Hoarseness, Dysphonia, & Stridor

Essentials of Diagnosis

• The primary symptoms of laryngeal disease are hoarseness and stridor

General Considerations

• Hoarseness is caused by an abnormal vibration of the vocal folds

Acute hoarseness

• Acute laryngitis is the most common cause of hoarseness

• Acute laryngitis is thought to be viral in origin, although Moraxella catarrhalis and Haemophilus influenzae isolates from the nasopharynx occur at higher than expected frequencies

Persistent hoarseness

• Vocal fold nodules or polyps (from overuse of voice or improper use over extended periods of time) produce prolonged hoarseness

• Vocal fold polypoid changes (from vocal abuse, smoking, chemical industrial irritants, or hypothyroidism)

• Gastroesophageal reflux is a common cause of chronic hoarseness and should be considered if other causes of abnormal laryngeal airflow (such as tumor) have been excluded by laryngoscopy; < 50% of patients have typical symptoms of heartburn and regurgitation

• In patients with a history of tobacco use, laryngeal cancer or lung cancer (leading to paralysis of a recurrent laryngeal nerve) must be strongly considered in persistent hoarseness

Symptoms and Signs

• The voice is "breathy" when too much air passes incompletely apposed vocal folds, as in unilateral vocal fold paralysis or vocal fold mass

• The voice is harsh when the vocal folds are stiff and vibrate irregularly, as is the case in laryngitis or malignancy

• Heavy, edematous vocal folds produce a rough, low-pitched vocal quality

• Stridor, a high-pitched sound, is the result of turbulent airflow from a narrowed upper airway

  • Airway narrowing at or above the vocal folds produces inspiratory stridor

  • Airway narrowing below the vocal folds produces either expiratory or biphasic stridor

• In gastroesophageal reflux-induced hoarseness, the voice is usually worse in the morning and improves during the day; associated symptoms include a feeling of a lump in the throat or an excessive desire for throat clearing

Differential Diagnosis

• Laryngitis

• Voice overuse

• Vocal fold nodules, polyps, or papillomas

• Intubation granulomas

• Laryngeal cancer

• Lung cancer

• Unilateral vocal cord paralysis

• Hypothyroidism

• Retrosternal goiter, thyroiditis, multinodular goiter, or thyroid carcinoma

• Gastroesophageal reflux

• Angioedema

Imaging Studies

• Consider chest radiograph for tumor

Diagnostic Procedures

• Evaluation of an abnormal voice begins with obtaining a history of the circumstances preceding its onset and an examination of the airway

• Laryngoscopy should be done when hoarseness has persisted for > 2 weeks

• In gastroesophageal reflux, nonresponders to medical management should undergo pH testing and manometry

Medications

• Erythromycin may reduce the severity of hoarseness and cough in acute laryngitis

Vocal cord polypoid changes

• Attention to the underlying cause may resolve the problem

• Inhaled corticosteroid spray (eg, beclomethasone, 42 mcg/spray, or dexamethasone, 84 mcg/spray, two or three times daily) may hasten resolution

Gastroesophageal reflux

• Empiric trial of a proton pump inhibitor at twice-daily dosing (eg, omeprazole, 20 mg twice daily orally) for 2–3 months is a practical alternative to an initial pH study

• If symptoms improve and cessation of therapy leads to recurrence of symptoms, resume a proton pump inhibitor at the lowest dose effective for remission, usually daily but at times on a demand basis

• H₂-receptor antagonists are generally less clinically effective

Surgery

• Recalcitrant nodules or polyps may require excision

Complications

• In hoarseness from acute laryngitis, patients should avoid vigorous use of the voice (singing, shouting) while laryngitis is present to avoid formation of vocal nodules

Prognosis

Acute laryngitis

• Self-limited

• May persist for 1–2 weeks after other symptoms of upper respiratory tract infection have cleared

Vocal nodules

• Benign condition

Prevention

• Prevent vocal abuse, particularly among singers

• Modification of voice habits to avoid formation of vocal fold nodules

When to Refer

• All cases of stridor

• Rapid-onset stridor should be evaluated emergently