Hoarseness

Hoarseness: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

Acute

❑ Acute laryngitis

❑ Vocal overuse

❑ Vocal cord trauma

❑ Angioedema

❑ Epiglottitis

Chronic

❑ Smoking

❑ Recurrent vocal abuse

❑ Gastroesophageal reflux

❑ Vocal cord polyp

❑ Vocal cord nodule

❑ Laryngeal nerve injury

❑ Hypothyroidism

❑ Laryngeal carcinoma

❑ Conversion reaction

Diagnostic Approach

Persistent or progressive hoarseness is the most suspicious finding.

If the voice is coarse, rough, gravelly, or husky, the medial surface of the cord is irregular, and a polyp or an early malignancy should be suspected. A breathy voice occurs when the vocal cords do not approximate completely, due to unilateral vocal cord paralysis. A wet, gurgling, full voice suggests supraglottic salivary pooling, as with a peritonsillar abscess or supraglottic tumor. Loss of vocal range with weakness and cracking of the voice may occur with excessive vocal strain. An elderly patient may develop a high, shaky voice resulting from decreased respiratory force.

Clinical Findings

Acute laryngitis  Other symptoms of upper respiratory infection, such as sore throat or cough, will usually be present. Most often due to viral upper res-piratory infection, B. catarrhalis and H. influenza are also frequent pathogens.

Vocal overuse  Common causes include inhaling smoke or dust, irritant fumes, or shouting.

Vocal cord trauma  Onset follows intubation or a blow to the neck. Intubation injury may progress to ulceration with painful phonation. Trauma may progress to stridor with subcutaneous emphysema present if the larynx is fractured.

Angioedema  Transient edema without erythema occurs in the tongue, lips, periorbital region, or gut, as well as the larynx. There is a sensation of swelling in the throat.

Epiglottitis  A signal presentation is sore throat out of proportion to the degree of pharyngeal erythema, which progresses rapidly to stridor.

Smoking  A raspy voice is caused by vocal cord thickening due to edema or inflammation in a chronic heavy smoker.

Gastroesophageal reflux  Heartburn and an acidic taste in the throat are clear indicators, but more subtle symptoms may include a nocturnal cough, frequent throat clearing, a globus sensation or sore throat with an identifiable infectious or allergic source.

Vocal cord polyp  A polyp causes a low and gravelly voice. They arise in patients with hypothyroidism, chronic sinusitis, GERD, and in smokers.

Vocal cord nodule  Nodules occur when edematous cords have been used excessively.

Laryngeal nerve injury  The voice is weak and breathy, since a glottic gap remains during phonation with one vocal cord paralyzed. Causes include viral neuritis, tumor in the mediastinum (lung cancer) or neck (usually thyroid), injury during neck surgery, aortic aneurysm, and trauma or radiation to the neck, chest, or larynx (intubation).

Hypothyroidism  The voice is deep and husky. Other signs such as goiter, periorbital edema, fatigue, and delayed relaxation of the ankle jerk reflex are found.

Laryngeal carcinoma  Dysphagia and pain occur before hoarseness unless the tumor involves the vocal cords. Other presentations include pain with swallowing, fetid breath, or an unexplained lymph node in the neck. Tobacco and alcohol use are predisposing factors.

Conversion reaction  Intermittent hoarseness or aphonia can be a manifestation of psychological issues. Paradoxical vocal cord motion (adduction with inspiration) and intermittent whispered phonation, or complete aphonia interspaced with normal phonation, are clues.

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

More About Laryngitis

• Back to disease: Laryngitis: Introduction
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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