Hoarseness is a symptom of the changed voice quality that patients have described. This article's goal is to assist doctors in determining the root cause of dysphonia. Careful history-taking and physical examination may assist determine the underlying cause and guide therapy.

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Approximately one-third of the population will have dysphonia (impaired voice production) at some time in their lives. Although the terms dysphonia and hoarseness are sometimes used interchangeably, hoarseness is a symptom of decreased voice quality reported by patients, whereas dysphonia denotes poor voice production as identified by a physician.

Patients with dysphonia may be of any age or gender, although it is more common among teachers, senior citizens, and other people who have heavy vocal demands. 1 in 13 individuals has voice issues every year. Only a small percentage of patients seek medical attention for vocal problems, despite reporting a considerable speech impairment. Dysphonia is the cause of frequent trips to the doctor. Dysphonia is often brought on by benign or self-limiting diseases, but it may also be the first sign of a more severe or developing problem that has to be identified and treated right once.

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History

As with any other presenting problem, getting a patient's history when they have hoarseness is straightforward. Smoking history, dysphagia, odynophagia or otalgia, stridor, hemoptysis, recent fevers, night sweats, and unexplained weight loss are all significant warning flags. If any of these conditions exist and the hoarseness persists, an otorhinolaryngologist should be consulted right once. Intermittent hoarseness is less likely to be caused by a fixed lesion.

Heartburn and any recent upper respiratory illnesses should be included in the history. Check the patient's technique while using a steroid inhaler and see whether they gargle after each puff. As the RLN may have been harmed, find out whether the patient has recently had surgery or suffered a neck or chest trauma. Similar to this, recent intubation may have caused laryngeal damage (particularly if it was protracted or violent).

Hypothyroidism, neurological disorders like Parkinson's disease or myasthenia gravis, and inflammatory or autoimmune illnesses like rheumatoid arthritis are examples of associated systemic diseases. Voice hoarseness is very common among those who use their voices professionally. The social history should include both professional and extracurricular pursuit.

 

Questions about voice

Was the start of your hoarseness sudden or gradually developing? Is your voice always hoarse, or does it ever go back to normal? Did you have an upper respiratory tract illness at the time or did it last? Are you in discomfort or does speaking need effort? Does using your voice cause it to weaken or tire? What about the way your voice is different? Do you have trouble projecting or speaking loudly? Have your pitch or range changed recently? Do you ever experience spoken air-outs? Does your voice tremble or falter? Before the commencement of the dysphonia, were you intubated? Have you had surgery on your chest, neck, spine, or brain before the beginning of dysphonia? Have you lately used steroids, antibiotics, or inhaledadications? Do you need a voice for your job? Do you need to use your voice often throughout the day? Do you smoke, vape, or partake in recreational drug use? Does it feel dry in your throat? Have you received head and neck radiation treatment? Do you suffer from any arthritic or neurological conditions? Before the voice change, did you experience any physical, emotional, or psychological trauma?

 

Symptoms

Globus pharyngeus (persisting sensation of a lump in throat) Dysphagia Sore throat Chronic throat clearing Cough Odynophagia (pain with swallowing) Nasal drainage Postnasal drainage Acid reflux Regurgitation Heartburn Hemoptysis Nonanginal chest pain Waterbrash (sudden appearance of salty liquid in the mouth) Halitosis (“bad breath”) Weight loss Night sweats Fever (>101.5°F) Otalgia (ear pain) Dyspnea (difficulty breathing)

Relevant medical background to dysphonia

Occupation and/or avocation requiring extensive voice use (eg, teacher, singer). Absenteeism from occupation due to dysphonia. Prior episodes of hoarseness. Relationship of instrumentation (eg, intubation) to the onset of dysphonia. Relationship of prior surgery to neck or chest to the onset of dysphonia Cognitive impairment (the requirement for a proxy historian) Anxiety, depression, stress

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Examination

The larynx cannot be seen, and evaluating hoarseness is challenging. A comprehensive head, neck, and chest exam may rule out a lot of differential diagnoses. First, pay attention to the voice's quality, pitch, and loudness. Ask the patient to hold the vowel sound "ah" for as long as they can during this time, then time it. Although the maximum phonation duration might vary, if it is fewer than eight seconds, an organic disease is often indicated.

Listen for stridor during the respiratory examination. This is a concerning indication of airway blockage and has to be immediately referred for direct visualisation. A restrictive lung disease that is influencing the amount of air moving through the larynx and consequently the patient's voice may be indicated by decreased lung expansion and auscultation.

Examination of the oropharynx and oral cavity may reveal lesions that impact the resonance chamber and, as a result, the patient's impression of a change in voice. Check and feel the tonsils and base of the tongue in particular. Additionally, a cranial nerve test must be performed since it can reveal a central pathology. If the history points to a central or neurological disorder, further neurological testing should be taken into consideration. Examine the thyroid and the neck for any lumps. If any systemic reasons are suspected, further system investigations would be advised. Indirect laryngoscopy may be helpful if the medical professional is skilled in the practice.

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Investigation and management

According to NICE recommendations, every patient over 45 with persistent, unexplained hoarseness should be sent to a specialist for further evaluation. However, it is advised that any chronic hoarseness present for more than three weeks necessitates referral for direct visualisation. The urgency of the referral should reflect concomitant symptoms and related red flags.

A simple referral and care protocol for common benign diseases is shown in the attached figure. Any suspected mass should be imaged, a fine needle aspiration performed and then sent to an otorhinolaryngologist for follow-up care. Before visualising the larynx, imaging is not advised if the rest of the evaluation has been normal.

Voice rest should be advised if the history and examination point to voice overuse or phonotrauma. Patients must be made aware that whispering is bad for their voices and should be avoided. For patients who use their voices professionally, a recommendation for speech treatment will be crucial. It has been shown that hydration of the vocal folds by a high fluid intake, steam inhalation, or the use of humidifiers is a key factor in enhancing the health and effectiveness of the vocal cords. Other vocal hygiene techniques include giving up alcohol and tobacco use and consuming less coffee.

Laryngopharyngeal reflux (LPR) patients often have raspy voices when they first arrive. Heartburn and persistent throat clearing are the most frequent additional signs and symptoms. Proton pump inhibitors should be tested, and lifestyle changes to reduce reflux should be made. Recent research has revealed that laryngopharyngeal reflux is overdiagnosed, thus if symptoms persist after using the aforementioned treatment techniques, a referral to an otorhinolaryngologist should be made and a different diagnosis should be sought after. Additionally, more cancerous pathologies may coexist with LPR.

Laryngitis often develops with signs of an upper respiratory illness or recent vocal abuse. A history of earlier incidents could exist. Simple viral laryngitis often goes away on its own within three weeks. Encourage voice relaxation, appropriate hydration, and vocal cleanliness throughout this time. Lozenge-sucking might also be beneficial.

Laryngitis caused by steroid inhalers is rather common and often curable. Make sure the patient is using the inhaler correctly and gargling after each usage in addition to cleaning their mouth. It would be fair to begin taking an antifungal drug if oral thrush was discovered during an examination of the oral cavity and oropharynx. Additionally, the patient could express intolerance to hot and spicy foods. As steroid inhalers have been demonstrated to be ineffective, consider whether they are still necessary and, if so, at what dosage.

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Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

About the author of this article: Dr Monish Raut is a practising super specialist from New Delhi.