A concise approach to the hoarse voice

Persistent dysphonia has a significant impact on a patient’s quality of life and remains a common problem within the general practice setting. While a significant proportion of patient presentations are of the acute inflammatory nature in association with upper respiratory tract infections, the persistent of dysphonia beyond a period of 2 weeks requires further assessment.

In this short paper, I will attempt to highlight my approach to the assessment of dysphonia to identify the minority with malignancy and diagnosing the benign pathologies that afflict the larynx. So beginning with the history, some key questions in my mind are:

1. Any recent upper respiratory infections? Even a minor viral URTI can cause sufficient abnormality of the delicate mucosal folds of the larynx or exacerbate pre-existing pathology
2. Are there any associated sinister upper aero-digestive tract symptoms? In the region of the larynx and hypopharynx, malignancies cause symptoms such as dysphagia, odynophagia, haemoptysis or referred otalgia
3. Smoking and alcohol history? The risk of malignancy is proportional to the pack year smoking history. Alcohol has a synergistic effect. Smoking can also cause a range of benign laryngeal pathology that can be treated such as hyperkeratosis, Reinke’s oedema (Fig 1) as well as lung cancers that can lead to recurrent laryngeal nerve palsy leading to breathiness
4. Pattern of symptoms? Excessive voice use with occupational demands can create vocal strain. Anxiety/Depression and public speaking fears are often associated with muscle tension. Reflux generally creates an episodic pattern, and is usually worse in the morning. Sudden onset after excessive strain (eg. football spectator) can indicate an acute haemorrhage into the vocal cord
5. Voice demand of patient? Are there occupational factors that are associated with risk of developing benign nodules (teacher, lawyers, doctors, singers, salespeople) and what are the occupational voice needs of the patient
6. Presence of laryngopharyngeal reflux? Silent extra-oesophageal acid reflux can cause a range of symptoms ranging from globus, irritation, throat clearing, “phlegminess” and dysphonia
7. Any associated chest disease? The use of steroid inhalers for COPD can cause laryngeal candidiasis. Persistent cough from reflux, COPD or post-nasal drip from rhinosinusitis can cause vocal cord microtrauma. Lung cancer, TB or thoracic surgery can cause recurrent laryngeal nerve palsy which can manifest as breathy dysphonia
8. Thyroid disease and surgery? Myxedema can cause deposits of proteoglycans that thicken the vocal cords manifesting as a deep hoarse dysphonia and thyroid surgery is a risk factor for vocal cord palsy
9. Any associated neurological symptom? Conditions such as a CVA, multiple sclerosis, motor neurone disease can cause bulbar dysfunction which results in centrally mediated vagal dysfunction
10. Recent intubation? This can be associated with vocal cord granuloma and scarring/indentation disrupting the mucosal wave and cricoarytenoid unit dysfuction
11. Impact on the patient’s quality of life? Assessment of the impact of the condition on the patient’s psychological, social and occupational demands. Motivation to seek treatment and pursue speech therapy if required

These questions can rapidly give clues to the causes of the patient’s diagnosis and also the overall impact of the disability. Very often like the old medical adage, the answer remains hidden in the history.

Moving on to the examination, I begin with a general vocal assessment. This involves the patient uttering a sentence in their normal voice projection. It is crucial at this stage to identify if possible if the dysphonia is breathy or hoarse. Breathiness indicates air escape within the larynx. It signifies a range of conditions where the mobility of vocal cords is affected (eg recurrent laryngeal nerve palsy). Hoarseness indicates pathology of the mucosal fold and where the vocal wave is affected (eg malignancy, Reinke’s oedema, nodules) Fig 2.

Figure 1: Reike’s Oedema

Figure 2: Early vocal cord cancer

Figure 3: Nasal septal Perforation

After this I move on to a systematic physical examination of the patient in the following order:

1. Examination of nose and nasopharynx including nasendoscopy. Are there polyps or any evidence of post-nasal drip? Is there significant crusting or septal perforation heralding Wegener’s (Fig 3)?
2. Examination of oropharynx. Is there candidiasis? Is there another sinister ulcer/lesion?
3. Examination of the larynx. Direct per-nasal or per-oral laryngoscopy to assess mucosal fold, mobility and pyriform fossa. Complete assessment for malignancy and reflux. Analysis of vocal cord mobility and glottis closure (eg presbylarynx in old age leading to atrophy and air escape) or vocal cord palsy
4. A thorough examination of all nodal regions of the neck and the thyroid gland

Once the history and examination are completed, an accurate diagnosis can be made in a vast majority of patients. Unless a malignancy is suspected a biopsy under general anaesthetic or further imaging is not required. In some cases stroboscopy may be required in a setting of a voice clinic.

My general treatment approach is outlined below:

Vocal Hygiene

1. I take every opportunity to educate my patients about vocal hygiene, including projection, breath control and avoidance of shouting
2. Maintain adequate hydration , this is crucial to the lubrication of the cords
3. Complete smoking cessation including discussion of quitting techniques and medications
4. Reduction of caffeine (drying effect)

Treatment of Laryngopharygeal Reflux

1. General dietary and lifestyle modifications for reflux including avoiding alcohol and spicy meals
2. Initial double dose proton-pump inhibitor for 3 months followed by maintenance once daily
3. Judicious use of prokinetics (domperidone) and alginates
4. Consider fundoplication for treatment refractory reflux in consultation with gastroenterology and upper GI surgery colleagues

Speech Therapy

1. Speech therapy has a crucial role in treating the aetiology of vocal pathology (eg nodules), treating the effect of vocal pathology on the function of the patient (eg. muscle tension dysphonia) and training in compensatory techniques (eg supraglottic swallow for cord palsy)

Surgery

1. Laser treatment. The cardon dioxide and KTP lasers have revolutionised the endoscopic management of benign and malignant laryngeal conditions. I routinely offer this for pre-malignant and malignant pathology as the oncological outcomes are identical to radiotherapy(RT) and it keeps the options of radiotherapy open for future use. RT can generally only be used once in a lifetime within a field and furthermore these patients are at up to 20% lifetime risk of another cancer in the head and neck region which may require RT. All malignant cases are discussed at the Westmead Comprehensive Cancer Care Centre, where I am a surgeon at the cancer MDT. This allows for discussion with my RT colleagues of the planned treatment.
   The laser is also very useful for a range of benign conditions such as Reinke’s oedema, granulomas and webs.
2. Coblation treatment. This is a radiofrequency based technique which I utilise for benign conditions such as polyps and papillomas.
3. Injection and thyroplasty techniques. These techniques offer a very effective treatment for breathy dysphonia due to volume loss in the cords (eg age atrophy) or for vocal cord palsy. Depending on the aetiology and the expected prognosis the appropriate implant materials can be injected or inserted into the vocal cord. For example, in a palliative setting of advanced lung cancer and vocal cord palsy causing aspiration, a temporary injectable such as Perlane/Restylane can be used or alternatively bioplastique when longer duration is desired. A Gore-tex implant inserted externally for a more permanent solution.
   The decision for surgery is taken with the patient being aware of the technical aspects of the procedure, risk and benefits, expected outcome and post-operative care including any speech therapy that may be required.

Conclusion

A precise diagnosis can be obtained for the vast majority of phonatory conditions. It is important not to underestimate the impact of dysphonia on a patient’s psychosocial functioning. The bright side of it is that good outcomes can be obtained for benign and malignant conditions with a combination of surgery and speech therapy, including for vocal cord cancers where up to 90-95% 5 year survival in achievable with laser treatment, one of the highest in head and neck cancers.