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Hoarseness : Hoarseness Is It Serious?

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Hoarseness : Hoarseness Is It Serious? HOARSENESS : HOARSENESS IS IT SERIOUS? IS IT SERIOUS ? Hoarseness is a symptom of dysfunction of the vocal folds! It is a very common symptom UNIVERSITY OF KENTUCKY It affects most of us somewhere Chandler Medical Center throughout our lives Sanford M. Archer, M.D. Professor of Surgery & Pediatrics OtolaryngologyOtolaryngology––HeadHead & Neck Surgery DISORDERS OF VOICE LISTENING TO YOUR PATIENT PRODUCTION Is there a weak or damped voice? Pulmonary disorders - Lungs Is the voice barely perceptible? Hoarseness - Laryngeal Are the lungs or pulmonary tree restricted in Art icu lat ion disord ers - OlOral movement? Does the patient have difficulty in articulating Resonance disorders - words? Oropharyngeal, Nasal Is the voice hyper/hypohyper/hypo--nasal?nasal? Are the sounds muffled? Are the words dysarthric? ETIOLOGY OF HOARSENESS The most common cause of hoarseness in my practice is NOT maliggy,ynancy, yet ... All adults who use tobacco and have persistent hoarseness of greater than 3 weeks duration have a malignancy until proven otherwise! Page 1 ETIOLOGY OF HOARSENESS Congenital causes Inflammatory causes Tumors Trauma Neurologic disorders Psychogenic disorders Other causes CONGENITAL CAUSES Congenital glottic webs Cysts Laryngomalacia Cri du chat TUMORS Benign Laryngeal papilloma Hemangioma Malignant Squamous cell carcinoma Thyroid carcinoma Others Page 2 Page 3 TRAUMA Vocal abuse External trauma Cho king Neck trauma (MVA, fisticuffs) Page 4 NEUROLOGIC DISORDERS Spasmodic dysphonia Benign essential tremor Vocal cord ppyaralysis Myasthenia gravis Muscular dystrophy CVA ALS Functional dysphonia/aphonia PSYCHOGENIC VOCAL CORD PARALYSIS VOICE DISORDERS Emotional Stress - (musculoskeletal tension ) Iatrogenic (neck, chest surgery) Voice Disorders w/o 2° Laryngeal Pathology Thyroid malignancy Voice Disorders w/ 2° Laryngeal Pathology Vocal nodule Thoracic lesions Contact ulcer Skull base tumors Psychoneurosis Conversion Reaction CV anomalies Mutism Laryngeal intubation/trauma Aphonia Dysphonia CNS anomalies Psychosexual Conflict Idiopathic Iatrogenic OTHER DISORDERS INFLAMMATORY CAUSES Smoking Hypothyroidism Foreign bodies Hormonal disorders Allergic angioneurotic edema Rhidhiiheumatoid arthritis Acute laryngitis (URI) Chronic laryngitis SLE Laryngopharyngeal reflux Polychondritis Contact ulcers, vocal nodules & polyps Dysphonia plicae ventricularis Amyloidosis Granulomatous diseases of the larynx Page 5 CHRONIC LARYNGITIS Smoking Vocal abuse Poor vocalhil technique Laryngopharyngeal reflux WORKUP OF PERSISTENT HOARSENESS LISTEN to the voice Nasal exam (signs of allergy, sinus) Oral(l exam (PND, pa late & tongue mobility) LOOK at the vocal folds Neck exam (muscle tension, masses, tracheal deviation, thyroid enlargement) ACUTE ONSET OF ONSET OF HOARSENESS HOARSENESS Acute URI Vocal abuse Chronic, intermittent IflInflamma tion Chronic, progressive Hemorrhage Page 6 CHRONIC, PROGRESSIVE SYMPTOMS Tumors Vocal nodules Vocal ppypolyps Spasmodic dysphonia Functional dysphonia Aging changes CHRONIC, RECURRING SYMPTOMS Neurologic disorders Tumors Laryngophlflharyngeal reflux Postnasal discharge (PND) REFLUX : REFLUX: Pathophysiology Pathophysiology – Critical Factors Normal Defensive Normal Aggressive LES tone Factors Factors Frequency and duration of transient LES tone Gastrin LES relaxations Anatomic factors Pepsin Esophageal clearing Bile acids Acidity of the gastric contents Mucosal resistance Pancreatic enzymes Amount of time acid is in the Gastric emptying Gastric acid esophagus/pharynx/larynx Volume of gastric material Page 7 RELAXATION OF THE LES MUCOSAL INJURY & pH Drugs Foods pH < 4.0 correlates highly with Calcium channel Caffeine severity of mucosal injury blockers Fatty foods pH > 4. 0 correlates with leveling off Anticholinergic Chocolate agents of symptoms Peppermint Narcotics Alcohol pH < 4.0 results in reduced ability for Estrogens mucosa to heal +/or repair itself Nitrates Others Smoking GASTROESOPHAGEAL REFLUX: GASTROESOPHAGEAL REFLUX : Symptoms Epidemiology Nighttime, supine symptoms are most common: Heartburn present in 11% of people daily Dyspepsia or indigestion - Most common symptom Symptoms present in 1/3 of population Heartburn everyyy 3 days Dysphagia 2/3 of people experience dyspepsia at some point in their lives Chest pain Prevalence of GERD-GERD-relatedrelated symptoms increases with age LARYNGOPHARYNGAL REFLUX: LARYNGOPHARYNGAL REFLUX : Symptoms Epidemiology Daytime, upright symptoms are most common: Incidence of 4 - 10% of patients Hoarseness - most common symptom Globus pharyngeus presenting to ORL practice Frequent throat clearing Incidence of 1% of pppatients presenting to Chronic cough primary care practice Dysphagia Frequent sore throats 2/3 of patients with laryngeal & voice Paroxysmal laryngospasm disorders have GERD as primary cause or Prolonged vocal warmwarm--upup significant cofactor Asthma 80% do not have dyspepsia ! Koufman, 1996 Page 8 LARYNGOPHARYNGAL REFLUX: Laryngeal Examination Mild to moderate vocal fold edema (reflux laryngitis) Laryngeal granulomas & contact ulcerations Vocal nodules Paroxysmal laryngospasm Hyperplasia of the interarytenoid space Erythema of the posterior larynx or pharynx Larygeal/subglottic stenosis LARYNGOPHARYNGAL REFLUX: Evaluation Videostroboscopy Barium esophagram Motility & peristalsis problems Tumors, diverticula , strictures Esophagitis Spontaneous reflux Hiatal hernia LES integrity 24 hr ambulatory pH monitoring of esophagus & pharynx Acid suppressive therapy TREATMENT OF CHRONIC LARYNGITIS & LPR LARYNGOPHARYNGEAL REFLUX 182/233 consecutive patients with chronic Lifestyle modifications laryngitis LPR Dietary restrictions Symptoms of persistent sore throat, PND Avoid late night snacks or meals w/ throat clearing, hoarseness, cough w/o pulmonary disease Tobacco use cessation Reduction of alcohol intake 96% of patients experienced relief of symptoms w/ treatment preventing reflux Elevation of head of bed of gastric acid Medical therapy Hanson et al, Ann Otol Laryngol 104; 1995 Page 9 OUTCOMES OF TREATMENT FOR LPR Outstanding results by those who recognize LPR and treat it effectively Need to educate other physicians and patients about LPR Must develop better methods to document causality of GER-GER-relatedrelated laryngeal disease GOOD VOCAL CARE SPEECH THERAPY Humidification Useful for : Warm mist vaporization Functional disorders Mucolytic agents Inflammatory disorders TtTreatmen tfllit of allergies Neurologic disorders Treatment of reflux laryngitis PrePre--surgicalsurgical evaluation Cessation of smoking and tobacco use Avoidance of vocal abuse such as yelling, screaming, and whispering Often, a course of vocal rest may be worthwhile REFERRAL TO OTOLARYNGOLOGIST Abnormal finding on physical exam Normal laryngeal exam with persistent hoarseness Inability to visualize the vocal folds or larynx Page 10 WHAT CAN WE DO? Mirror exam A smoker with persistent Flexible fiberoptic exam hoarseness of greater than Videostro boscopy* 3 weeks duration has a Recommend a Neurology referral malignancy until proven Early, quick feedback on YOUR otherwise. patient HOARSENESS IS IT SERIOUS? IT CERTAINLY CAN BE! Page 11.
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