Hoarseness of Voice: Causes, Evaluation & Management

20-Mark Model Answer | RGUHS ENT | Pattern: 65-year-old Male, 2 months hoarseness, cough on swallowing

PART I: DEFINITION AND ANATOMY

• Adequate subglottic air pressure (respiratory drive)
• Normal vocal fold structure (cover-body theory - mucosal wave)
• Neural coordination (RLN + SLN + CNS)
• Resonance chambers (pharynx, oral cavity, nasal cavity)

Cummings Otolaryngology (7e): "Voice production requires the interplay of respiratory drive, laryngeal valving, and supraglottic resonance. Disruption at any level produces dysphonia."

PART II: CAUSES OF HOARSENESS

CLASSIFICATION (Mnemonic: TINS-NF)

┌─────────────────────────────────────────────────────────────┐
│              CAUSES OF HOARSENESS                           │
├──────────────────────┬──────────────────────────────────────┤
│  T - Tumours         │  Laryngeal Ca (glottic, supraglottic)│
│                      │  Hypopharyngeal Ca, Thyroid Ca        │
│                      │  Bronchogenic Ca (RLN compression)    │
│                      │  Oesophageal Ca, Mediastinal nodes    │
│                      │  Papilloma (benign), Haemangioma      │
├──────────────────────┼──────────────────────────────────────┤
│  I - Inflammatory    │  Acute laryngitis (viral, bacterial)  │
│                      │  Chronic laryngitis (TB, syphilis)    │
│                      │  LPR / GORD                           │
│                      │  Reinke's oedema, Wegener's           │
├──────────────────────┼──────────────────────────────────────┤
│  N - Neurological    │  RLN palsy (unilateral/bilateral)     │
│                      │  Vagal nerve palsy (skull base)       │
│                      │  Myasthenia gravis, MS, Parkinson's   │
│                      │  Wallenberg syndrome, CVA             │
│                      │  Spasmodic dysphonia                  │
├──────────────────────┼──────────────────────────────────────┤
│  S - Structural      │  Vocal cord nodules / polyps / cysts  │
│                      │  Arytenoid fixation / subluxation     │
│                      │  Trauma (intubation, external)        │
│                      │  Post-surgical (thyroidectomy)        │
│                      │  Cricoarytenoid arthritis (RA)        │
├──────────────────────┼──────────────────────────────────────┤
│  N - Non-organic     │  Functional / Psychogenic dysphonia   │
│                      │  Muscle tension dysphonia             │
│                      │  Puberphonia (mutational falsetto)    │
├──────────────────────┼──────────────────────────────────────┤
│  F - Functional/     │  Hypothyroidism (myxoedema voice)    │
│      Systemic        │  Acromegaly, Amyloidosis              │
│                      │  Drugs (ACE inhibitors, inhaled       │
│                      │  steroids, antihistamines)            │
│                      │  Smoking, alcohol                     │
└──────────────────────┴──────────────────────────────────────┘

Scott-Brown's Otorhinolaryngology (8e), Vol 2: The larynx is divided into supraglottis (epiglottis, aryepiglottic folds, false cords, ventricles), glottis (vocal cords), and subglottis. Pathology at any level disturbs phonation differently.

Cummings: "Vocal fold paresis causes can be divided into trauma, idiopathic, tumour, and neurologic or other medical diseases. Trauma can be surgical - such as from thyroidectomy, anterior cervical spine surgery, or thoracic procedures - or from endotracheal intubation. Skull base tumours, mediastinal lymphadenopathy, and esophageal cancers can impinge at various points on the vagus nerve or its recurrent branch."

PART III: CLINICAL SCENARIO ANALYSIS

Red Flag Assessment for This Patient

Patient Profile:
┌─────────────────────────────────────────────┐
│  65-year-old MALE                           │
│  Hoarseness: 2 MONTHS (persistent)         │
│  Cough on SWALLOWING (aspiration symptom)  │
│  Associated: ?weight loss, ?dysphagia      │
└─────────────────────────────────────────────┘
         ↓
RED FLAGS PRESENT:
• Age >50 + Male
• Persistent hoarseness >3 weeks
• Cough on swallowing = aspiration = RLN palsy OR
  Supraglottic/Hypopharyngeal Ca
• Must EXCLUDE MALIGNANCY until proven otherwise

Most Likely Differential Diagnoses:

PART IV: EVALUATION

FLOWCHART - APPROACH TO HOARSENESS

HOARSENESS (>3 weeks in adult / >2 months here)
           │
           ▼
┌──────────────────────────────────────────────────┐
│          DETAILED HISTORY                        │
│  • Duration, onset (sudden vs gradual)           │
│  • Character (breathy, rough, weak, high pitch)  │
│  • Cough: dry, productive, haemoptysis           │
│  • Swallowing: odynophagia, dysphagia, aspiration│
│  • Smoking/alcohol (pack-years)                  │
│  • Voice abuse/occupation (teacher, singer)      │
│  • Prior surgery: thyroid, cardiac, thoracic     │
│  • Constitutional: weight loss, fatigue          │
│  • Drug history: ACE inhibitors, steroids        │
└──────────────────────────────────────────────────┘
           │
           ▼
┌──────────────────────────────────────────────────┐
│         PHYSICAL EXAMINATION                     │
│                                                  │
│  General: pallor, cachexia, clubbing             │
│  Neck: lymph node examination (levels I-VI)      │
│         thyroid palpation                        │
│  Respiratory: chest auscultation                 │
│               (lung mass, pleural effusion)      │
│  Oral cavity: tongue base, tonsils               │
│  CN examination (esp. IX, X, XI, XII)            │
└──────────────────────────────────────────────────┘
           │
           ▼
┌──────────────────────────────────────────────────┐
│     INDIRECT LARYNGOSCOPY (IDL) - FIRST STEP    │
│  (Held mirror, patient breathing "ee-ee")        │
│  Look for:                                       │
│  • Vocal cord mobility - unilateral/bilateral    │
│    paralysis (cadaveric, paramedian, lateral     │
│    positions)                                    │
│  • Mucosal lesion - leukoplakia, ulcer, growth   │
│  • Cord oedema, haemorrhage, asymmetry           │
│  • Supraglottic involvement                      │
│  • Interarytenoid region                         │
└──────────────────────────────────────────────────┘
           │
           ▼
┌──────────────────────────────────────────────────┐
│    FLEXIBLE NASO-LARYNGOSCOPY (FNL)             │
│  (Outpatient, awake - GOLD STANDARD for          │
│   initial laryngeal visualization)               │
│  • Dynamic assessment of cord movement          │
│  • Stroboscopy attachment for mucosal wave       │
│  • Assess subglottis                             │
│  • Laryngopharyngeal reflux signs (oedema,       │
│    erythema - postcricoid, arytenoid)            │
└──────────────────────────────────────────────────┘
           │
           ├──────────────────────────┐
           ▼                          ▼
   CORD LESION SEEN            CORD PALSY SEEN
   (growth/ulcer)              (immobile cord)
           │                          │
           ▼                          ▼
   DIRECT                     IMAGING WORKUP
   LARYNGOSCOPY +              (see below)
   BIOPSY under GA

DETAILED INVESTIGATIONS

A) Laryngoscopic Evaluation

Cummings: "Computed tomography of the neck and chest to examine the full course of the recurrent laryngeal nerve is usually indicated. MRI can be considered when skull base or intracranial lesions are suspected."

Scott-Brown's: "Flexible fibre-optic laryngoscopy... the supraglottic collapse on inspiration, which is typical of laryngomalacia, is easily seen." (and analogously, cord mobility assessment for paralysis).

B) Imaging Investigations (Especially for RLN Palsy Workup)

┌─────────────────────────────────────────────────────────────┐
│           IMAGING FLOWCHART FOR RLN PALSY                   │
│                                                             │
│  CONTRAST CT NECK + THORAX (MANDATORY)                      │
│  → Covers full RLN course from skull base to aortic arch    │
│  → Detect: lung apical tumour (Pancoast), mediastinal mass  │
│             thyroid enlargement, lymphadenopathy            │
│             oesophageal Ca, aortic aneurysm (left RLN)      │
│                      │                                      │
│                      ▼                                      │
│  MRI Brain + Skull Base                                     │
│  → If CNS cause suspected (Wallenberg, MS, tumour)          │
│                      │                                      │
│                      ▼                                      │
│  Chest X-ray PA view                                        │
│  → Mediastinal widening, hilar mass, pleural effusion       │
│                      │                                      │
│                      ▼                                      │
│  Barium Swallow / UGI Endoscopy                            │
│  → If oesophageal pathology suspected                       │
│                      │                                      │
│                      ▼                                      │
│  Ultrasound Neck / FNAC                                     │
│  → Thyroid nodule, cervical lymphadenopathy                 │
└─────────────────────────────────────────────────────────────┘

C) Voice Analysis

• Acoustic analysis: MDVP (Multi-Dimensional Voice Program) - measures jitter, shimmer, harmonic-to-noise ratio
• Maximum Phonation Time (MPT): Normal >15 sec; reduced in glottic insufficiency
• Perceptual assessment: GRBAS scale (Grade, Roughness, Breathiness, Asthenia, Strain)
• Voice Handicap Index (VHI): Patient-reported outcome measure

Cummings: "Maximum phonation time, measured as the length of time that the patient can phonate a sustained vowel, is often decreased" in vocal fold paresis.

D) Laboratory Tests

• Thyroid function (hypothyroidism - myxoedema voice)
• Blood glucose (diabetic neuropathy)
• Rheumatoid factor, ANA (cricoarytenoid arthritis in RA)
• Lyme titer, ESR (if systemic disease suspected)
• Serum ACE (sarcoidosis)
• HIV serology (if indicated)

PART V: MANAGEMENT

MANAGEMENT FLOWCHART

CONFIRMED DIAGNOSIS
        │
        ├───────────────────────────────────────────────┐
        │                                               │
        ▼                                               ▼
LARYNGEAL CARCINOMA                            RLN PALSY
(Most likely in this 65M)                      (Unilateral)
        │                                               │
        ▼                                               ▼
STAGING (TNM)                              Find CAUSE first
CT + MRI + PET-CT                          (treat primary)
        │                                               │
        ├──────────────────────────┐                    ▼
        │                          │          If idiopathic / iatrogenic:
        ▼                          ▼          Voice therapy initially
    EARLY STAGE              ADVANCED         (6 months)
   (T1/T2, N0, M0)          STAGE              │
        │                 (T3/T4, N+)          ▼
        ▼                          │    If no recovery after 6-12 months:
   GLOTTIC Ca:                     │    VOCAL FOLD MEDIALIZATION
   Radiotherapy               Combined      • Injection laryngoplasty
   (voice preservation)       CRT           • Thyroplasty Type I
   OR CO2 laser              + Surgery      • Arytenoid adduction
   cordectomy                              │
        │                          │      ▼
        ▼                          ▼    SPEECH THERAPY
  SUPRAGLOTTIC Ca:           Laryngectomy   (always adjunct)
  Supraglottic               (total/partial)
  laryngectomy                +
  + selective neck           Voice
  dissection                rehabilitation

A) Management of Laryngeal Carcinoma

Staging (AJCC/TNM 8th Edition)

GLOTTIC CARCINOMA
├── T1: Limited to vocal cord(s), normal mobility
│   ├── T1a: One cord
│   └── T1b: Both cords
├── T2: Extends to supraglottis / subglottis; impaired mobility
├── T3: Limited to larynx; cord fixation / pre-epiglottic space
├── T4a: Thyroid cartilage / outside larynx invasion
└── T4b: Prevertebral space / encases carotid / mediastinum

SUPRAGLOTTIC CARCINOMA
├── T1: One subsite, normal mobility
├── T2: >1 subsite or adjacent structures, normal/impaired mobility
├── T3: Cord fixation / postcricoid / pre-epiglottic space
└── T4: As above

Treatment Principles

• T4 disease
• Cartilage invasion
• Failed radiotherapy
• Compromised airway

1. Tracheoesophageal voice (TEP) - via Provox/Blom-Singer prosthesis (BEST)
2. Electrolarynx (external vibrator device)
3. Oesophageal voice (air swallowing technique)

Cummings: "Tracheoesophageal voice and speech" after laryngectomy; "Esophageal voice and speech" and "Electrolarynx voice" are all documented rehabilitation options.

B) Management of Unilateral Vocal Cord Paralysis

• Voice therapy with speech-language pathologist
• Treat underlying cause (lung tumour, thyroid surgery, etc.)

• Injection laryngoplasty: Gel-foam (temporary), Restylane, Radiesse, autologous fat, calcium hydroxyapatite

• Isshiki Thyroplasty Type I - silicone block placed via external approach through thyroid cartilage window to push paralyzed cord medially
• Arytenoid adduction - rotation of arytenoid cartilage toward midline (for large posterior glottic gap)
• Combined thyroplasty + arytenoid adduction - for complete RLN palsy

• Tracheostomy (for airway)
• Posterior cordotomy / arytenoidectomy (endoscopic laser) for decannulation (at cost of voice quality)

Scott-Brown's: "Vocal cord medialization procedures such as thyroplasty and augmentation injection can improve the dysphonia and aspiration."

C) Voice Therapy (All Categories)

• Resonant voice therapy
• Lee Silverman Voice Therapy (LSVT) - especially for Parkinson's
• Semi-Occluded Vocal Tract Exercises (SOVT) - lip trills, straws
• Vocal Function Exercises (Stemple)
• Accent method, Lessac-Madsen Resonant Voice Therapy

Scott-Brown's: Dedicated chapters on LSVT, SOVT, Stemple Vocal Function Exercises, Eclectic Voice Therapy as standard approaches.

PART VI: ANATOMY DIAGRAM (LARYNX)

        SUPERIOR
           │
    ┌──────┴──────┐
    │  EPIGLOTTIS  │ ← Supraglottis begins
    └──────┬──────┘
           │
    ┌──────┴──────────────┐
    │  ARYEPIGLOTTIC FOLD │
    └──────┬──────────────┘
           │
    ┌──────┴────────────┐
    │  FALSE CORD        │
    │  (Vestibular fold) │
    └──────┬────────────┘
           │
    ╔══════╧════════╗  ← VENTRICLE (sinus of Morgagni)
    ║  VOCAL CORD   ║  ← GLOTTIS (phonation occurs here)
    ║  TRUE CORD    ║     - Thyroarytenoid muscle
    ╚══════╤════════╝     - Vocalis muscle (medial belly)
           │               - Mucosal cover (epithelium +
           │                 Reinke's space + ligament)
    ┌──────┴────────┐
    │  SUBGLOTTIS   │ ← extends to inferior cricoid border
    └──────┬────────┘
           │
         TRACHEA
         INFERIOR

RLN COURSE (Left side - LONGER):
Aortic arch → mediastinum → tracheoesophageal groove → 
Berry's triangle → enters larynx via cricothyroid joint

PART VII: RECENT ADVANCES

1. Laryngeal Imaging

• High-speed videoendoscopy (HSV): Captures up to 4,000 frames/sec vs 25 fps for stroboscopy; reveals true mucosal dynamics, ideal for spasmodic dysphonia and voice tremor
• Narrow Band Imaging (NBI) laryngoscopy: Enhances vascular patterns; differentiates benign from malignant lesions without biopsy (sensitivity ~90%)
• Optical Coherence Tomography (OCT): Sub-surface microstructural imaging; may reduce need for biopsy in early glottic lesions
• AI-assisted laryngeal image analysis: Deep learning algorithms for automated polyp/carcinoma detection

2. Vocal Fold Augmentation

• Injectable hyaluronic acid fillers (cross-linked) - longer lasting than Gel-foam
• Autologous fat injection - biocompatible, durable
• Calcium hydroxyapatite (Radiesse): Long-duration vocal fold medialization

3. Laryngeal Framework Surgery

• Modified Isshiki thyroplasty with implantable Gore-Tex/silicone prostheses
• Cricothyroid subluxation - for pitch adjustment
• In-office laryngeal injection under flexible endoscopy (awake, outpatient, no GA) - major recent advance

4. Transoral Laser Microsurgery (TLM) - KTP/CO2

• CO2 laser with micromanipulator or KTP laser via flexible fiber
• Organ-preserving surgery for T1/T2 glottic Ca
• Better voice outcomes vs open surgery

5. Robotic Surgery (TORS)

• Transoral robotic surgery for supraglottic Ca
• Better visualization, dexterity, reduced tracheostomy rates

6. Chemo-radiation organ preservation

• RTOG 91-11 protocol: Concurrent cisplatin + RT superior to induction chemo for larynx preservation
• Modern protocols: Intensity Modulated Radiotherapy (IMRT) reduces xerostomia and dysphagia

7. Biologics / Immunotherapy

• Anti-PD-1 (pembrolizumab, nivolumab) for recurrent/metastatic laryngeal SCC
• HPV-targeted therapies in younger patients (HPV 16 + laryngeal Ca)

Recent Evidence (PMID 37527869 - Cleveland Clinic J Med, 2023): "Current guidelines from the American Academy of Otolaryngology-Head and Neck Surgery on the diagnosis and treatment of dysphonia include patient referral for laryngoscopy when hoarseness persists beyond 4 weeks in at-risk patients." Direct visualization via laryngoscopy is the standard of care.

Recent Evidence (PMID 34391543 - Med Clin North Am, 2021): Hoarseness review covering physiology, differential diagnosis, role of LPR in dysphonia, and myriad tools available for treatment. Role of reflux should be examined critically.

PART VIII: SPECIFIC WORKUP SUMMARY FOR THIS PATIENT

65M, 2 months hoarseness + cough on swallowing

STEP 1: HISTORY
• Smoking history (pack-years) - MOST IMPORTANT
• Alcohol - synergistic risk with smoking
• Weight loss, haemoptysis, dysphagia (odynophagia)
• Prior neck/chest/cardiac surgery (RLN iatrogenic)
• Voice character: breathy (RLN palsy) vs harsh (cord lesion)
• Aspiration: cough especially for liquids = glottic incompetence

STEP 2: EXAMINATION
• Full ENT examination
• Neck - lymph nodes (levels II, III, IV especially for laryngeal Ca)
• Thyroid, tracheal deviation
• Chest - signs of lung carcinoma
• IDL / Flexible laryngoscopy - MANDATORY

STEP 3: INVESTIGATIONS
• FNL with stroboscopy - cord mobility + mucosal wave
• CT Neck + Thorax with contrast (MOST IMPORTANT IMAGING)
  → rules out lung Ca, thyroid Ca, oesophageal Ca pressing RLN
• CECT / MRI for laryngeal carcinoma staging
• CXR - mediastinal widening
• TFT - hypothyroidism
• Blood: CBC, LFT, RFT, electrolytes
• If cord lesion on endoscopy → MLB + Biopsy under GA

STEP 4: DIAGNOSIS AND TREATMENT
Based on findings:
• Carcinoma larynx → Staging + Oncology MDT (surgery/RT/CRT)
• RLN palsy due to lung/mediastinal Ca → Treat primary, voice therapy
• Chronic laryngitis → Conservative + anti-reflux therapy
• Benign lesion (polyp) → Microlaryngoscopy + excision

REFERENCES

QUICK REVISION TABLE (RGUHS Pattern)

RGUHS Examiner Note: For a 20-mark question, this answer should be structured as: Definition (2) + Causes with classification (4) + Clinical scenario analysis (2) + History and Examination (3) + Investigations with flowchart (4) + Management with diagram (4) + Recent advances (1) = 20 marks. All flowcharts above can be redrawn as hand-drawn diagrams in the exam.