Download Clinical Problem of a Hoarse Voice - Ipswich-Year2-Med-PBL-Gp-2

Week 6: Clinical Problem of a
Hoarse Voice
Hoarseness results from imperfect phonation due to
impairment of normal vocal cord mobility or vibration.
It is an important symptom as it may signal a serious
cause such as malignancy or a disease with potential
for airway obstruction
Presentation
• It is a common presentation in General Practice, with causes
ranging from the very common, trivial, self-limiting conditions, to a
life-threatening disorders
• It may be of sudden presentation lasting only a few days or develop
gradually and persist for weeks or months.
• The cut-off point between acute and chronic hoarseness is three
weeks duration
So , you call the next patient into your room and as soon as she starts
speaking to introduce herself, you notice she has a hoarse voice.
Without any further info and before taking a history. What is the most
probable diagnoses?????
PROBABILITY DIAGNOSIS
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Viral URTI: acute laryngitis
Non-specific irritative laryngitis
Vocal abuse (shouting, screaming etc.)
Acute tonsillitis
Nodules and polyps of cords
Phonaesthenia in elderly - ‘tired’ voice
In acute hoarseness the diagnosis is usually obvious from the history alone.
You ask Mrs X what you can do for her today, and she replies in a
hoarse voice “I just came in to get a script for the OCP.” You are
concerned by her voice, and are determined to find out more
about it. WHAT DO YOU WANT TO ASK IN THE HISTORY TO HELP
DETERMINE A DIAGNOSES??
History
Important to ask:
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Nature- Many voice disturbances are typically described by the catch-all term "hoarseness”
– Hoarseness is a coarse, scratchy sound
– Breathlessness is when the voice feels or sounds weak
– Vocal fatigue : loss of control of vocal quality with extended periods of voice use.
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Duration of voice complaints
Onset (ie, sudden or gradually progressive) and pattern
Potential triggering/Contributing factors (vocal abuse, concurrent upper respiratory tract infection, change
in medications, exposure to known allergens or toxins)
Aggrevating and alleviating factors, such as improvement with voice rest, or fatigue with use
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Other respiratory symptoms to indicate URTI- cough, sore throat
Other head and neck symptoms (eg, dysphagia, odynophagia, otalgia)
History of smoking and alcohol use
History of reflux or sinonasal disease
History of past surgery involving the neck (especially thyroid, carotid, and cervical spine), base of skull, or
chest
History of trauma or endotracheal intubation
Occupation, hobbies, and habits impacting voice use
Medical comorbidities which may affect voice (eg, rheumatoid arthritis or tremor)
The patient is vague and dismissive throughout the history, insisting she only
came in to get the script and must get back to work. She eventually agrees
to an examination. What are you going to do in the examination?
Physical Examination
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The physical examination should begin by noting the quality of the patient's voice for
yourself
– is it actually Hoarseness, breathless or vocal fatigue?
– Does it sound wet, gurgling, suggesting salivary pooling? Caused by peritonsillar abscess
or supraglottic tumor mass
– Does the voice have a whispered quality, or tremor?
– Inability to produce any sound is aphonia.
Although not absolutely definitive, various voice qualities may correlate with underlying
aetiologies for the voice disorder (too much details)
assess the ear, upper airway mucosa, tongue mobility, cranial nerve function, and
respiratory pattern and rate.
Palpate the neck for enlargement of the thyroid gland or cervical nodes.
Systemic diseases should be considered when suggested by symptoms or examination, and
include hypothyroidism, and neurologic conditions such as tremor, Parkinson disease,
amyotrophic lateral sclerosis, or multiple sclerosis.
Having finished the examination, you quickly think to yourself- so now what
are some things I don’t want to have missed??
SERIOUS DISORDERS NOT TO BE
MISSED
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Carcinoma: larynx, lung including laryngeal nerve palsy
Imminent airway obstruction (e.g. acute epiglottitis, croup)
Other rare severe infections (e.g. tuberculosis, diphtheria)
Foreign body
Motor neurone disease
Myaesthenia gravis
RED flag for underlying malignancy, (when not associated with an UTRI)
• Odynophagia
• shortness of breath
• weight loss
• Stridor
• history of smoking and alcohol use
• Cough
(increases risk for laryngeal SCC)
• Hemoptysis
• throat pain
NOTE: Referred ear pain via cranial
nerves IX and X may represent one of the
• Dysphagia
first symptoms of laryngopharyngeal
cancer.
Case Cont:
• Turns out the patients voice has been ‘husky’
for a few months now, she thinks it came on
gradually, it is not painful and she has not
noticed any other symptoms
• On examination, you found no abnormalities.
• Does this hoarseness warrant further
investigation?
When to Investigate further?
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Acute cases that are unexplained, fail to respond by 3 - 4 weeks or recur.
All chronic cases > 3weeks.
Any case with stridor or non-tender cervical lymphadenopathy.
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Chronic hoarseness must be investigated to exlude:
– Carcinoma of the larynx
– Non-malignant vocal cord lesions include polyps, vocal nodules, contact ulcers,
granulomas, other benign tumours and leucoplakia
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The most common diagnosis is still:
– children – overuse ‘screamer's nodules’
– adults - non-specific irritant laryngitis
What particular investigations are you going to do?
INVESTIGATIONS
The following need to be considered:
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Thyroid function tests.
Chest X-ray if it is possibly due to lung carcinoma with recurrent laryngeal nerve
palsy.
The choice of imaging to detect suspected neoplasia or laryngeal trauma is special
CT scan, although is not a substitute for direct laryngeal visualisation.
REFER to ENT
• Chronic Hoarseness >3week, in the absence of symptoms of an acute respiratory
infection
• Patients with associated symptoms concerning for malignancy
• ENT consult should include:
– complete head and neck examination of the laryngopharynx, with visualization
of the true and false vocal cords and epiglottis, via laryngoscopy
TREATMENT
Acute hoarseness
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Treat according to cause.
Advise vocal rest or minimal usage at normal conversation.
Avoid irritants (e.g. dust, tobacco, alcohol).
Consider inhalations and cough suppressants in cases of acute URTI
and coughing paroxysms.
Chronic hoarseness
• Establish the diagnosis and treat accordingly
• Consider referral to ENT specialist.
PITFALLS
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Toxic fumes
Vocal abuse
Benign tumours of vocal cords (e.g. polyps, ‘singers’
nodules, papillomas)
Gastro-oesophageal reflux → pharyngolaryngitis
Goitre
Dystonia
Physical trauma (e.g. post-intubation), haematoma
Fungal infection (e.g. Candida with steroid inhalation,
immunocompromised)
Allergy (e.g. angioedema)
Leucoplakia
MASQUERADES
Consider:
- drugs: antipsychotics, anabolic steroids
- smoking →non-specific laryngitis
-hypothyroidism, acromegaly
Is the patient trying to tell me something?
Rarely, hoarseness can be a functional or deliberate symptom
referred to as ‘hysterical aphonia’. In this condition, patients
purposely hold the cords apart while speaking.
-functional aphonia
-functional stridor
References
• Murtaghs
• Up-to-date