Hoarseness and Laryngitis
Dept of Otolaryngology
BERJIS N, MD
Definition of Hoarseness
• the perceived
•
•
breathiness quality of
the voice (Bailey)
a rough or noisy
quality of voice
(Dorland)
a rough, harsh voice
quality (Stedman)
Symptom –vs- Diagnosis
• Hoarseness is a symptom of a disease
process
• Although hoarseness appears on the ICD9
as a diagnosis (784.49):
– it is really a symptom resulting from the
underlying disease process
– the underlying disease process is your
diagnosis (ex. vocal nodules)
Anatomy: Laryngeal Cartilage
Anatomy: Laryngeal Muscles
Histology
• Mucosal layer
– Pseudostratified squamous epithelium
superiorly and inferiorly
– Nonkeratinizing squamous epithelium at
contact surface of medial cord
Histology
• Subepithelial tissues: three layered lamina
propria
– Superficial Layer (Reinke’s space)
– Intermediate layer
– Deep layer
• the intermediate and deep layers make up the
vocal ligament
• Vocalis and thyroarytenoid muscle
Histology
Physical Examination
• Laryngeal mirror
– Advantages: fast, inexpensive, minimal
equiptment
– Disadvantages: gag, nonphysiologic, no
permanent image capability
Physical Examination
• Rigid Laryngoscopy (70 or 90-degree
telescope)
– Advantages: best optic image, magnifies,
video documentation
– Disadvantages: gag, nonphysiologic,
expensive
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
Surgical Treatment
Varices and Ectasias
Cysts
• Treatment
– Cold instrument resection
• Subepithelial infusion of saline and epinephrine is
helpful
• Must retreive entire cyst wall to prevent recurrence
• Preserve normal SLP
– Microspot CO2 laser not as effective due to
necessity of delicate tangential dissection
Cysts
• Results
– Mucosal wave usually improves
– Does not return to normal if cysts has
replaced substantial amount of SLP
• SLP does not regenerate
Cysts
Granulomas
• Results from hypertrophic inflammatory
reaction due to traumatic mucosal
disruption
• Majority found in arytenoid region
• Usually exophytic with narrow base
• Typically arise in patients with LPR
• Seen with endotracheal intubation
Granulomas
• Treatment
– Vocal therapy including antireflux
management
– Surgical resection
• conservative management has failed
• concern of a neoplastic process
• airway compromise
Granulomas
Granulomas
Granulomas
Granulomas
Polypoid Corditis (Reinke’s
Edema)
• Extensive swelling of SLP
• Usually on superior surface of musculo-
membranous vocal fold
• Typically bilateral but asymmetric volume
• Multifactorial cause
– Smoking
– LPR
– Vocal hyperfunction
Polypoid Corditis (Reinke’s
Edema)
• Treatment
–
–
–
–
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 musculo-
membranous 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
Physiology
1. Airway protection
2. Swallowing
3. Voice production
4. Air passage
inspiration
phonation
Common laryngeal disorders
1. Acute laryngitis
2. Croup
3. Epiglottitis
4. Vocal nodule
5. Vocal polyp
6. Vocal granuloma
7. Laryngeal carcinoma
8. Laryngeal trauma
9. Laryngopharyngeal reflux (LPR)
Laryngitis
•Laryngitis is
inflammation of the vocal
cords
•Laryngitis can be acute
(short term) or chronic
• Short term laryngitis
usually follows
upper respiratory
infections.
• Long term laryngitis
is most commonly
caused by misuse,
overuse and
exposure to smoke,
dust and other
irritants, as well as
acid reflux.
Acute laryngitis
Pathogen - adenovirus, influenza
Morexella catarrharis
Hemophilus influenza
Streptococcus pneumoniae
Symptoms - hoarseness
cough, +/- fever, malaise
Sign
- TVC swelling
Acute laryngitis
Treatment - voice rest
- mucolytic, anticold
+/- antibiotic
Symptoms
> 2 week,
recurrent
DDx - chronic laryngitis
Croup
(acute laryngotracheobronchitis)
- Severe respiratory infection
- 6 months-2 yrs.
Pathogen - parainfluenza*influenza, adenovirus
- follow by bacterial esp. H. influenza
Symptoms
- early URI symptoms
- 2-3 days
- barking cough, stridor
- exhausted, lying down
Croup
(acute laryngotracheobronchitis)
Diagnosis - symptoms & signs
- flexible scope
- x-ray
norrowing of subglottis
“Pencil’s sign”
Pencil’s
sign
Normal
Croup
(acute laryngotracheobronchitis)
Treatment - early detection
- observe, admit
- humidification, hydration, O2
- antibiotic (penicillin)
severe
- steroid
- intubation
Epiglottitis
Signs - epiglottis > swelling, inflam
- ** laryngospasm เมื่อกดลิ ้น
- fiberoptic
X-ray - “Thumb’s sign”
Epiglottitis
Treatment -
admit, closed monitoring
broad spectrum penicillin
hydration, humidification
+/- steriod
prepare for intubation
Aetiology
• Congenital
• Traumatic
• Inflammatory
• Neoplastic
• Functional
Congenital
• Laryngomalacia
(75%)
- a “rough” cry associated with
stridor which is worse when
feeding and begins within a few
weeks of birth
Congenital
• Neurological (10%)
- unilateral or bilateral recurrent
nerve palsies (idiopathic or birth
trauma)
Congenital
• Other
- laryngocoele
(blind sac of the laryngeal ventricle)
- haemangioma
(site determines severity of
dysphonia)
Laryngitis Sicca
Laryngistis sicca is caused by
inadequate hydration. The
protective mucus normally
needed for the vocal cords
becomes too thick and they
cannot open or close properly.
Acid Reflux
•Acid reflux affects singers
in that the stomach acid
can flow past the
esophagus into the throat.
•Small amounts of reflux
can cause considerable
damage.
The left picture is damage
from acid reflux. Notice
how the vocal cords are
mostly red instead of white.
The right picture is the
same vocal cords after
successful treatment.
Grandulomas
Another result of acid reflux.
Symptoms
• Hoarseness
• Bad/bitter taste in mouth
(especially in morning)
• Chronic (on-going) cough
• Asthma-like symptoms
• Frequent throat clearing
• Referred ear pain
• Pain or sensation in throat
• Post-nasal drip
• Feeling of "lump" in throat
• Singing: Difficulty hitting high
notes
• Problems while swallowing
Hemorrhage
A vocal hemorrhage is actually a ruptured blood
vessel on the true vocal cord, and bleeding into the
tissues of the fold.
It is a rare occurrence caused by aggressive use of
the vocal cords (e.g. cheerleading)
Common Signs of Vocal Abuse
by Prof. David Otis Castonguay, Radford Univ.
• Throat is tender to the touch after use.
• Voice is hoarse at the end of singing.
• Throat is very dry, with a noticeable “tickle” that
•
•
is persistent. Check dehydration.
Inability to produce your highest notes at
pianissimo volume.
Persistent hoarseness or an inability to sing with
a clear voice after 24-48 hours of vocal rest.
www.radford.edu/~dcastong/ARTARCH/vocal.html