Hoarseness & Stridor

Key Features

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)

• Laryngopharyngeal reflux (gastroesophageal reflux into the larynx) 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

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, typically inspiratory, 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

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 can help identify structural and functional problems with the voice, including vocal fold paralysis, muscle tension dysphonia, and spasmodic dysphonia

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