hoarseness and laryngitis

Hoarseness and LaryngitisHoarseness and Laryngitis

Dept of OtolaryngologyDept of Otolaryngology

BERJIS N, MDBERJIS N, MD

Definition of HoarsenessDefinition of Hoarseness

• the perceived the perceived breathiness quality breathiness quality of the voice (Bailey)of the voice (Bailey)

• a rough or noisy a rough or noisy quality of voice quality of voice (Dorland)(Dorland)

• a rough, harsh voice a rough, harsh voice quality (Stedman)quality (Stedman)

Symptom –vs- DiagnosisSymptom –vs- Diagnosis• Hoarseness is a symptom of a Hoarseness is a symptom of a

disease processdisease process

• Although hoarseness appears on the Although hoarseness appears on the ICD9 as a diagnosis (784.49):ICD9 as a diagnosis (784.49):– it is really a symptom resulting from the it is really a symptom resulting from the

underlying disease processunderlying disease process– the underlying disease process is your the underlying disease process is your

diagnosis (ex. vocal nodules)diagnosis (ex. vocal nodules)

Anatomy: Laryngeal Anatomy: Laryngeal CartilageCartilage

Anatomy: Laryngeal Anatomy: Laryngeal MusclesMuscles

HistologyHistology

• Mucosal layerMucosal layer– Pseudostratified squamous epithelium Pseudostratified squamous epithelium

superiorly and inferiorlysuperiorly and inferiorly– Nonkeratinizing squamous epithelium at Nonkeratinizing squamous epithelium at

contact surface of medial cordcontact surface of medial cord

HistologyHistology

• Subepithelial tissues: three layered Subepithelial tissues: three layered lamina proprialamina propria– Superficial Layer (Reinke’s space)Superficial Layer (Reinke’s space)– Intermediate layerIntermediate layer– Deep layerDeep layer

•the intermediate and deep layers make up the intermediate and deep layers make up the vocal ligamentthe vocal ligament

• Vocalis and thyroarytenoid muscleVocalis and thyroarytenoid muscle

HistologyHistology

Physical ExaminationPhysical Examination

• Laryngeal mirrorLaryngeal mirror– AdvantagesAdvantages: fast, inexpensive, minimal : fast, inexpensive, minimal

equiptmentequiptment– DisadvantagesDisadvantages: gag, nonphysiologic, no : gag, nonphysiologic, no

permanent image capabilitypermanent image capability

Physical ExaminationPhysical Examination

• Rigid Laryngoscopy (70 or 90-degree Rigid Laryngoscopy (70 or 90-degree telescope)telescope)– AdvantagesAdvantages: best optic image, : best optic image,

magnifies, video documentationmagnifies, video documentation– DisadvantagesDisadvantages: gag, nonphysiologic, : gag, nonphysiologic,

expensiveexpensive

Physical ExaminationPhysical Examination

• Flexible fiberoptic nasolaryngoscopeFlexible fiberoptic nasolaryngoscope– AdvantagesAdvantages: well tolerated, physiologic, : well tolerated, physiologic,

video documentationvideo documentation– DisadvantagesDisadvantages: time consuming, : time consuming,

expensive, resolution limited by expensive, resolution limited by fiberoptics fiberoptics

Physical ExaminationPhysical Examination

• VideostroboscopyVideostroboscopy– AdvantagesAdvantages: allows apparent “slow : allows apparent “slow

motion” assessment of mucosal motion” assessment of mucosal vibratory dynamics, video vibratory dynamics, video documentationdocumentation

– DisadvantagesDisadvantages: time consuming, : time consuming, expensiveexpensive

Surgical TreatmentSurgical Treatment

Varices and EctasiasVarices and Ectasias

CystsCysts

• TreatmentTreatment– Cold instrument resectionCold instrument resection

•Subepithelial infusion of saline and epinephrine Subepithelial infusion of saline and epinephrine is helpfulis helpful

•Must retreive entire cyst wall to prevent Must retreive entire cyst wall to prevent recurrencerecurrence

•Preserve normal SLPPreserve normal SLP

– Microspot CO2 laser not as effective due to Microspot CO2 laser not as effective due to necessity of delicate tangential dissectionnecessity of delicate tangential dissection

CystsCysts

• ResultsResults– Mucosal wave usually improvesMucosal wave usually improves– Does not return to normal if cysts has Does not return to normal if cysts has

replaced substantial amount of SLPreplaced substantial amount of SLP•SLP does not regenerateSLP does not regenerate

CystsCysts

GranulomasGranulomas

• Results from hypertrophic Results from hypertrophic inflammatory reaction due to inflammatory reaction due to traumatic mucosal disruptiontraumatic mucosal disruption

• Majority found in arytenoid regionMajority found in arytenoid region

• Usually exophytic with narrow baseUsually exophytic with narrow base

• Typically arise in patients with LPRTypically arise in patients with LPR

• Seen with endotracheal intubationSeen with endotracheal intubation

GranulomasGranulomas

• TreatmentTreatment– Vocal therapy including antireflux Vocal therapy including antireflux

managementmanagement– Surgical resectionSurgical resection

•conservative management has failed conservative management has failed

•concern of a neoplastic processconcern of a neoplastic process

•airway compromiseairway compromise

GranulomasGranulomas

GranulomasGranulomas

GranulomasGranulomas

GranulomasGranulomas

Polypoid Corditis (Reinke’s Polypoid Corditis (Reinke’s Edema)Edema)• Extensive swelling of SLPExtensive swelling of SLP

• Usually on superior surface of musculo-Usually on superior surface of musculo-membranous vocal foldmembranous vocal fold

• Typically bilateral but asymmetric volumeTypically bilateral but asymmetric volume

• Multifactorial causeMultifactorial cause– SmokingSmoking– LPRLPR– Vocal hyperfunctionVocal hyperfunction

Polypoid Corditis (Reinke’s Polypoid Corditis (Reinke’s Edema)Edema)• TreatmentTreatment

– Smoking cessationSmoking cessation– Antireflux medicationAntireflux medication– Preoperative vocal therapyPreoperative vocal therapy– SurgerySurgery

• Epithelial microflap elevation with SLP contouring and Epithelial microflap elevation with SLP contouring and reduction using either cold instruments, Microspot CO2 reduction using either cold instruments, Microspot CO2 laser, or bothlaser, or both

• Vocal ligament should never be visualizedVocal ligament should never be visualized

• Both vocal folds can be treated in one procedure if flap Both vocal folds can be treated in one procedure if flap is elevated on superior surface of vocal foldis elevated on superior surface of vocal fold

Polypoid Corditis (Reinke’s Polypoid Corditis (Reinke’s Edema)Edema)

PapillomatosisPapillomatosis

• Human papillomavirus 6 and 11Human papillomavirus 6 and 11

• Confined to epitheliumConfined to epithelium– Excision should preserve SLPExcision should preserve SLP

• Most commonly found in musculo-Most commonly found in musculo-membranous region, but may extend membranous region, but may extend into arytenoid, ventricle, subglottisinto arytenoid, ventricle, subglottis

PapillomatosisPapillomatosis

• Surgical treatmentSurgical treatment– Cold instrumentsCold instruments– MicrodebriderMicrodebrider– Microspot CO2 laserMicrospot CO2 laser

• Resection of lesions inhibits Resection of lesions inhibits recurrence in 30% of chronic patientsrecurrence in 30% of chronic patients

PapillomatosisPapillomatosis

PhysiologyPhysiology

1.1. Airway protectionAirway protection2.2. Swallowing Swallowing

3.3. Voice productionVoice production

4.4. Air passageAir passage

inspiration

phonation

Common laryngeal Common laryngeal disordersdisorders

1. Acute laryngitis1. Acute laryngitis

2. Croup2. Croup

3. Epiglottitis3. Epiglottitis

4. Vocal nodule4. Vocal nodule

5. Vocal polyp5. Vocal polyp

6. Vocal granuloma6. Vocal granuloma

7. Laryngeal carcinoma7. Laryngeal carcinoma

8. Laryngeal trauma8. Laryngeal trauma

9. Laryngopharyngeal reflux 9. Laryngopharyngeal reflux (LPR)(LPR)

LaryngitisLaryngitis

•Laryngitis is inflammation Laryngitis is inflammation of the vocal cordsof the vocal cords

•Laryngitis can be acute Laryngitis can be acute (short term) or chronic (short term) or chronic (long term).(long term).

•Short term Short term laryngitis usually laryngitis usually follows upper follows upper respiratory respiratory infections.infections.

•Long term Long term laryngitis is most laryngitis is most commonly caused commonly caused by misuse, overuse by misuse, overuse and exposure to and exposure to smoke, dust and smoke, dust and other irritants, as other irritants, as well as acid reflux.well as acid reflux.

Acute laryngitisAcute laryngitisPathogen - adenovirus, influenzaPathogen - adenovirus, influenza

Morexella catarrharisMorexella catarrharis

Hemophilus influenzaHemophilus influenza

Streptococcus pneumoniaeStreptococcus pneumoniae

Symptoms - hoarseness cough, +/- fever, malaise

Sign - TVC swelling

Acute laryngitisAcute laryngitisTreatment Treatment - voice rest- voice rest

- mucolytic, anticold- mucolytic, anticold

+/- antibiotic+/- antibiotic

Symptoms > 2 week, recurrent

DDx - chronic laryngitis

Croup Croup (acute (acute laryngotracheobronchitis)laryngotracheobronchitis)

- Severe respiratory infection- Severe respiratory infection

- - 6 months-2 yrs. 6 months-2 yrs.

Pathogen Pathogen - parainfluenza*influenza, - parainfluenza*influenza, adenovirusadenovirus

- follow by bacterial esp. - follow by bacterial esp. H. H. influenzainfluenzaSymptoms - early URI symptoms

- 2-3 days - barking cough, stridor- exhausted, lying down

Croup Croup (acute (acute laryngotracheobronchitis)laryngotracheobronchitis)

Diagnosis Diagnosis - symptoms & signs- symptoms & signs

- flexible scope- flexible scope

- x-ray- x-ray

norrowing of norrowing of subglottissubglottis

““Pencil’s sign”Pencil’s sign”

Pencil’s sign

NormalNormal

Croup Croup (acute (acute laryngotracheobronchitis)laryngotracheobronchitis)

Treatment Treatment - early detection- early detection

- observe, admit- observe, admit

- humidification, hydration, O2- humidification, hydration, O2

- antibiotic (penicillin)- antibiotic (penicillin)

severe severe - steroid- steroid

- - intubationintubation

EpiglottitisEpiglottitis

SignsSigns - epiglottis > swelling, inflam- epiglottis > swelling, inflam

- ** laryngospasm - ** laryngospasm เมื่��อกดลิ้นเมื่��อกดลิ้น- fiberoptic- fiberoptic

X-ray - “Thumb’s sign”

EpiglottitisEpiglottitis

TreatmentTreatment- admit, closed monitoring- admit, closed monitoring

- broad spectrum penicillin- broad spectrum penicillin

- hydration, humidification- hydration, humidification

- +/- steriod- +/- steriod

- prepare for intubation- prepare for intubation

AetiologyAetiology

• CongenitalCongenital

• TraumaticTraumatic

• InflammatoryInflammatory

• NeoplasticNeoplastic

• FunctionalFunctional

CongenitalCongenital

• LaryngomalaciaLaryngomalacia (75%)(75%)

- a “rough” cry associated with - a “rough” cry associated with stridor which is worse when stridor which is worse when

feeding and begins within a feeding and begins within a few few weeks of birth weeks of birth

CongenitalCongenital

• NeurologicalNeurological (10%)(10%)

- unilateral or bilateral recurrent - unilateral or bilateral recurrent nerve palsies (idiopathic or birth nerve palsies (idiopathic or birth trauma)trauma)

CongenitalCongenital

• OtherOther

- laryngocoele- laryngocoele

(blind sac of the laryngeal (blind sac of the laryngeal ventricle)ventricle)

- haemangioma- haemangioma

(site determines severity of (site determines severity of dysphonia)dysphonia)

Laryngistis sicca is caused by inadequate hydration. The protective mucus normally needed for the vocal cords becomes too thick and they cannot open or close properly.

Laryngitis Sicca

Acid RefluxAcid Reflux•Acid reflux affects singers Acid reflux affects singers in that the stomach acid in that the stomach acid can flow past the can flow past the esophagus into the throat. esophagus into the throat.

•Small amounts of reflux Small amounts of reflux can cause considerable can cause considerable damage.damage.

The left picture is damage from acid reflux. Notice how the vocal cords are mostly red instead of white.The right picture is the same vocal cords after successful treatment.

Another result of acid reflux.Grandulomas

Symptoms Symptoms

•HoarsenessHoarseness

•Bad/bitter taste in mouth Bad/bitter taste in mouth (especially in morning)(especially in morning)

•Chronic (on-going) coughChronic (on-going) cough

•Asthma-like symptomsAsthma-like symptoms

•Frequent throat clearingFrequent throat clearing

•Referred ear painReferred ear pain

•Pain or sensation in throatPain or sensation in throat

•Post-nasal dripPost-nasal drip

•Feeling of "lump" in throatFeeling of "lump" in throat

•Singing: Difficulty hitting Singing: Difficulty hitting high noteshigh notes

•Problems while swallowing Problems while swallowing

HemorrhageA vocal hemorrhage is actually a ruptured blood vessel on the true vocal cord, and bleeding into the tissues of the fold.It is a rare occurrence caused by aggressive use of the vocal cords (e.g. cheerleading)

Common Signs of Vocal Common Signs of Vocal AbuseAbuseby Prof. David Otis Castonguay, Radford Univ.by Prof. David Otis Castonguay, Radford Univ.

• Throat is tender to the touch after use.Throat is tender to the touch after use.

• Voice is hoarse at the end of singing.Voice is hoarse at the end of singing.

• Throat is very dry, with a noticeable “tickle” Throat is very dry, with a noticeable “tickle” that is persistent. Check dehydration.that is persistent. Check dehydration.

• Inability to produce your highest notes at Inability to produce your highest notes at pianissimo volume.pianissimo volume.

• Persistent hoarseness or an inability to sing Persistent hoarseness or an inability to sing with a clear voice after 24-48 hours of vocal with a clear voice after 24-48 hours of vocal rest. rest. www.radford.edu/~dcastong/ARTARCH/vocal.htmlwww.radford.edu/~dcastong/ARTARCH/vocal.html