Hoarseness: Causes of Hoarseness: Examination and Investigations

HOARSENESS
Hoarseness is defined as the roughness of voice, which results from an abnormality within the larynx with variation in periodicity, and intensity of consecutive sound waves.
Pathophysiology Of Hoarseness:
For the normal production of voice, vocal cords should be able to approximate properly with each other, have proper size and stiffness and have an ability to vibrate in response to the air column. Any condition that interferes with these functions may cause hoarseness. Loss of approximation may be seen in vocal cord paralysis, fixation of crico-arytenoid joint or any lesion present between the cords, preventing its approximation. Size and stiffness of the vocal cords may change due to paralysis, oedema, tumour, fibrosis and partial surgical excision. Cords are unable to vibrate properly in the presence of oedema, congestion, sub-mucosal haemorrhage, nodule, polyp or tumour.

Causes of Hoarseness:

Hoarseness may be acute (less than a few weeks in duration) or chronic (more than a few weeks in duration) in type.
The causes of acute hoarseness are:

• Acute inflammation Acute laryngitis
• Acute laryngo-tracheo-bronchitis
• Laryngeal diphtheria
• Trauma
• a- Vocal abuse
• Foreign body in the larynx
• Inhalation of irritant fumes
• Cutthroat
• Intubation & other instrumentation
• External injury to the larynx
• Sudden paralysis of vocal cords
• After thyroidectomy
• Trauma to the recurrent laryngeal nerve
• Other neurological conditions like CVA
• Laryngeal oedema due to allergy
• Functional e.g. psychosomatic, hysteria

The causes of chronic hoarseness are:

• Congenital
• Laryngeal web
• Congenital laryngeal paralysis
• Congenital cysts and tumours
• Chronic Inflammation e.g., Chronic laryngitis
• Laryngeal tuberculosis c- Other chronic inflammations e.g. Syphilis
• Intubation granuloma
• Vocal Nodules
• Tumours of the larynx: benign and malignant
• Vocal cord paralysis
• Vocal cord polyp
• Laryngocele

Sometimes weakness of voice is present which is not true hoarseness, as in:

• Myasthenia gravis
• General debility
• Myxoedema
• Functional dysphonia
• Acromegaly
• Convalescence from severe illness

Management Of Patient with Hoarseness

History: Mode of onset and duration of Hoarseness is very important. Any hoarseness persisting for more than three weeks requires thorough examination and investigations and the malignancy should be excluded first, especially in patients above forty years of age. Patient’s occupation, habits and associated complaints should be noted to find the cause.
Examination: Examination of the larynx by indirect laryngoscopy or flexible laryngoscopy is very helpful. Examination of the neck, oral cavity, nose and chest must be done thoroughly.
Investigations: Laboratory and radiological investigations should be done accordingly. Direct laryngoscopy examination and biopsy of any lesion may be needed.