Describe the causes and assessment of hoarseness.

Assessment of the Hoarse Patient

• Hoarseness (dysphonia) is any alteration in the quality of the voice.
• It arises whenever the mass, tension, or the ability of the cords to approximate and to vibrate evenly is disturbed — and thinking of it in those terms organises the whole differential.
• The single most important rule IN this chapter: hoarseness persisting beyond 3 weeks, particularly in a smoker or a patient over 40, requires visualisation of the larynx and must be regarded as carcinoma until proved otherwise

Causes and Management

• Organising the causes BY mechanism makes the differential manageable:
• Inflammatory — acute laryngitis, viral and self-limiting; chronic laryngitis from smoking, voice abuse, reflux and irritants; laryngopharyngeal reflux.
• Structural lesions of the cords — nodules, polyps, cysts, REINKE’S oedema, granuloma, sulcus vocalis, papillomatosis and leukoplakia, considered separately
• Neurological — vocal cord palsy; spasmodic dysphonia, a focal dystonia causing a strained, strangled voice with breaks, treated with botulinum toxin injection; Parkinson disease, giving a soft monotonous voice; myasthenia gravis, with fatigue of the voice; and essential tremor
• Neoplastic — carcinoma of the larynx, and lesions compressing the recurrent laryngeal nerve
• Functional and behavioural — muscle tension dysphonia.
• Systemic and endocrine — hypothyroidism.
• Age-related — puberphonia (mutational falsetto), in which an adolescent boy retains a high-pitched voice after normal laryngeal growth, treated very effectively by speech therapy; and presbyphonia, from cord atrophy and bowing in the elderly
• Management depends entirely on the cause, but some measures apply to all:
• Stop smoking, which is the single most important instruction
• Voice hygiene — adequate hydration; avoiding shouting, whispering (which is more traumatic than soft speech) and throat clearing; voice rest in acute inflammation, but only briefly; and humidification
• Treat reflux with lifestyle measures and a proton pump inhibitor for an adequate trial of 2 to 3 months
• Speech and language therapy is the mainstay for muscle tension dysphonia, nodules, puberphonia and psychogenic disorders, and is under-used — many patients are offered surgery when therapy would have sufficed
• Review inhaled steroids, advising a spacer and mouth rinsing
• Phonosurgery — microlaryngeal excision of a lesion preserving the vocal ligament; medialisation (thyroplasty or injection) for a paralysed or bowed cord; and botulinum toxin for spasmodic dysphonia
• The golden rule at operation is to preserve the layered structure of the cord and to avoid stripping.
• Hoarseness beyond three weeks means seeing the larynx, particularly in a smoker or anyone over forty
• Hoarseness is often the earliest sign of glottic cancer, which is curable in over ninety per cent when caught early
• A whisper with a normal cough is psychogenic, the cough proving the cords can adduct, and it takes seconds to demonstrate
• Check thyroid function in unexplained hoarseness; hypothyroid voice change is completely reversible
• Androgens lower a woman voice irreversibly, which must be mentioned before such drugs are prescribed
• Breathy means incomplete closure and harsh means added mass.
• Whispering is more traumatic than soft speech, which is the opposite of what patients assume and must be said explicitly
• Reflux frequently causes hoarseness without heartburn, which is why it is missed and why an adequate trial is needed
• Ask about inhaled steroids and advise a spacer and mouth rinsing.
• Stroboscopy shows the mucosal wave and reveals scar, sulcus and early tumour that a still view misses
• Speech therapy is under-used; many patients are offered surgery when therapy alone would have sufficed
• Puberphonia responds very well to speech therapy, and needs no surgery despite the dramatic presentation
• Spasmodic dysphonia is a focal dystonia, treated with botulinum toxin rather than with voice rest
• Never strip a vocal cord; a scarred cord is permanently hoarse and nothing restores the mucosal wave
• Consider tuberculous laryngitis in India, secondary to pulmonary disease, in a hoarse patient with weight loss