Hoarseness Kevin Katzenmeyer, MD Faculty Advisor: Byron J Bailey, MD The University of Texas Medical Branch Department of Otolaryngology Grand Rounds Presentation October 24, 2001
Hoarseness Common referral Hoarseness reflects any abnormality of normal phonation
Cartilaginous skeleton
Cricoarytenoid Joint True synovial joint
Intrinsic Musculature Abductors Adductors Tensors
Intrinsic Musculature
Innervation
Abduction
Adduction
Tension
Vocal Fold Anatomy
Laryngeal function Sphincteric function Respiration Phonation Other Stabilizes the thorax by preventing exhalation during lifting Compresses abdominal cavity during coughing or straining
Phonation Physical act of sound production by means of passive vocal fold interaction with the exhaled airstream Pitch Quality Volume
Sound Production Contraction of expiratory muscles Rise in subglottic air pressure Escape through glottis Closure Bernoulli effect elasticity
Phonation Glottal puff Release of air as upper margins of TVC separate Phase delay Delay of closure between upper and lower margins of TVC Mucosal wave Horizontal and vertical components
Mucosal wave/phase delay
Body-Cover Theory Changes to mucosal wave Stiffness tension
Mucosal wave Velocity increases Increased airflow Increased subglottic pressure
Fundamental Frequency Pitch (measure in Hertz) Changes in vibration frequency Mass Stiffness viscosity
Workup Any patient with hoarseness of two weeks duration or longer must undergo visualization of the vocal cords
Workup History Physical Examination Ancillary tests
History URI Laryngitis Overuse with edema and inflammation Paralyses Granulomas from coughing
History Trauma Arytenoid dislocation Nerve paralysis Laryngeal fractures Mucosal lacerations
History Intubation Arytenoid dislocations Nerve injury granulomas
History Pulmonary conditions power source COPD Asthma
History Gastrointestinal LPR Autoimmune RA Endocrine Hypothyroidism
Neurologic disorders
Surgical History Skullbase procedures Carotid endarterectomies Thyroidectomies Aortic aneurysm repairs
Medications
Social History Tobacco Alcohol?Inflammation?Drying of secretions?malignancy
Occupational History Voice abuse
Associated Symptoms
Physical Examination Head & neck examination Laryngeal examination Physiologic position Image quality Magnification Cost Required equipment Time/skill necessary
Laryngeal examination Indirect mirror Flexible laryngoscopy Rigid laryngoscopy
Indirect mirror examination Advantages Quick Inexpensive Little equipment Disadvantages Gag Anatomic features nonphysiologic
Flexible laryngoscopy Advantages Well tolerated Complete examination Video documentation Disadvantages More time Expensive
Rigid laryngoscopy Advantages Best images Magnification Video documentation Disadvantages Expensive Nonphysiologic Gag Anatomic features
Videostroboscopy Light quasi-synchronized with vocal fold vibrations Bell microphone Electroglottography Video recording Detailed review Comparison after treatment
Videostroboscopy Synchronous = motionless Asynchronous = slow motion
Videostroboscopy Vocal fold closure pattern Vocal fold vibratory pattern Mucosal wave of each vocal fold Symmetry
Videostroboscopy
Radiographic studies MRI CT
Laryngeal EMG Myopathy normal frequency of firing but decreased amplitude Neuropathy decreased frequency but occasional normal amplitudes Polyphasic reinnervation potentials indicate some loss of function but reinnervation has begun
Laryngeal EMG
Differential Congenital Inflammatory Neoplastic Traumatic Neurologic Endocrine Iatrogenic Local factors
Vocal Cysts
Vocal Nodules Usually bilateral Voice rest and speech therapy for 6 months Surgical removal
Vocal cord granulomas LPR Intubation Treat medically
Vocal Cord Paralysis Lesion at nuclear level cadaveric Lesion above nodose ganglion abducted Lesion below nodose ganglion - paramedian
Vocal Cord Paralysis Superior laryngeal nerve subtle voice changes with decreased pitch range, tilting of the larynx with a rotation of the glottis
Vocal Cord Paralysis Children Neurologic Traumatic Idiopathic Adults Iatrogenic Traumatic Neoplastic Idiopathic neurologic
Vocal Cord Paralysis