess
❏ d) Previous irradiation to the neck
9. Investigation shows extensive laryngeal
papillomas. Savva smokes and drinks
heavily. What advice can you give him
about the papillomas and his prognosis
(choose TWO)?
❏ a) 1-5% of patients with papillomas
develop significant or severe atypia and/or
malignancy
❏ b) Smoking increases the risk of developing
papillomas
❏ c) Papillomas do not occur outside the
larynx
❏ d) Papillomas tend to be recurrent, and
multiple surgical interventions may be
needed
10. Which ONE condition cannot be
improved with speech therapy?
❏ a) Vocal nodules
❏ b) Laryngeal papillomas
❏ c) Unilateral vocal cord paralysis
❏ d) Puberphonia
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HOW TO TREAT Editor: Dr Lynn Buglar
Co-ordinator: Julian McAllan
Quiz: Dr Lynn Buglar
The mark required to obtain points is 80%. Please note that some questions have more than one correct answer. Your CPD activity will be updated on your RACGP records every January, April, July and October.
NEXT WEEK Checkups are one of the most common reasons for consults, so discussing and conducting screening is a common activity in general practice. Next week’s How to Treat presents tips on
informing patients about screening. The author is Dr Lyndal Trevena, senior lecturer, school of public health, University of Sydney; researcher, screening & test evaluation program and Sydney Health
Decision Group; and a GP, Cremorne, NSW.
36
| Australian Doctor | 26 May 2006
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