Hoarseness. Common referral Hoarseness reflects any abnormality of normal phonation.
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Transcript of Hoarseness. Common referral Hoarseness reflects any abnormality of normal phonation.
Hoarseness
Hoarseness
Common referral Hoarseness reflects any abnormality of normal
phonation
Cartilaginous skeleton
Cricoarytenoid Joint
True synovial joint
Intrinsic Musculature
Abductors Adductors Tensors
Intrinsic Musculature
Innervation
Abduction
Adduction
Tension
Vocal Fold Anatomy
Laryngeal function
Sphincteric function Respiration Phonation Other
– Stabilizes the thorax by preventing exhalation during lifting
– Compresses abdominal cavity during coughing or straining
Phonation
Physical act of sound production by means of passive vocal fold interaction with the exhaled airstream
Pitch Quality Volume
Sound Production
– Contraction of expiratory muscles– Rise in subglottic air pressure– Escape through glottis– Closure
Bernoulli effect elasticity
Phonation
Glottal puff– Release of air as upper margins of TVC separate
Phase delay– Delay of closure between upper and lower margins
of TVC
Mucosal wave– Horizontal and vertical components
Mucosal wave/Phase delay
Body-Cover Theory
Changes to mucosal wave– Stiffness– tension
Mucosal wave
Velocity increases– Increased airflow– Increased subglottic pressure
Fundamental Frequency
Pitch (measure in Hertz) Changes in vibration frequency
– Mass– Stiffness– viscosity
Workup
“Any patient with hoarseness of two weeks duration or longer must undergo visualization of the vocal cords”
Workup
History Physical Examination Ancillary tests
History
URI– Laryngitis– Overuse with edema and inflammation– Paralyses– Granulomas from coughing
History
Trauma– Arytenoid dislocation– Nerve paralysis– Laryngeal fractures– Mucosal lacerations
History
Intubation– Arytenoid dislocations– Nerve injury– granulomas
History
Pulmonary conditions – power source– COPD– Asthma
History
Gastrointestinal– LPR
Autoimmune – RA
Endocrine – Hypothyroidism
Neurologic disorders
Surgical History
Skullbase procedures Carotid endarterectomies Thyroidectomies Aortic aneurysm repairs
Medications
Social History
Tobacco Alcohol ?Inflammation ?Drying of secretions ?malignancy
Occupational History
Voice abuse
Associated Symptoms
Physical Examination
Head & neck examination Laryngeal examination
– Physiologic position– Image quality– Magnification– Cost– Required equipment– Time/skill necessary
Laryngeal examination
Indirect mirror Flexible laryngoscopy Rigid laryngoscopy
Indirect mirror examination
Advantages– Quick– Inexpensive– Little equipment
Disadvantages– Gag– Anatomic features– nonphysiologic
Flexible laryngoscopy
Advantages– Well tolerated– Complete examination– Video documentation
Disadvantages– More time– Expensive
Rigid laryngoscopy
Advantages– Best images– Magnification– Video documentation
Disadvantages– Expensive– Nonphysiologic– Gag– Anatomic features
Videostroboscopy
Light quasi-synchronized with vocal fold vibrations– Bell microphone– Electroglottography
Video recording– Detailed review– Comparison after treatment
Videostroboscopy
Synchronous = motionless Asynchronous = slow motion
Videostroboscopy
Vocal fold closure pattern Vocal fold vibratory pattern Mucosal wave of each vocal fold Symmetry
Videostroboscopy
Radiographic studies
MRI CT
Laryngeal EMG
Myopathy – normal frequency of firing but decreased amplitude
Neuropathy – decreased frequency but occasional normal amplitudes
Polyphasic reinnervation potentials indicate some loss of function but reinnervation has begun
Laryngeal EMG
Differential
Congenital Inflammatory Neoplastic Traumatic Neurologic Endocrine Iatrogenic Local factors
Vocal Cysts
Vocal Nodules
Usually bilateral Voice rest and speech therapy for 6 months Surgical removal
Vocal cord granulomas
LPR Intubation Treat medically
Vocal Cord Paralysis
Lesion at nuclear level – cadaveric Lesion above nodose ganglion – abducted Lesion below nodose ganglion - paramedian
Vocal Cord Paralysis
Superior laryngeal nerve – subtle voice changes with decreased pitch range, tilting of the larynx with a rotation of the glottis
Vocal Cord Paralysis
Children– Neurologic– Traumatic– Idiopathic
Adults– Iatrogenic– Traumatic– Neoplastic– Idiopathic– neurologic
Vocal Cord Paralysis