Hoarseness a Guide to Voice Disorders

MedicineToday PEER REVIEWED ARTICLE POINTS: 2 CPD/1 PDP Hoarseness a guide to voice disorders

Hoarseness is usually associated with an upper respiratory tract infection or voice overuse

and will resolve spontaneously. In other situations, treatment often requires collaboration

between GP, ENT surgeon and speech pathologist.

RON BOVA Voice disorders are common and attributable to Inflammatory causes of voice MB BS, MS, FRACS a wide range of structural, medical and behav- dysfunction JOHN McGUINNESS ioural conditions. Dysphonia (hoarseness) refers Acute laryngitis FRCS, FDS RCS to altered voice due to a laryngeal disorder and Acute laryngitis causes hoarseness that can result may be described as raspy, gravelly or breathy. in complete voice loss. The most common cause Dr Bova is an ENT, Head and Intermittent dysphonia is normally always secon - is viral upper respiratory tract infection; other Neck Surgeon and Dr McGuinness dary to a benign disorder, but constant or pro- causes include exposure to tobacco smoke and a is ENT Fellow, St Vincent’s gressive dysphonia should always alert the GP to short period of vocal overuse such as shouting or Hospital, Sydney, NSW. the possibility of malignancy. As a general rule, a singing. The vocal cords become oedematous patient with persistent dysphonia lasting more with engorgement of submucosal blood vessels than three to four weeks warrants referral for (Figure 3). complete otolaryngology assessment. This is par- Treatment is supportive and aims to maximise ticularly pertinent for patients with persisting vocal hygiene (Table), which includes adequate hoarseness who are at high risk for laryngeal can- hydration, a period of voice rest and minimised cer through smoking or excessive alcohol intake, exposure to irritants. Antibiotics are not indicated and for patients with a family history or personal if a viral infection is suspected, and corticosteroids history of head and neck cancer. are rarely indicated for this common condition. The mechanism of voice production is Effortful speaking or singing during an acute attack described in the box on page 39. of laryngitis may lead to vocal cord haemorrhage

• Intermittent dysphonia is usually always secondary to a benign disorder. Constant or progressive dysphonia should always alert the GP to the possibility of malignancy. • Radiological investigations such as CT scans miss the majority of vocal cord lesions. Flexible endoscopic nasolaryngeal examination is the most sensitive investigatory tool. • Treatment for chronic laryngitis due to laryngopharyngeal reflux is an eight- to 12-week empirical course of a proton pump inhibitor as well as dietary and lifestyle modification. IN SUMMARY • Muscle tension dysphonia is a common cause of hoarseness and results from excessive and unnecessary tension of laryngeal muscles during phonation. Speech therapy is the cornerstone of management. • A patient presenting with persisting hoarseness who is at high risk of laryngeal malignancy through smoking, excessive alcohol intake or a history of head and neck cancer should be referred for early specialist assessment.

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Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2007. Copyright for illustrations as stated. How is voice produced?

Voice production is a complex process requiring co-ordination between the lungs, larynx, pharynx and oral cavity. The lungs act like a power source, blowing expired air up through the vocal cords in the larynx (Figures 1a and b). The vocal cords vibrate hundreds of times per second, producing sound, the resonance of which is modified by muscular activity in the pharynx and oral cavity. Normal voice requires functioning vocal cords that are lined by smooth, well hydrated epithelium (Figure 2). Even the slightest alteration in vocal cord structure can result in hoarseness.

Tongue Epiglottis Epiglottis

True vocal Thyroid False vocal cord cartilage cords

Trachea False vocal Laryngeal cord © copyright ventricle True vocal cords Cricoid cartilage Oesophagus © copyright Thyroid Trachea FIGURES 1A AND 1B © CHRIS WIKOFF, 2007

Figure 1a (top left). Laryngeal structures as seen from above during examination.

Figure 1b (top right). Coronal section through the larynx. Note the true vocal cords are separated by a space (laryngeal ventricle) from folds of supraglottic tissue (false vocal cords).

Figure 2 (left). Typical view obtained of a normal larynx using a flexible nasendoscope. The vocal cords are pale, smooth and easily visualised. or formation of a haemorrhagic polyp. This is par- • a feeling of throat irritation or dryness ticularly relevant for a singer or other professional • mild throat discomfort with speaking and voice user who attempts to resume prelaryngitis swallowing vocal demands too early. • chronic cough, often with severe bouts of laryngospasm where there is a choking Chronic laryngitis sensation; patients may describe it as an Chronic laryngitis (chronic inflammation of the inability to get their breath laryngeal mucosa) often impairs mucociliary • sensation of postnasal drip with chronic transport, such that mucus that would normally throat clearing and a feeling of retained be transported efficiently into the pharynx and mucus in the back of the throat swallowed may collect in the back of the larynx • sensation of a lump in the throat. and pharynx. Symptoms are varied and include: Chronic laryngitis can be caused by multiple • hoarseness, which often comes and goes irritants, including: • vocal fatigue, especially towards the end of • tobacco smoke the day • environmental or occupational pollutants

MedicineToday ❙ February 2007, Volume 8, Number 2 39

Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2007. Copyright for illustrations as stated. Hoarseness continued

Benign lesions of the vocal Table. Measures to improve cords vocal hygiene Vocal cord nodules Vocal cord nodules are small, fibrous, A period of voice rest, especially for bilateral swellings that develop on the acute laryngitis anterior vocal cords as a result of excessive voice use (Figure 5). They are analo- Hydration with noncaffeinated drinks, gous to calluses and frequently found in especially during periods of heavy singers and children who shout exces- voice use sively. Patients complain of fluctuating Limiting of vocal loudness (e.g. use of hoarseness, often associated with inter- a microphone for teaching or public mittent sudden changes in vocal pitch. speaking) Voice therapy usually causes the nodules Avoidance of habitual and frequent Figure 3. Acute laryngitis. to regress. Persistent symptomatic nod- throat clearing ules may be treated with microsurgical laryngopharyngeal reflux (this is excision. Avoidance of irritants, including passive • described in the box below). smoking • fungal laryngeal infection, which Vocal cord polyps Humidified environment (e.g. use of mainly occurs in immunosuppressed Vocal cord polyps are unilateral pedun- menthol or eucalyptus inhalations) patients but may also be seen in culated lesions that commonly occur in Avoidance of medications that have patients taking inhaled men with a history of voice abuse and an anticholinergic drying effect corticosteroids heavy smoking (Figure 6). The aetiology systemic autoimmune causes such as is unknown but the polyps are often very Not smoking • Wegener’s granulomatosis, amyloidosis, vascular, which makes repeated trauma Speech therapy or vocal training, systemic lupus erythematosus and a probable causative factor. Microsurgical especially for professional voice users relapsing polychondritis, which are excision is nearly always required for both extremely rare. diagnostic and therapeutic purposes.

Laryngopharyngeal reflux and chronic laryngitis

Laryngopharyngeal reflux, which occurs when acid refluxes through an incompetent upper oesophageal sphincter and irritates the larynx, is a common cause of chronic laryngitis. Even small amounts of acid reflux can cause minor laryngeal oedema resulting in hoarseness in addition to the other symptoms of chronic laryngitis, especially chronic throat mucus clearing and dry cough. Despite having concurrent gastro- oesophageal reflux disease (GORD) due to lower oesophageal sphincter dysfunction, patients may not complain of heartburn or chest pain because the oesophageal mucosa is much more resistant to small quantities of acid reflux. A classic feature of severe laryngopharyngeal reflux is granulation tissue overlying the posterior vocal cord but this is relatively uncommon; a reflux granuloma is shown in Figure 4. Treatment for chronic laryngitis due to laryngopharyngeal reflux is an eight- to 12-week empirical course of a proton pump inhibitor as well as dietary and lifestyle modification, including elevation of the head of the bed. Speech therapy is useful, especially for patients with reflux granulomas, and aims to modify vocal cord closure patterns to minimise contact trauma between the posterior cords. Microsurgical removal is sometimes required for granulomas that are large or refractory to conservative measures. A relatively new treatment for stubborn granulomas involves paralysing the affected vocal cord by injecting botulinum toxin type A (Botox, Dysport). This minimises phonatory trauma and allows the Figure 4. Reflux induced granuloma of the left granuloma to resolve, but severe breathy dysphonia lasting months is unavoidable. posterior vocal cord. This lesion and the patient’s Patients with severe or persistent reflux symptoms refractory to medical management symptoms resolved with antireflux therapy. may require comprehensive evaluation by a gastroenterologist.

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of transmission during vaginal delivery in the presence of a history of genital warts in pregnancy has been estimated to be approximately 0.5%.1 Laryngeal papil- lomas may present in adulthood but are rare after the age of 30 years. The most common presenting symptom in older children and adults is hoarseness, but stridor and respiratory compromise may be seen in severe widespread disease. The mainstay of treatment has been laser microsurgical removal, but disease Figure 5. Vocal cord nodules in an amateur Figure 6. A vocal cord polyp in a young healthy recurrence is the norm and many patients singer. man just prior to microsurgical excision. require multiple operations. Intralesional injection of antiviral agents such as cido- fovir (Vistide) is a relatively new treatment for severe cases. Rarely, recurrent papillomatosis is complicated by malignant transformation (approximately 0.5%) or extension in the tracheobron chial tree – a serious and often incurable condition.

Malignant lesions of the vocal cords Squamous cell carcinoma Squamous cell carcinoma (SCC) of the larynx is the most common malignancy Figure 7. Severe diffuse laryngeal papillom- Figure 8. Exophytic tumour affecting the of the upper aerodigestive system. It most atosis obscuring and affecting the entire right vocal cord. This lesion was successfully commonly affects men aged in their 50s or supraglottic larynx. This patient presented treated with endoscopic laser microsurgical 60s, but the incidence in women is increas- with severe hoarseness. excision. ing. The major risk factors are smoking and alcohol use, but 5% of cancers occur Laryngeal cysts are often assumed to be men when using in patients who do not smoke or drink Laryngeal cysts can occur throughout the the telephone. Examination reveals diffuse excessively. larynx and are usually due to mucus reten- boggy swelling of both vocal cords. Vocal cord cancer presents with pro- tion in the tiny mucus secreting glands in Smoking cessation and speech therapy gressive hoarseness; stridor and dysphagia the submucosa of the entire upper aero - are usually successful, but intractable cases occur in advanced disease. Early stage digestive tract. Surgical excision is usually require micro surgical excision of the tumours appear as exophytic or ulcera- required when they are located on the redundant mucosa with aspiration of the tive lesions affecting the free edge of the vocal cords and result in hoarseness. oedematous fluid. vocal cord; they rarely metastasise and hence have an excellent prognosis (Figure Reinke’s oedema Respiratory papillomatosis 8). Treatment options include radiother- Reinke’s oedema (oedema in the superfi- Respiratory papillomatosis is caused by apy and surgical resection. Endoscopic cial layers of the vocal cord) is a common human papilloma virus (HPV) and microsurgical laser resection is gaining condition caused by long term expo- results in multiple warty lesions through- acceptance as the surgical treatment of sure to irritants such as cigarette smoke. out the larynx (Figure 7). Infection most choice for early stage vocal cord cancer. This interesting condition is more com- commonly occurs at the time of birth, Cancers affecting the supraglottis and mon in women than men and presents and affected individuals usually present subglottic larynx can also produce dyspho- with chronic raspy dysphonia – pitch is with hoarseness, stridor or ‘noisy breath- nia as a result of encroachment into the reduced to the point that affected women ing’ between 2 and 4 years of age. The risk laryngeal airway, by direct extension to the

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vocal cords or infiltration into the intrinsic The most common form is adductor neck along the tracheo-oesophageal muscles of the larynx. Initial symptoms are spasmodic dysphonia, in which there is groove and is intimately associated with often subtle, so patients frequently present increased closure of the vocal cords the back of the thyroid gland). Less com- with advanced disease. Common present- resulting in speech that is punctuated by monly, the vagus nerve may be paralysed ing symptoms include stridor, hoarseness, frequent strangulated and constricted higher in the neck or skull base, resulting haemoptysis and dysphagia. Cervical neck stops. Intelligibility of the patient may be in palatal asymmetry in addition to vocal nodal metastasis is very common with impaired markedly. Abductor spasmodic cord paraly sis. Patients present with a supraglottic cancers, and hence patients dysphonia, in which sudden increased breathy voice, reduced vocal pitch and may present with a neck lump. Treatment opening of the vocal cords occurs and significant vocal fatigue. The paralysed involves surgery, radiotherapy or com- results in a breathy voice, is far less com- cord often lies in an open position, result- bined modality therapy. mon. Other neurological symptoms are ing in a large glottic gap that can lead to sometimes present in patients with spas- significant aspiration. Neuromuscular disorders modic dysphonia, including tremors and The common causes of vocal cord Muscle tension dysphonia facial dystonia. paralysis are: Muscle tension dysphonia is a relatively Treatment of spasmodic dysphonia has • iatrogenic (thyroid or thoracic surgery) common yet poorly understood cause of been revolutionised by injection of botu- • idiopathic – although unproven, viral hoarseness. It is thought to result from linum toxin type A to temporarily paralyse neuritis is suspected to be a relatively excessive and unnecessary tension of the hyperfunctioning muscle group. This common aetiological factor because laryngeal muscles during phonation. On is done as an outpatient procedure using recurrent laryngeal nerve palsy often examination, patients typically constrict electromyographic guidance. Excellent occurs after an upper respiratory tract their supraglottic laryngeal muscles to the results lasting three to four months can be infection point where it can be difficult to visualise expected. • cancer (thyroid, laryngopharynx, their vocal cords during vocalisation. It lung, oesophageal) may develop as a compensatory vocal Presbyphonia • thoracic aortic aneurysm technique in patients with glottic insuffi- Presbyphonia is hoarseness resulting from • cerebrovascular accident, head trauma ciency such as age related vocal atrophy; age related laryngeal changes. It is very (central vagal paralysis). alternatively, it may occur as a primary common in elderly patients and charac- When the cause is unknown, patients imbalance of laryngeal muscle use. It is terised by an intermittent hoarse, breathy require a comprehensive radiological thought to be compounded by stress or or wavery voice that often fatigues easily. assessment of the head, neck and chest to anxiety. Laryngeal muscle atrophy results in the exclude malignant infiltration of the vagus The major complaint is usually fluc- vocal cords having a bowed appearance or its recurrent laryngeal nerve branch. tuating hoarseness and vocal fatigue, and, in combination with age related loss Subsequent management depends on the sometimes with a feeling of tightness or of vocal cord tone and elasticity, leads to cause of the nerve palsy. The treatment discomfort in the throat. It is important varying degrees of hoarseness. Elderly options to rehabilitate the paralysed vocal to ask about reflux laryngitis because this patients may also be taking medications cord include: may be an exacerbating factor in a signif- with anticholinergic side effects, which • Nonsurgical management. If there is no icant number of patients. Speech therapy contribute to vocal dryness. aspiration and the patient is happy to reduce excessive laryngeal tension Speech therapy helps to increase laryn- with the voice, the paralysed cord can during voice use is the cornerstone of geal muscle tone and improve voice qual- be left alone with the expectation that management. ity. Injection of fat or synthetic materials partial compensation will occur after into the vocal cords is possible in severe approximately six months. In cases Spasmodic dysphonia cases, but it is rarely indicated. where the nerve is bruised or Until relatively recently, spasmodic dys- temporary neuritis is suspected after phonia was considered a psychiatric diag- Vocal cord paralysis an upper respiratory tract infection, nosis. It is now recognised as a regional Vocal cord paralysis most commonly complete recovery can be expected. dystonic reaction of the larynx charac- occurs as a consequence of paralysis of the • Injection thyroplasty. This involves terised by involuntary spasms of the vocal recurrent laryngeal nerve (a distal branch injection of fat or artificial substances cords. Like many dystonic reactions, it of the vagus nerve that innervates the (Gelfoam, Teflon) into the paralysed is absent at rest (therefore breathing is intrinsic laryngeal muscles and ascends vocal cord to medialise it in an normal) but precipitated by speaking. from the mediastinum into the root of the attempt to reduce the glottic gap. The

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Permission granted for use by Entthyroid.com.au for educational purposes. © Medicine Today 2007. Copyright for illustrations as stated. procedure requires a short general patient who smokes or has a high alcohol anaesthetic and has minimal intake and when it is associated with other Who wants your opinion? morbidity. throat symptoms such as dysphagia, • Laryngeal framework surgery. This stridor or haemoptysis. Radiological WE DO. Did you find a particular involves insertion of a Silastic or investigations such as CT scans detect article in this issue helpful in your Gortex implant into the vocal cord via only large lesions and miss the majority of practice? Do you have something to a small window through the thyroid vocal cord lesions. Flexible endoscopic say about an article we have cartilage resulting in medialisation of naso laryngeal examination is the most published or some of the opinions the paralysed cord. The procedure can sensitive investigatory tool and can be per- expressed? Write and tell us, and we be performed under local anaesthetic formed easily in the office setting. Treat- will consider your letter for and requires an overnight stay in ment varies according to the cause but publication. We are more likely to hospital. often requires collaboration between GP, print short letters (no longer than 250 ENT surgeon and speech pathologist. MT words), so please be succinct. Final comments Write to: Medicine Today, Everyone experiences hoarseness at some Reference PO Box 1473, Neutral Bay, NSW 2089 time in their lives. Fortunately it is usually associated with an upper respiratory tract 1. Silverberg MJ, Thorsen P, Lindeberg H, Grant infection or voice overuse and will resolve LA, Shah KV. Condyloma in pregnancy is strongly spontaneously. Persistent unexplained predictive of juvenile-onset recurrent respiratory hoarseness should alert the GP to the pos- papillomatosis. Obstet Gynecol 2003; 101: 645-652. sibility of a benign or malignant laryngeal lesion, especially when it occurs in a DECLARATION OF INTEREST: None.