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)
  • hghghghg

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
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