Hoarseness
Mucosal Vocal Fold Lesions
Paresis and LPR
Melanie Giesler, DO
Hoarseness
Symptom and disease – symptom of
disease process and is an ICD9 code
– the perceived breathiness quality of the voice
(Bailey)
– a rough or noisy quality of voice (Dorland)
– a rough, harsh voice quality (Stedman)
Anatomy: Laryngeal Cartilage
Anatomy: Laryngeal Muscles
Anatomy: Laryngeal Muscles
Anatomy: Laryngeal Innervation
Anatomy: Laryngeal Motion
Tension of vocal ligament
Anatomy: Laryngeal Motion
Adduction of vocal ligament
Anatomy: Laryngeal Motion
Abduction of vocal ligament
Histology
History
Onset and duration of vocal symptoms
Potential causes or exacerbating influences
Other risk factors
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Tobacco
Alcohol
LPR
Dehydration
Medications
Allergies
Voice Abuse – one episode or chronic – teachers/preachers
Neurologic Disorders
History of Trauma/Surgery
Physical Examination
Flexible fiberoptic nasolaryngoscope
– Advantages: well tolerated, physiologic, video
documentation
– Disadvantages: time consuming, expensive,
resolution limited by fiberoptics
Physical Examination
Videostroboscopy
– Advantages: allows apparent “slow motion”
assessment of mucosal vibratory dynamics,
video documentation
– Disadvantages: time consuming, expensive
Benign Vocal Fold Lesions
Polyps
Nodules
Varices and Ectasias
Cysts
Granulomas
Polypoid Corditis/Reinke’s Edema
Papillomatosis
Polyps
Polyps
Nodules
Varices and Ectasias
Cysts
Granulomas
Polypoid Corditis (Reinke’s
Edema)
Extensive swelling of SLP
Usually on superior surface of musculomembranous vocal fold
Typically bilateral but asymmetric volume
Multifactorial cause
– Smoking
– LPR
– Vocal hyperfunction
Polypoid Corditis (Reinke’s
Edema)
Treatment
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Smoking cessation
Antireflux medication
Preoperative vocal therapy
Surgery
Epithelial microflap elevation with SLP contouring and
reduction using either cold instruments, Microspot CO2 laser,
or both
Vocal ligament should never be visualized
Both vocal folds can be treated in one procedure if flap is
elevated on superior surface of vocal fold
Polypoid Corditis (Reinke’s
Edema)
Papillomatosis
Human papillomavirus 6 and 11
Confined to epithelium
– Excision should preserve SLP
Most commonly found in musculomembranous region, but may extend into
arytenoid, ventricle, subglottis
Papillomatosis
Surgical treatment
– Cold instruments
– Microdebrider
– Microspot CO2 laser
Resection of lesions inhibits recurrence in
30% of chronic patients
Papillomatosis
Vocal Cord Paralysis
Etiology
Causes of Vocal Cord Paralysis in Adults:
Cause
Unilateral %
Bilateral %
Surgery
24
26
Idiopathic
20
13
Malignancy
25
17
Trauma
11
11
Neurologic
8
13
Intubation
8
18
Other
5
5
Benninger et al., Evaluation and Treatment of the Unilateral Paralyzed Vocal Fold. Otolaryngol Head Neck Surg 1994;111-497-508
Evaluation - Electromyography
Normal
– Joint Fixation
– Post. Scar
Fibrillation
– Denervation
Polyphasic
– Synkinesis
– Reinnervation
Evaluation - Imaging
Chest X-ray
– Screen for intrathoracic lesions
MRI of Brain
– Screen for CNS disorders
CT Skull Base to Mediastinum
Direct Laryngoscopy
– Palpate arytenoids, especially when no LEMG
Laryngopharyngeal Reflux
(LPR)
Other aliases: extraesophageal reflux, reflux laryngitis,
posterior laryngitis
Contributes up to 50% of laryngeal complaints
Backflow of gastric contacts into larynx, pharynx, and upper
aerodigestive tract
Upper esophageal sphincter (UES) dysfunction
Affects 50 million Americans
– Present in 4-10% of those with gastroesophageal reflux disease
(GERD)
– About 20-70% with LPR have symptoms of GERD
Upper Esophageal Sphincter
C-shaped sling attached to cricoid cartilage
– Cricopharyngeus
– Thyropharyngeus
– Proximal cervical esophagus
Innervated by pharyngeal plexus
– Vagus nerve
Superior laryngeal nerve
Recurrent laryngeal nerve
– Glossopharyngeal nerve
– Sympathetics from superior cervical ganglion
Key Symptoms
Cervical dysphagia
Globus
Respiratory complaints
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Sore throat
Chronic cough
Throat clearing
Dysphonia
Hoarseness
Upright (daytime) reflux
Heartburn uncommon
Normal acid clearance
Comparison to
Gastroesophageal Reflux
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Cervical dysphagia
Globus
Respiratory complaints
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Sore throat
Chronic cough
Throat clearing
Dysphonia
Hoarseness
Upright (daytime) reflux
Heartburn uncommon
Normal acid clearance
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Dysphagia
Less respiratory complaints
Rare dysphonia
Supine (nighttime) reflux
Heartburn
Delayed acid clearance
Regurgitation
Esophagitis
Other Symptoms
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Asthma exacerbation
Ear pain
Excess throat mucus
Halitosis
Laryngospasm
Neck pain
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Odynophagia
Postnasal drip
Voice complaints
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Breaks
Fatigue
Longer warmup time
Loss of upper singing range
Physical Findings
Posterior laryngitis
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Edema
Posterior commissure and arytenoids
Increased vascularity
Erythema
Edema
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Infraglottic (pseudosulcus vocalis)
Diffuse
Ventricular effacement
(Belafsky et al, 2001)
Mucosal hypertrophy
Laryngeal pachydermia (granularity, cobblestone)
Ulcers, granulomas, scarring, stenosis
Implications
Asthma
Bronchiectasis
Cervical dysphagia
Chronic cough
Chronic dysphonia
Chronic laryngitis
Chronic rhinitis
Dental caries
Globus pharyngeus
Laryngeal carcinoma
Laryngeal papillomas
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Laryngomalacia
Laryngospasm
Laryngotracheal stenosis
Obstructive sleep apnea
Otitis media
Paradoxical vocal-fold
motion disorder
Recurrent croup
Reinke edema
Ulceration
Vocal fold granulomas
Pediatric Considerations
Abnormal crying
Anorexia
Apnea
Chronic cough
Chronic nasal pain
Dental erosion
Dysphagia
Irritability
Laryngomalacia
Nasal obstruction
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Otitis media/otalgia
Recurrent upper
respiratory infections
Regurgitation/vomiting
Rhinorrhea
Sleeping disorders
Subglottic stenosis
Sinusitis
Torticollis (Sandifer’s
Syndrome)
Diagnosis
Ambulatory 24-hour double-probe pH monitoring
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Current standard
Probes above upper and lower esophageal sphincters
Detects acidic reflux events only
Impedence
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Multiple electrode pairs on pH-probe-type catheter
Track retrograde bolus transit
Measures acidic and nonacidic events
No set guidelines lead to controversy and misdiagnoses
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Edema, ventricular effacement, and pseudosulcus vocalis are more
common findings
Physicians commonly look for posterior laryngitis