Hoarseness

Hoarseness—a rough or harsh sound to the voice—can result from infections, inflammatory lesions, or exudates of the larynx; laryngeal edema; and compression or disruption of the vocal cords or recurrent laryngeal nerve. This common sign can also result from a thoracic aortic aneurysm, vocal cord paralysis, and systemic disorders such as rheumatoid arthritis. It's characteristically worsened by excessive alcohol intake, smoking, inhaling noxious fumes, excessive talking, and shouting.

Hoarseness can be acute or chronic. For example, chronic hoarseness and laryngitis result when irritating polyps or nodules develop on the vocal cords. Gastroesophageal reflux into the larynx should also be considered as a possible cause of chronic hoarseness. Hoarseness may also result from progressive atrophy of the laryngeal muscles and mucosa due to aging, which leads to diminished control of the vocal cords.

History and physical examination

Obtain a patient history. First, consider his age and sex; laryngeal cancer is most common in men between ages 50 and 70. Be sure to ask about the onset of hoarseness. Has the patient been overusing his voice? Has he experienced shortness of breath, a sore throat, a dry mouth, a cough, or difficulty swallowing dry food? In addition, ask if he has been in or near a fire within the past 48 hours. Be aware that an inhalation injury can cause sudden airway obstruction.

Next, explore associated symptoms. Does the patient have a history of cancer, rheumatoid arthritis, or aortic aneurysm? Does he regularly drink alcohol or smoke?

Inspect the oral cavity and pharynx for redness or exudate, possibly indicating an upper respiratory infection. Palpate the neck for masses and the cervical lymph nodes and thyroid for enlargement. Palpate the trachea—is it midline? Ask the patient to stick out his tongue; if he can't, he may have paralysis from cranial nerve involvement. Examine the eyes for corneal ulcers and enlarged lacrimal ducts (signs of Sjögren's syndrome). Dilated jugular and chest veins may indicate compression by an aortic aneurysm.

Take the patient's vital signs, noting especially a fever and bradycardia. Inspect for asymmetrical chest expansion or signs of respiratory distress—nasal flaring, stridor, and intercostal retractions. Then auscultate for crackles, rhonchi, wheezing, and tubular sounds, and percuss for dullness.

Medical causes

Gastroesophageal reflux.With gastroesophageal reflux, retrograde flow of gastric juices into the esophagus may then spill into the hypopharynx. This, in turn, irritates the larynx, resulting in hoarseness as well as a sore throat, a cough, throat clearing, and a sensation of a lump in the throat. The arytenoids and the vocal cords may appear red and swollen.

Hypothyroidism.With hypothyroidism, hoarseness may be an early sign. Others include fatigue, cold intolerance, weight gain despite anorexia, and menorrhagia.

Laryngeal cancer.Hoarseness is an early sign of vocal cord cancer, but may not occur until later in cancer of other laryngeal areas. The patient usually has a long history of smoking. Other common findings include a mild, dry cough; minor throat discomfort; otalgia; and, sometimes, hemoptysis.

Laryngeal leukoplakia.Leukoplakia is a common cause of hoarseness, especially in smokers. Histologic examination from direct laryngoscopy usually reveals mild, moderate, or severe dysphagia.

Laryngitis.Persistent hoarseness may be the only sign of chronic laryngitis. With acute laryngitis, hoarseness or a complete loss of voice develops suddenly. Related findings include pain (especially during swallowing or speaking), a cough, a fever, profuse diaphoresis, a sore throat, and rhinorrhea.

Rheumatoid arthritis.Hoarseness may signal laryngeal involvement in reumatoid arthritis. Other findings include pain, dysphagia, a sensation of fullness or tension in the throat, dyspnea on exertion, and stridor.

Thoracic aortic aneurysm.Thoracic aortic aneurysm typically produces no symptoms, but may cause hoarseness. Its most common symptom is penetrating pain that's especially severe when the patient is supine. Other clinical features include a brassy cough; dyspnea; wheezing; a substernal aching in the shoulders, lower back, or abdomen; a tracheal tug; facial and neck edema; jugular vein distention; dysphagia; prominent chest veins; stridor; and, possibly, paresthesia or neuralgia.

Tracheal trauma.Torn tracheal mucosa may cause hoarseness, hemoptysis, dysphagia, neck pain, airway occlusion, and respiratory distress.

Vocal cord paralysis.Unilateral vocal cord paralysis causes hoarseness and vocal weakness. Paralysis may accompany signs of trauma, such as pain and swelling of the head and neck.

Vocal cord polyps or nodules.Raspy hoarseness, the chief complaint, accompanies a chronic cough and a crackling voice.

Other causes

Inhalation injury.Inhalation injury from a fire or explosion produces hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum. Subsequent signs and symptoms include crackles, rhonchi, and wheezing, which rapidly deteriorate to respiratory distress.

Treatments.Occasionally, surgical trauma to the recurrent laryngeal nerve results in temporary or permanent unilateral vocal cord paralysis, leading to hoarseness. Prolonged intubation may cause temporary hoarseness.

Nursing considerations

▪ Observe the patient for stridor, which may indicate bilateral vocal cord paralysis.

▪ When hoarseness lasts for longer than 2 weeks, indirect or fiber-optic laryngoscopy is indicated to observe the larynx at rest and during phonation.

Patient teaching

▪ Explain the importance of resting the voice.

▪ Teach the patient alternative ways to communicate.

▪ Stress the importance of avoiding alcohol, smoking, and second-hand smoke.

Book Source Details

• Book Title: Nursing: Interpreting Signs and Symptoms
• Author(s): Springhouse
• Year of Publication: 2007
• Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Larynx symptoms: Introduction (review 25 causes)
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More About This Book: Title: Nursing: Interpreting Signs and Symptoms Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 1-58255-668-7

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