Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 8-27: Dysphonia, Hoarseness, & Stridor + Key Features Download Section PDF Listen +++ +++ 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 + Clinical Findings Download Section PDF Listen +++ +++ 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 + Diagnosis Download Section PDF Listen +++ +++ 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 + Treatment Download Section PDF Listen +++ +++ 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 + Outcome Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Andreassen ML et al. Emerging techniques in assessment and treatment of muscle tension dysphonia. Curr Opin Otolaryngol Head Neck Surg. 2017 Dec;25(6):447–52. [PubMed: 28984699] + +Lechien JR et al. Association between laryngopharyngeal reflux and benign vocal folds lesions: a systematic review. Laryngoscope. 2019 Sep;129(9):E329–41. [PubMed: 30892725] + +Lechien JR et al. Laryngopharyngeal reflux disease: clinical presentation, diagnosis and therapeutic challenges in 2018. Curr Opin Otolaryngol Head Neck Surg. 2018 Dec;26(6):392–402. [PubMed: 30234664] + +Lechien JR et al. Voice outcomes of laryngopharyngeal reflux treatment: a systematic review of 1483 patients. Eur Arch Otorhinolaryngol. 2017 Jan;274(1):1–23. [PubMed: 27007132] + +Jaworek AJ et al. Acute infectious laryngitis: a case series. Ear Nose Throat J. 2018 Sep;97(9):306–13. [PubMed: 30273430] + +Stachler RJ et al. Clinical Practice Guideline: Hoarseness (dysphonia) (update). Otolaryngol Head Neck Surg. 2018 Mar;158(1 Suppl):S1–42. [PubMed: 29494321]