HOARSENESS AND LARYNGITIS

HOARSENESS AND LARYNGITIS

  1. 1
    Current Diagnosis

    • The general term to describe vocal difficulty is dysphonia. Hoarseness is a specific term for rough voice quality, which is one type of dysphonia. Laryngitis signifies laryngeal inflammation, which is one possible cause of dysphonia.

    • An accurate history and physical examination guide the diagnosis of voice complaints. Although many portions of the examination for dysphonia can be done in a general setting, videostroboscopy is often necessary for diagnosis and may be available only in specialized laryngology offices.

    • The most common cause of acute hoarseness is viral laryngitis. Symptoms are self-limited and usually resolve within 2 weeks.

    • Dysphonia persisting for longer than 2 weeks suggests the possibility of another diagnosis, such as vocal cord paralysis, neoplasm, phonotraumatic lesion, or chronic laryngitis.

    • Indications for referral of a patient with voice complaints to an otolaryngologist include dysphonia that persists for longer than 2 weeks, that is of acute onset during voicing, or that is accompanied by other symptoms such as otalgia, dysphagia, or difficulty breathing.

  2. 2
    Current Therapy

    • Appropriate treatment of voice complaints depends on accurate diagnosis.

    • Supportive therapy is all that is necessary for most cases of acute laryngitis associated with viral upper respiratory tract infections.

    • Laryngopharyngeal reflux is a common cause of chronic laryngitis, and appropriate therapy often requires twice-daily administration of proton pump inhibitors for at least 2 months.

    • Microlaryngeal phonosurgery may be indicated for some patients with benign phonotraumatic lesions.

    • Vocal cord medialization can rehabilitate the voice in a patient with unilateral vocal cord paralysis.

    • Many patients with dysphonia benefit from voice therapy, alone or in combination with other treatment strategies.

    Voice is an essential component of communication. Vocal difficulty is very distressing to patients and can have a negative impact on physical, social, and emotional qualities of life. To understand the pathophysiology, evaluation, and treatment of voice complaints, it is important to understand the anatomy and physiology of normal voice production. Looking first at how good voice quality is achieved makes it readily apparent how alterations in vocal fold vibration, symmetry, or closure can lead to various vocal difficulties.

    To aid discussion of voice complaints, clarification of terminology is necessary. Although “hoarseness” is a term that most patients use to describe any type of voice complaint and “laryngitis” is the presumptive explanation that many patients provide for their symptoms, each of these terms has a more precise meaning.

    Dysphonia is the general term for vocal difficulty. Hoarseness implies a rough or raspy change in voice quality and is one type of dysphonia. Other categories include limited vocal projection, strained vocal effort, and change in pitch—each of which may occur with or without vocal roughness. The term “laryngitis” specifically describes inflammation of the larynx. This inflammation may be acute or chronic, and again it describes some but certainly not all cases of dysphonia. This distinction will be made clear as the evaluation and management of dysphonia are described.

  3. 3
    Normal Laryngeal Function

    The larynx plays a central role in voice production by serving as a vibrating instrument that turns airflow from the lungs into sound. The sound is shaped into intelligible speech through the resonating and articulating functions of the pharynx and oral cavity. The ability of the larynx to create vibration and serve as a sound source is a function of its complex, layered microanatomy. The deeper layers of the vocal fold include the thyroarytenoid muscle and the vocal ligament, which position the more superficial layers of the superficial lamina propria and epithelium during phonation. Compared with the fibrous nature of the vocal ligament, the superficial lamina propria is a loose gelatinous layer whose pliability allows for voice production.

    During inspiration (Figure 1A), the vocal folds are abducted so that air can move past the larynx without resistance. During phonation (Figure 1B), the vocal folds are held in an adducted position while the lungs drive air toward the larynx. Air pressure builds in the subglottis, beneath the vocal folds, until it overcomes the forces of vocal fold closure, pushes past the vocal folds, and generates negative pressure in its wake as it moves past the larynx. A combination of the vocal folds’ intrinsic viscoelasticity and the negative pressure created through Bernoulli’s effect draws the vocal fold edges back together, allowing subglottic pressure to rebuild and the cycle to repeat.

    Repeated cycles of opening and closing at the level of the vocal fold edges generate a so-called mucosal wave, which travels from the inferior edge of each vocal fold up across the medial and superior edges (Figure 1C). These waves may repeat hundreds of times each second, depending on pitch. This cycled opening and closing of the vocal folds during phonation imparts pressure waves to the air column that moves the vocal folds, generating sound. The ability of vocal folds to vibrate easily and symmetrically in this very rapid fashion allows for clear, smooth voicing.

    FIGURE 1    A, Normal vocal folds in abducted position for  inspiration.

    B, Normal vocal folds in adducted position for phonation. C, Displacement of the vocal fold medial edges creates mucosal wave propagation during phonation and produces  voice.

  4. 4
    Evaluation of Dysphonia

    Central to the evaluation of dysphonia is the understanding that any disruption of vocal fold closure, symmetry, or vibration impairs the ability of the vocal folds to generate a clear sound source. Most voice complaints arise from anatomic or functional limitations in glottal closure or mucosal wave formation, although other parts of the respiratory tree are also responsible for components of the voice.

    General points concerning evaluation of dysphonia are discussed in this section, with specific causes discussed afterward.

    History

    A careful history can provide many clues that point toward the proper diagnosis in patients with dysphonia. Although many patients offer the complaint of “hoarseness” as a general term, a careful historian distinguishes between complaints related to voice quality, vocal projection, vocal effort or strain, vocal fatigue, and so on. Two questions that can help a patient organize his or her own thoughts related to poor voice are “What abnormal things does your voice do now that it did not do before?” and “What normal things did your voice do before that it no longer can do?” The acuteness of onset, duration, severity, and progression of any complaint should be determined.

    The history should also determine what other factors or events might have caused or exacerbated the dysphonia. Recent sources of laryngeal inflammation might include intubation, excessive voice use, or upper respiratory tract infection. Baseline conditions that foster chronic laryngeal inflammation include environmental allergies, rhinitis, and laryngopharyngeal reflux. Laryngopharyngeal reflux can exist in the absence of heartburn, with reflux-associated inflammation of the larynx and pharynx providing symptoms of globus pharyngeus, throat clearing, nonproductive cough, effortful swallowing, and even mild dysphagia in association with dysphonia.

    Concerning the possibility of laryngeal malignancy, any patient with dysphonia should be asked about smoking and alcohol use, because these are risk factors for squamous cell carcinoma. Another important question in distinguishing inflammatory dysphonia from a mass lesion of the vocal fold concerns whether there are any periods of normal voice or the dysphonia is constant—inflammation may wax and wane, but dysphonia associated with mass lesions is usually progressive and unremitting. Finally, the history should elicit other possible head and neck complaints, including dyspnea, stridor, dysphagia, odynophagia, otalgia, sore throat, and pain with speaking (odynophonia). If hoarseness is associated with some of these symptoms for longer than 2 weeks, the suspicion of malignancy is increased.

    Physical Examination

    The physical examination for patients with dysphonia includes a complete head and neck evaluation with focus on the larynx and laryngeal function. Although much of the head and neck examination can be performed in a general setting, some portions of the laryngeal examination require specialized equipment found only in some otolaryngology offices that specialize in voice care. Routine head and neck evaluation should include systematic examination of the ears, nose, oral cavity, oropharynx, and neck.

    Complaint of otalgia in the setting of an unremarkable ear examination suggests a possibility of referred pain from a lesion of the larynx or pharynx, and is concerning for possible malignancy.

    Edematous and erythematous nasal mucosa suggests rhinitis, with the possibility of postnasal drip contributing to laryngeal inflammation.

    Tremor of the tongue or palate might suggest neurologic disorder, whereas pharyngeal erythema and exudate suggest possible acute infection. Pachydermia (cobblestoning) of the posterior pharyngeal wall suggests the possibility of laryngopharyngeal reflux. Tenderness with manipulation of the hyoid bone suggests tension of the strap muscles and correlates closely with complaint of odynophonia and the possibility of muscle tension dysphonia. A neck mass might represent either metastatic lymphadenopathy from a laryngeal malignancy or a primary lesion which itself compresses the recurrent laryngeal nerve and causes paralytic dysphonia. Surgical scarring along the neck suggests the possibility that prior thyroid surgery, carotid endarterectomy, or anterior approach to the cervical spine might have led to vocal fold paralysis.

    Laryngeal Examination

    Beyond a general examination of the head and neck, there should be directed evaluation of the larynx and laryngeal function. The examiner should listen to the voice carefully, because vocal characteristics such as roughness, breathiness, strain, vocal breaks, and diplophonia (pitch instability, with two different pitches present simultaneously) can help guide the differential diagnosis of dysphonia. Visual examination of the larynx has many forms, ranging from mirror examination to flexible fiberoptic laryngoscopy to videostrobolaryngoscopy.

    Mirror examination offers an adequate view of the vocal folds in many patients but may be limited by patient tolerance, physician inexperience, and the inherently limited ability of this technique to brightly illuminate the larynx or record the examination for later review. Flexible laryngoscopy is routinely available in almost all otolaryngology offices, is well tolerated by patients, and offers good views of the larynx that can be recorded with appropriate equipment. Mirror examination and flexible laryngoscopy are limited to observation of vocal fold motion and anatomy but cannot observe laryngeal function because they do not visualize vibration of the vocal folds. To examine vocal fold vibration, videostroboscopy uses a strobe light to create the impression of slow-motion analysis of mucosal waves. Stroboscopy is typically available only in selected otolaryngology practices in which laryngologists specialize in the treatment of voice disorders.

    Other Testing

    Videostroboscopic evaluation, combined with a thorough history and routine physical examination, can establish the diagnosis for almost all patients with voice complaints, but further testing is sometimes indicated. For instance, electromyography is used by some laryngologists for further evaluation of vocal fold paralysis or paresis. More commonly, radiographic studies are used for further evaluation of some voice complaints. Computed tomography (CT) scans are ordered most often in the evaluation of suspected laryngeal neoplasms and for patients with vocal fold paralysis.

    In the case of neoplasm, CT scanning is useful to assess the extent of the primary lesion and to evaluate possible metastatic cervical lymphadenopathy. In patients with laryngeal malignancy, chest radiography is also important to assess for pulmonary metastases. For patients with vocal fold paralysis who do not have a clear history of surgical injury of the recurrent laryngeal nerve, a CT scan from skull base to thoracic inlet identifies possible lesions along the course of the recurrent laryngeal nerve. Central problems are less likely, but if they are suspected as a cause of vocal fold paralysis, then magnetic resonance imaging of the brain may be indicated as well.

  5. 5
    Types of Dysphonia

    Although not comprehensive, the conditions discussed here account for the vast majority of voice complaints. Some patients with voice complaints have more than one condition, and not every patient will fit neatly into a single category. Nevertheless, understanding how each of these conditions creates dysphonia, and knowing which particular history and physical examination findings might be associated with each cause, can help a physician to appropriately diagnose and manage voice complaints.

    Acute Laryngitis

    Acute laryngitis is the most common cause of hoarseness and dysphonia. It is most often viral in nature, and onset of laryngeal symptoms may be associated with other symptoms of upper respiratory tract infection, including fever, myalgia, sore throat, and rhinorrhea. Viral inflammation of the vocal folds leads to diminished and more effortful vocal fold vibration, yielding a voice characterized by increased effort and a harsh, strained quality with decreased projection. Characteristic findings on laryngoscopy include vocal fold edema and erythema with decreased amplitude of the mucosal wave. Treatment of acute viral laryngitis is supportive, with counseling for hydration, humidification, and mucolytics. Symptoms generally are self-limited and resolve within 2 weeks. During this time, patients should be instructed to use the voice in a comfortable fashion, rather than straining or pushing to get loudness, because pushing behaviors may lead to the development of persistent muscle tension dysphonia.

    Bacterial or fungal infections also cause acute laryngitis in rare cases. With appropriate physical findings and in the right clinical setting, antibiotic or antifungal therapy may be used to treat these conditions. Amoxicillin-clavulanate (Augmentin) is often the antibiotic of choice, and fluconazole (Diflucan) is a commonly used antifungal agent.

    Chronic Laryngitis

    Chronic laryngitis is the nonspecific condition of prolonged laryngeal inflammation; the term itself does not indicate an etiology for the inflammation. Among the many possible sources for this inflammation are mechanical irritation from traumatic coughing or prolonged speaking, chemical irritation from environmental irritants (e.g., smoking, inhaled medications), and irritation from postnasal drip or laryngopharyngeal reflux. More than one cause may exist simultaneously. Issues related to cigarette use, excessive voice use, medication effect, and rhinitis can be identified with careful history taking. Laryngopharyngeal reflux is a very common source of chronic laryngitis. It may manifest with several nonspecific symptoms, such as throat irritation, globus pharyngeus, frequent throat clearing, and nonproductive cough, with or without accompanying heartburn.

    Because vocal fold inflammation increases with continued mechanical trauma, the hoarseness of chronic laryngitis typically gets worse with prolonged voice use and improves with voice rest. Examination findings in chronic laryngitis include generalized laryngeal edema and erythema, and careful inspection may also reveal interarytenoid hyperplasia, subglottic edema, laryngeal ventricular obliteration, and an increase in thick glottic secretions.

    Treatment of chronic laryngitis is tailored to the cause of the inflammation. Vocal hygiene with moderate voice use and instructions to reduce throat clearing and coughing may diminish mechanical irritation, and smoking cessation is recommended to any smoker with laryngeal complaints. Several studies have suggested that an appropriate trial of proton pump inhibitors for treatment of laryngopharyngeal reflux includes twice-daily therapy for at least 2 months, in contrast to the once-daily dosing often used for typical heartburn complaints. Lifestyle counseling to limit consumption of caffeine, carbonation, alcohol, and acidic foods can improve reflux, and attention to hydration and humidification decreases the viscosity of glottic secretions. For patients who are troubled by vocal difficulties associated with chronic laryngitis, referral to a speech–language pathologist for voice therapy can improve compliance with suggested lifestyle changes and help foster vocal improvement.

    Vocal Fold Paralysis

    The dysphonia in cases of vocal fold paralysis usually relates to poor vocal fold closure (Figure 2). The result is a breathy voice with limited projection and increased vocal effort. The farther from midline the immobile vocal fold, the more air leaks through the incompetent glottal valve without being turned into sound. Patients whose immobile vocal fold sits in a lateral position may have severely weak and breathy voices, whereas patients whose immobile vocal fold sits near midline may have a perceptually near-normal conversational voice and complain only of mild increase in effort, vocal fatigue, or problems with loud projection. Because of their glottal insufficiency, patients may complain of “running out of air” with prolonged speech. Impaired glottal closure may also decrease airway protection during swallowing, so patients with vocal fold paralysis need to be questioned about aspiration as well. Whereas rehabilitation of poor voice may be elective, patients with increased aspiration risk need prompt therapy.

    FIGURE 2    Vocal fold paralysis prevents the right vocal fold  from closing to midline and creates  dysphonia.

    Evaluation of vocal fold paralysis includes identification of the cause of paralysis. Surgical injury to the recurrent laryngeal nerve accounts for almost half of all cases of unilateral vocal fold paralysis, and cervical or thoracic neoplasm and idiopathic paralysis account for most of the remaining cases. In a patient without a clear surgical history explaining the paralysis, CT scanning from skull base to mediastinum can identify any possible lesions along the course of the recurrent laryngeal nerve. In those patients whose histories suggest other possible causes (e.g., central neurologic injury, Lyme disease), further investigations, such as magnetic resonance imaging of the brain or blood work may be indicated as well. Some physicians perform laryngeal electromyography to help with the prognosis of paralysis or to differentiate neurologic injury from cricoarytenoid joint fixation; however, this study is neither standardized nor routine in many practices. Although flexible laryngoscopy alone may be satisfactory to document vocal fold immobility, stroboscopy can be added to investigate the impact of glottal insufficiency on vocal cord vibration and possible vocal fold flutter.

    Treatment of vocal fold paralysis might include any combination of voice therapy, injection laryngoplasty, transcervical medialization laryngoplasty, and laryngeal reinnervation. Depending on the cause of the paralysis, some patients experience gradual recovery with synkinetic reinnervation or recovery of purposeful vocal fold motion over a period of several months. Based on the degree of voice and swallowing handicap, treatment of patients with vocal fold paralysis may be optional rather than necessary. Voice therapy can help teach patients to produce a stronger voice despite the paralysis, but by itself will not help a paralyzed vocal cord to recover motion. Various medialization techniques have been developed to help reposition an immobile vocal fold in the midline, where the contralateral mobile vocal fold can provide for complete glottal closure and lead to improved voice and swallowing. Injection medialization can be performed in the office or in the operating room, with temporary or permanent materials; if recovery of vocal fold motion is thought possible, then temporary injection is preferred. Transcervical medialization is a permanent but reversible surgical technique performed by otolaryngologists that repositions an immobile vocal fold in the midline. Laryngeal reinnervation offers the possibility of midline positioning of the immobile vocal fold with restored tone and bulk of the vocal fold musculature; however, because results may not mature for several months, this technique is less commonly performed than either injection or transcervical medialization.

    Phonotraumatic Lesions: Nodules, Polyps, and Cysts

    During vibration, vocal folds are subject to the shearing stresses of vibration. Although vocal fold structure is designed to accommodate these stresses in most circumstances, patients with vocal abuse or excessive voice use are at risk for development of lesions as the result of cumulative phonotrauma. Depending on the location and nature of these lesions, they are categorized as nodules, polyps, or cysts.

    Vocal fold nodules are areas of fibrovascular scarring that are located just beneath the epithelium, at the level of the basement membrane and superficial lamina propria. They are typically bilateral and symmetrical, sitting at the junction of the anterior one third and the posterior two thirds of each vocal fold. Polyps are typically unilateral lesions that may be edematous or fibrous in nature and may contain hemorrhage (Figure 3). They usually are exophytic and extend outward from the vocal fold epithelium, although the fibrous base of a polyp may extend into the superficial lamina propria of a vocal fold.

    In contrast to an epithelial-based lesion such as a polyp, a vocal fold cyst is a subepithelial encapsulated lesion that sits entirely within the vocal fold; its size may exert a mass effect that deforms the medial edge of the involved vocal fold. These cysts are occasionally noted as congenital lesions in children, but in adults they are more often caused by traumatic occlusion of the ducts of the seromucinous glands within the larynx.

    FIGURE 3    A large right hemorrhagic polyp, which can impair  vocal fold vibration.

    Nodules, polyps, and cysts cause dysphonia by disturbing vocal fold vibration, leading to rough voice quality. These lesions get larger as traumatic voice use accumulates, and vocal roughness usually becomes more severe and more constant as the lesions progress.

    Because vibration is more easily disturbed at high pitch, performers with these lesions may notice that high pitch is affected first. Effort of phonation often increases, but projection remains intact. Lesions large enough to limit vocal fold closure may also cause a slightly breathy voice quality. Because patients with excessive voice use are at risk for these lesions, a history of social and occupational voice demands is valuable in cases of suspected phonotrauma.

    Treatment for these lesions always begins with voice therapy designed to modify the patient’s voice use so as to diminish trauma. Voice therapy may be all that is necessary to allow resolution of some early traumatic changes, particularly in the case of edematous nodules. If dysphonia persists despite voice therapy and other conservative measures, surgery may be considered. Surgery with the goal of voice preservation and restoration (phonosurgery) is typically performed by otolaryngologists who specialize in the care of persons with vocal difficulties. The goal of phonosurgery for these lesions is to remove the lesion that impairs vibration while preserving as much of the remaining, pliable superficial lamina propria as possible, so that vocal fold vibration can be restored.

    Reinke’s Edema

    Reinke’s edema, also known as polypoid corditis, is a benign swelling of the vocal folds that is most commonly seen in patients with a long- term smoking history. The edema, a reaction to long-term irritation, accumulates within the superficial lamina propria. The edema is most often bilateral and occurs diffusely along the entire length of the vocal fold, rather than being limited to a more discrete area, as is seen with phonotraumatic polyps (Figure 4). As vocal fold mass increases with disease progression, the pitch of the voice decreases, and this is the change in voice most associated with Reinke’s edema. A classic presentation of this condition is a female in her fifth or sixth decade of life who provides a long history of smoking and progressive deepening of her voice. In rare circumstances, the vocal folds gradually accumulate enough edema to compromise the airway, so breathing complaints should be evaluated as well.

    FIGURE 4    Symmetrical polypoid degeneration of the bilateral  vocal folds, characteristic of Reinke’s edema.

    Because a significant smoking history is also a risk factor for vocal fold leukoplakia and malignancy, good visualization of the vocal folds is necessary to evaluate for other lesions in these patients. If benign edema of the vocal folds is truly the only lesion noted, management depends on the degree to which voice quality is disturbing to the patient or the degree to which the airway is narrowed. Smoking cessation can lead to stabilization of pitch at its current level, and phonosurgery to remove excess vocal fold mass can help lead to normalization of pitch and improve the airway. Phonosurgery may be performed with cold instruments or with the pulsed photoangiolytic lasers, an emerging therapy; in either case, there is a risk of creating a vocal fold scar that might limit vocal fold vibration even as vocal fold contours are improved.

    Recurrent Respiratory Papillomatosis

    Recurrent respiratory papillomatosis (Figure 5) is a benign laryngeal neoplasm that is caused by the human papilloma virus. It is the most common source of hoarseness in children, although adults also may be affected. As the lesions grow on the laryngeal epithelium, they create hoarseness and sometimes effortful voice by disrupting vocal fold vibration, particularly if the lesions are located along the medial edge of either vocal fold. Large and bulky lesions may lead to airway compromise, and advanced disease may spread throughout the mucosa of the upper aerodigestive tract rather than being limited to the larynx. Although accurate diagnosis depends on histopathologic analysis, a diagnosis of benign papilloma can be suspected from the characteristic appearance of the vascular fronds, which can be seen under magnified visualization in the office or in the operating room.

    FIGURE 5    Recurrent respiratory papillomatosis, whose  presence along each vocal fold medial edge disrupts sound  production.

    Treatment of recurrent respiratory papillomatosis is surgery, which is performed with a carbon dioxide laser, microdebrider, cold instruments, or the emerging technology of pulsed potassium titanyl phosphate (KTP) laser. As its name implies, the condition is recurrent: Even though surgery may reduce or remove the papilloma temporarily, the tissue continues to harbor the papilloma virus, and the disease usually grows back. Because repeated surgeries are expected, the goal of any single procedure is to remove as much disease as possible while limiting surgical scarring of the vocal folds. Scarring created as a result of surgery is cumulative, and over time patients develop persistent dysphonia caused as much by repeated surgeries as by recurrence of the disease. An ability to treat epithelial lesions while limiting scarring at the level of the superficial lamina propria is one main advantage of pulsed laser photoangiolysis; that these pulsed laser procedures can be performed in the office as well as the operating room is another. To help limit the need for repeated surgical procedures, adjunct medical therapies such as interferon and cidofovir are sometimes used for treatment of advanced disease.

    Vocal Cord Cancer

    In 2008, an estimated 12,250 new cases of laryngeal cancer and 3,670 deaths attributable to laryngeal cancer occurred in the United States. The annual incidence of laryngeal cancer is 6.4 cases per 100,000 for men and 1.3 cases per 100,000 for women. Smoking is the single largest risk factor for laryngeal cancer, and excessive alcohol use has a synergistic effect as a risk factor as well. Survival rates for laryngeal cancer depend on the stage of the tumor at the time of diagnosis, which is a function of tumor size and possible tumor spread to the cervical lymph nodes or distant metastatic sites. Cancers that occur on the medial edge of the vocal fold produce dysphonia while still small, and many laryngeal cancers are diagnosed early.

    The dysphonia associated with laryngeal cancer is constant, progressive, and unremitting, without the intermittent vocal improvement that may occur in inflammatory conditions. The presence of dysphagia, odynophagia, otalgia, hemoptysis, or unexplained weight loss further increases the index of suspicion for malignancy. Cervical lymphadenopathy is associated with advanced tumors. Diagnosis may be suspected on the basis of laryngeal examination and is confirmed with biopsy. The presence or absence of mucosal waves on the involved vocal fold on videostroboscopic examination can help predict the depth of the lesion. Both a CT scan of the neck and chest radiographs are indicated to assess for tumor size and spread. Early cancers are treated with surgery or radiation therapy, with similar cure rates. Emerging technologies such as pulsed photoangiolytic lasers may allow for surgical treatment of early disease with better preservation of surrounding normal tissue. More advanced tumors are usually treated with a combination of radiation therapy and surgery or chemotherapy.

    Leukoplakia, or a raised white plaque on the epithelial surface, is a visual marker for the likely presence of dysplasia or carcinoma in situ. As a very early lesion, vocal fold leukoplakia may manifest with mild dysphonia or may be found incidentally on head and neck examination performed for other reasons. This early disease may take many years before progressing to invasive carcinoma, and recognition of leukoplakia presents an opportunity for early treatment to prevent progression of disease. Pulsed laser photoangiolysis has emerged as a state-of-the-art therapy for treatment of this epithelial lesion with preservation of the underlying vocal fold pliability.

     

  6. 6
    Neurologic Disorders and the Voice

    Neurologic conditions that affect the voice usually do so by causing poor coordination of vocal fold motion. Spasmodic dysphonia, for instance, leads to involuntary spasms that bring the vocal folds either tightly together (adductor spasmodic dysphonia) or apart (abductor spasmodic dysphonia) during phonation. These spasms lead to vocal breaks that are strained or breathy, respectively. Although the cause of spasmodic dysphonia is thought to lie within the central nervous system, the gold standard treatment of botulinum toxin is targeted at the end organ. Injection of botulinum toxin (Botox)1 into appropriate laryngeal muscles can weaken these muscles and diminish the spasm.

    Vocal fold tremor is a neurologic disorder that is distinct from spasmodic dysphonia. Its hallmark is tremulous voice quality caused by tremor of the larynx, which may occur both during phonation and at rest. Vocal fold tremor may exist alone or as part of systemic tremor. Botulinum toxin1 can decrease the amplitude of the tremor but may exacerbate the loss of projection that many tremor patients also have as a complaint. Medications such as anxiolytics or β-blockers that are used to treat systemic tremor may also improve the voice in patients with vocal fold tremor without worsening hypophonia.

  7. 7
    Functional Voice Disorders

    Functional dysphonia may exist by itself or in combination with an anatomic or neurologic source of dysphonia. The most common form of functional voice disorder is muscle tension dysphonia, which describes inappropriate hyperfunction of the supraglottic muscles.

    This hyperfunction often occurs in response to another source of hoarseness, as the patient tries to force out a strained voice with improved projection rather than accept the limited voice quality that may accompany the other disorder. The hyperfunction may then become an entrenched habit separate from the original pathology. In this sense, a classic scenario for muscle tension dysphonia is a patient who strains to speak more loudly during an acute laryngitis episode and whose strained, squeezed voice pattern persists even after the acute laryngitis has resolved. Patients with muscle tension dysphonia may complain of odynophonia as tension in the involved supraglottic muscles leads to muscular pain with prolonged speaking. Once other lesions have been evaluated, the treatment of muscle tension dysphonia is expert voice therapy with an emphasis on decreased hyperfunction.

  8. 8
    Presbylaryngis

    Presbylaryngis is the term that is used to describe the aging voice. It typically manifests in the seventh or eighth decade but can develop earlier. Acoustically, presbylaryngis results in a characteristic thinned voice, often with decreased projection and increased vocal strain. The condition occurs as cumulative voice use leads to traumatic thinning of the superficial lamina propria, particularly at the mid-cord level.

    This loss of superficial lamina propria leads to deficiency at the medial edge of each vocal fold, and a spindle-shaped defect in glottal closure may be noticed with close evaluation. Many patients with a complaint of presbylaryngis find that appropriate voice therapy to address breath support and vocal projection leads to satisfactory improvement in the voice without altering the vocal fold anatomy. For those patients who remain unsatisfied with their voice after therapy, vocal fold medialization procedures can restore straight vocal cord edges and may lead to improved projection; however, currently available injectables and implants that address contour defects cannot restore pliability.

  9. 9
    Conclusion

    Understanding the anatomy and physiology of normal voice production provides a framework through which dysphonia can be evaluated. Application of this knowledge during the history and physical examination guides the diagnosis of hoarseness and allows clinicians to distinguish among conditions as varied as acute laryngitis, benign phonotraumatic lesions, vocal fold paralysis, and laryngeal cancer as part of a differential diagnosis.

    Videostrobolaryngoscopy allows evaluation of vocal fold function as well as structure and can confirm diagnosis. As with any condition, accurate diagnosis directs appropriate therapy. Because no further evaluation or management is necessary for acute viral laryngitis, many patients with hoarseness require no more than a careful history and physical examination. However, if dysphonia persists for longer than 2 weeks or is accompanied by other laryngopharyngeal symptoms that are not thought to be related to an upper respiratory tract infection, referral should be made to an otolaryngologist for further evaluation.

  10. 10
    References

    Koufman J.A., Aviv J.E., Casiano R.R., et al. Laryngopharyngeal reflux: Position statement of the committee on speech, voice, and swallowing disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg. 2002;127:32–35.

    Merati A.L., Heman-Ackah Y.D., Abaza M., et al. Common movement disorders affecting the larynx: A report from the neurolaryngology committee of the AAO-HNS. Otolaryngol Head Neck Surg. 2005;133:654–665.

    Swibel Rosenthal L.H., Benninger M.S., Deeb R.H. Vocal fold immobility: A longitudinal analysis of etiology over 20 years. Laryngoscope. 2007;117:1864–1870.

    Wilson J.A., Deary I.J., Millar A., et al. The quality of life impact of dysphonia. Clin Otolaryngol. 2002;27:179–182.

    Zeitels S.M., Casiano R.R., Gardner G.M., et al. Management of common voice problems: Committee report. Otolaryngol Head Neck Surg. 2002;126:333–348.

    Zeitels S.M., Healy G.B. Laryngology and phonosurgery. N Engl J Med. 2003;349:882–892.

    1  Not FDA approved for this  indication.

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