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