Bangladesh J Otorhinolaryngol 2017; 23(1): 47-51 Original Article Hoarseness of Voice : An Etiological Study Salah Uddin Ahmmed1, AKM Asaduzzaman2, Mohammed Ahmed Ahsan3, Md Zakir Hossain2, Mohammad Ali Azad2, Mohammed Iftekharul Alam2

Abstract: Hoarseness of voice is one of the commonest symptom in otolaryngological practice and it indicates diseases ranging from totally benign condition to the most malignant condition. The aim of this study was to analyze clinical profile, to find out common etiological factors and association of common predisposing factors leading to hoarseness of voice. The study was carried out in the department of ENT, CMB, BAF Dhaka, from February 2014 to July 2016. A total of 130 patients having hoarseness of voice were selected coming to the OPD. All the patients then underwent a detailed history, ENT examinations and investigations to reach a diagnosis. Out of total 130 patients 76(58.47 %) were males and 54 (41.53) were females. Male predominance was observed with male female ratio of 1.49: 1. Common age group involved was 31- 40 years in 29 (20.7%) cases. Common etiology included chronic in 37 (28.46%) cases, vocal nodules in 20 (15.38%), vocal cord in 18 (13.84%), acute laryngitis in 10 (7.69%), in 9 (6.92%), hypothyroidism in 7 (5.38%) and Carcinoma in 6 (4.61%) patients. Most of the etiopathological factors found in this study were treatable disease. So, early diagnosis can reduce the morbidity and mortality. Key words: Hoarseness of Voice, aetiology, fiber optic laryngoscopy.

Introduction: or lower pitch. 2,3,4 It is most often associated Voice is an auditory perceptual term that with abnormalities of the vibratory margins of means the audible sound produced by the the vocal folds. 5 However the term can reflect larynx, which embodies such parameters as abnormalities anywhere along the vocal tract pitch, loudness, quality and variability. It is from the oral cavity to . Ideally the term the natural medium, well adapted to “Hoarseness” refers to laryngeal dysfunction communicate emotion.1 Hoarseness caused by abnormal vocal cord vibration. 2 generally refers to a change in voice quality Hoarseness is a symptom and not a disease.6 that may be manifested as a voice that sounds Hoarseness, a common voice disorder, due breathy, strained, rough, raspy, tremorous, to vocal cord lesions, may be either benign strangled, or weak, or a voice that has a higher or malignant.7 Possible causes of hoarseness are numerous and stem from many sources: 1. Classified ENT specialist, CMB, BAF anatomic, functional, neurologic, infectious, Dhaka, environmental and neoplastic. Common 2. Classified ENT specialist, CMH Dhaka, causes of hoarseness such as voice abuse 3. Classified specialist in Aerospace or viral laryngitis can be benign and self-limited , CMB, BAF. but other causes such as laryngeal cancer Address of Correspondence: Dr. Lt Col Salah Uddin Ahmed, Classified ENT specialist, CMB, can be life-threatening. These factors make BAF Dhaka, email: [email protected] the evaluation and treatment of a hoarse Bangladesh J Otorhinolaryngol Vol. 23, No. 1, April 2017 patient challenging and at times, downright laryngoscopy, fiber optic laryngoscopy, daunting.8,9 Hoarseness is more common in endoscopic rods, and other relevant routine certain professions such as teachers, investigations to reach a diagnosis. All the singers, salesmen, preachers and leaders data was collected on a predesigned data who have ex•cessive use and misuse of sheet and subsequently the data were voice.4 In children vocal abuse in the form of analyzed. screaming and shouting is quoted as one of the most widely quoted factor associated with Results: hoarseness10. Although hoarseness of voice A total of 130 patients were included in this is frequently encountered in the study. Sex distribution of the patients is otolaryngology outpatient department, shown in table-I. Among the 130 cases, Ortner’s syndrome also known as cardiovocal 76(58.47 %) were males and 54 (41.53) were syndrome is a rare cause of hoarseness of females. Male predominance was observed voice. 11 Complaints of hoarseness may with male female ratio of 1.49:1. represent serious disease. Therefore should not be ignored. In the words of Chevalier Jackson “Hoarseness is a symptom of Table I utmost significance and calls for a separate Sex distribution of patients (n= 130) consideration as a subject because of the Sex No. of patients (%) frequency of its occurrence as a distant Male 76(58.47 %) signal of malignancy and other conditions”.12 It is often the first and only sign of serious Female 54 (41.53) disease directly or indirectly affecting the Total 130 voice apparatus or systemic disease. Good Age range was between 9 years to 78 years vocal hygiene can prevent and treat some and majority, 28 (21.5%) patients were , and voice is a presented between 21-30 years, followed by cornerstone of management in some cases 27 (20.7%) between 31-40 years and lowest of hoarseness. number 02 (1.6%) were >70 years (table- II). Methods: This observational study was conducted at Table II CMB, BAF Dhaka during the period from Age distribution of patients (n=180) February 2014 to July 2016. A total of 130 cases of hoarseness of voice attending at the Age (years) No. of patients (%) outpatient department of ENT were included. 0-10 03 (2.30%) Patients with critically ill patients, patients 11-20 18(13.84%) who have undergone laryngeal , 21-30 26 (20.00%) tracheostomy and history of injuries were excluded. All the patients involved were 31-40 29 (22.30%) explained about the procedure and 41-50 25 (19.23%) involvement in this study and a voluntary 51-60 23 (17.69%) informed consent was obtained for the same. 61-70 04 (3.07%) Each patient underwent through clinical > 70 02 (1.53%) history, , ENT examinations which includes indirect Total 130

48 Hoarseness of Voice : An Etiological Study Salah Uddin Ahmmed et al

Table-III showed the distribution of etiological Table IV factors of hoarseness. Among them, the most Clinical presentation of patients with common cause was chronic laryngitis hoarseness 37(28.46%) followed by vocal cord 20 Presentation No. of cases (%) (15.38%), Vocal cord polyp 18 (13.84), acute Change in voice 130 (100%) laryngitis 10 (7.69%), vocal cord cyst 9 Vocal fatigue 73(56.15%) (6.92%), hypothyroidism 7 (5.38%), Foreign body sensation/ 53(40.76%) carcinoma larynx 6 (4.61%), vocal cord palsy, functional, sulcus vocalis, tuberculosis, irritation/pain Reinke’s oedema, leukoplakia and Laryngeal Cough 41 (31.53%) papilloma. Heart burn 28(21.53%) Fever 07 (5.39%)

Table-III Weight loss 06 (4.61%) Etiology of hoarseness of voice Dysphagia 03 (2.30%) Neck swelling 02 (1.53%) Etiology No. of patients (%) Dyspnoea 02 (1.53%) Chronic laryngitis 37 (28.46%) Vocal cord nodule 20 (15.38%) Discussion: With increasing stress in day to day life, Vocal cord polyp 18 (13.84%) rising levels of pollution, changing habits and Acute laryngitis 10 (7.69%) life style, hoarseness and voice disorders are becoming more and more prevalent. Vocal cord cyst 9 (6.92%) In the present study among 130 cases, 76 Hypothyroidism 7 (5.38%) (58.47%) were male with male to female ratio Carcinoma larynx 6 (4.61%) of 1.49:1 is comparable to the finding of 13 Vocal cord palsy 5(3.48%) Adobamen PO (2015). Similar results were also observed by studies done by Anwar K Functional 4(3.07%) (2012) et al. and Wani AA et al. (2012) where 2,14 Sulcus vocalis 4(3.07%) males were affected more than females. The distinct male preponderance could be Tuberculosis 3(2.30%) explained by the fact that, in outpatient Reinke’s oedema 3(2.30%) department of military hospital males are more than the females and the nature of job Leukoplakia 2(1.53%) of defense persons are voice prone. But in a Laryngeal papilloma 2(1.53%) study done by Sebastian S et al. (2012) found majority of cases are female which does not Change in voice was a predominant symptom correlate with the present study.15 This may present in all 130 (100%) patients followed be due to that the study was done among by vocal fatigue, foreign body sensation/ the teachers but the present study did not irritation in throat, cough, heart burn, fever, confined to a particular profession. Majority weight loss, dysphagia, neck swelling and of cases 29 (20.7%) were found in age group dyspnoea, (Table-IV). ranged from 31-40 followed by 26 (21.5%) in

49 Bangladesh J Otorhinolaryngol Vol. 23, No. 1, April 2017 age group from 31-40 years of age in our study, different geographical location and center to which correlates with the study by Vengala center. So, every case should be carefully RR et al (2015), Banjara H et al (2011) and and thoroughly evaluated to know the early Shrestha BL et al 2013. 16, 17, 18 In another diagnosis of underlying for study done by Babu VS from India also prevention and accurate management. observed that majority of patients (22.31%) Avoidance of vocal abuse, cessation of were in age group of 31 to 40 years of age. 19 smoking, tobacco and alcohol can lead to In the present study, we found laryngitis significant reduction in burden of hoarseness. including chronic and acute as highest in 47 Whether the patient notices vocal fatigue or (36.15%) cases, followed by vocal cord says that it’s harder to go with a worsening nodule, vocal cord polyp, vocal cord cyst, voice as the day progresses, the underlying hypothyroidism and carcinoma larynx etc. In cause of hoarseness must be found. Proper a study done by Baitha et al found laryngitis knowledge of clinicopathological profile is as highest number followed by vocal cord important to treat it competently and to bring nodule and vocal cord polyp, which is almost patient’s voice back. similar to the findings of the present study.20 Studies done by Reiter R and Kataria G et al References: found also laryngitis as the highest number 1. Kataria G, Saxena A, Singh B, Bhagat of cases, which support the results of the S and Singh R. Hoarseness of voice: present study.1,21 Other studies done by Etiological spectrum. Online J Shrestha BL et al and Baitha S et al showed Otolaryngol. 2015; 5(1): 13-22. their findings regarding the distribution of 2. Feierabend RH and Malik SN. etiology of hoarseness, some of the findings Hoarseness in Adults. Am Fam match and some do not match with the . 2009; 80(4): 363 - 370. present study.12,18 3. Rosen CA, Anderson D and Murry T. In our study, change in voice was found in all Evaluating hoarseness: keeping your patients (100%). Other symptoms were vocal patient’s voice healthy. Am Fam fatigue, foreign body sensation/irritation in the Physician. 1998; 57 (11): 2775-82. throat, cough, dysphagia, heart burn, weight 4. Ramesh P. Spectrum of Etiological loss, neck swelling, dyspnoea and fever. In a Factors for Hoarseness: A Retrospective study done by Kumar H and S Seth found Study in a Teaching Hospital. Glob J Oto change in voice in 100% of cases, besides 2016; 1(3): 1-4. change in voice other associated features 5. Wani AA, Rehman A, Hamid S, Akhter were also nearly similar to the present M, Baseena S. Benign Mucosal Fold study.22,23 Other studies done by Baitha and Lesion as a Cause of Hoarseness of Kataria G et al also found change in voice in Voice - A Clinical Study. Otolaryngology all 100% patients and other symptoms were 2012; 2:120. doi:10.4172/2161- also comparable with our study.1,12 119X.1000120. 6. Pal KS, Kaushal AK, Nagpure PS and Conclusion: Agarwal G. Etiopathological Study of Hoarseness is an early symptom and 100 Patients of Hoarseness of Voice: In indicates some underlying cause. The a Rural Based Hospital. Indian J etiology ranges from viral infections to life Otolaryngol Head Neck Surg 2014; threatening malignancies which vary in 66(1): 40–45.

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