Approach To A Patient Presenting With Hoarseness

Definition Of Hoarseness
Hoarseness is a change in the pitch or quality of the voice caused by abnormalities of vocal cords.

Etiology

Local Causes:

• URTI ( most common cause )
• Laryngitis
• Trauma to the vocal cords: shouting, coughing, vomiting, instrumentation.
• Hypothyroidism
• Acromegaly
• Chronic acid reflux
• Allergies
• Heavy smoking or drinking or both
• Carcinoma

Neurological Causes:

• Laryngeal nerve palsy
• Motor neuron disease
• Myasthenia gravis
• Multiple sclerosis

Muscular Causes:

• Muscular dystrophy

Functional Cause.

• Sometimes no definitive organic cause can be identified and it might be due to psychological causes.

Investigations: 

• Throat culture
• Examination of throat with a small mirror
• Laryngoscopy
• X-ray and CT of Neck.

Differential Diagnosis

1. Laryngitis: 

• hoarseness, malaise with or without fever and/ or pain on using voice.
• Usually viral. Can be caused by bacterial infections.

Management: advice patients to give rest to voice. Analgesics, Anti- biotics in case of bacterial infection.

2. Vocal Cord Nodules: 

• Usually caused by overuse of vocal cords. 
• Typically found in singers. 
• Visualized by laryngoscopy.

Management: Initial treatment is rest to vocal cords but may need surgical excision.

3. Functional Disorders: 

• More common in females. 
• Caused by hysterical paralysis of vocal cord adductors due to severe psychological stress. 
• Can cause the voice to be reduced to a whisper or to be lost completely.

Management: Patients need to be referred for laryngoscopy to rule out organic cause. Speech therapy and psychological support may help.

4. Laryngeal Carcinoma: 

• More common in males. 
• Smoking is the major risk factor. 
• Presents with hoarseness which is followed by stridor, dysphagia and pain.

Management: Urgent referral to ENT. Diagnosis is confirmed by laryngoscopy and biopsy. Treatment is surgery and radiotherapy.