Hoarseness (Dysphonia)

Background

There are a number of aetiologies of hoarseness, some of which are non-serious and some of which are.

History

• Duration, Onset, Progression, Severity of symptoms
  • Is it worse at any particular time of day?
• Make sure to try and define the nature of ‘hoarseness’ as the patient describes it
  • Breathy, halting/strangled, husky/muffled, nasal, honking, low pitched, raspy/harsh, soft/loss of volume, strained, fatigue-able
  • Make sure to differentiate as to whether it is hoarseness or change in voice (or both)
• Ask if anything makes it better or worse e.g. temperature, glass of water, speaking (and volume)
• Ask if there were any precipitating factors
• Ask about associated symptoms
  • Cough, sore throat, fever
  • Dysphagia, aspiration, ear pain, nasal blockage
  • Dyspnoea
  • Reflux, globus
  • Weight loss, anorexia, night sweats
• Ask about PMHx/Concurrent illness
  • In particular, throat problems e.g. URTI, previous tonsillitis etc
  • Any thyroid/neck surgery/problems
  • Any neurological conditions
• Ask about FHx
• Ask about SHx
  • Smoking
  • Alcohol
  • Occupation
    • Any singing (professionally or amateur)
    • Use of voice regularly
    • ?Chemical exposure

Examination

•  Check for any signs of airway obstruction
  • NB if you are at all worried about airway obstruction, make sure to ensure a patent airway and consult anaesthetics about further management, depending on the cause
• Assess voice quality, ability to cough and swallow
• Examine the neck for lymphadenopathy, scars, any thyroid abnormalities, any local tenderness
• Measure temperature and weight if appropriate
• Chest exam may be appropriate
• Neurological exam (including cranial nerves) may be appropriate
• Nasopharyngoscopy (if available) may be used to assess the vocal folds

Investigations

• Referral + Laryngoscopy and/or CXR are indicated for patients with hoarseness persisting for >3 weeks without a known cause (particular in patients >50yo, smokers and heavy drinkers)
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Causes

•  Infectious
  • Acute laryngitis
• Benign lesions
  • Vocal nodules
  • Polyps of the vocal folds
  • Papillomas of the larynx
  • Reinke’s Oedema
• Malignancy
  • Laryngeal cancer
  • Other neck/chest tumours e.g. lung, thyroid
• Neurological/Neuromuscular
  • Laryngeal nerve palsy (often secondary to tumours, vascular masses etc)
  • Laryngeal Reflux
  • Stroke
  • Parkinson’s Disease
  • Motor neuron disease
  • Myaesthenia Gravis
  • Muscle tension dysphonia
• Systemic/Endocrine
  • Hypothyroidism, acromegaly
  • Rheumatoid arthritis (affecting cricoarytenoid joints)
  • Granulomatous disease (sarcoid, Wegener’s)
• Medications
  • Inhaled steroids
  • Anticholinergics
• Functional
  • Voice overuse
  • Spasmodic dysphonia
  • Idiopathic
• Other contributing factors
  • GORD