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Dysphonia/Laryngeal Disorders

Terms in this set (24)

Dysphonia
This is another word for hoarseness
-Disorder characterized by altered vocal quality, pitch, loudness or vocal effort that impairs communication or reduces vocal related QOL
Laryngeal Anatomy
9 cartilages + Hyoid Bone
-Thyroid, cricoid and epiglottic cartilages
-Paired arytenoid (vocal cord motion)
-corniculate
-cuneform

Extrinsic Muscles:
-Supra and Infrahyoid constrictors and cricothyroid

Intrinsic
-Posterior cricoarytenoid (only one that opens up the vocal cords)
-Lateral cricoarytenoid (Acts to close the glottis)
-Thyroarytenoid
-these control the arytenoid cartilages

Cricothyroid muscles are responsible for controlling the pitch of the voice

Nerve Supply:
-Motor supply comes from CN X
-RLN supplies the intrinsic muscles
-EXT SLN supplies the cricothyroid muscle (adduction)
-Sensation above is SLN
-Below is RLN

Vibration
-Comes from vocal fold layers rubbing together to produce sound
-3 layers of lamina propria over vocalis muscle is what supplies it
Laryngeal Physiology
3 Functions:
-Conduit for air from the lungs to the outside
-Valve to protect the lungs
-Communication by making sound
Important historical Features
Chronology
Family History
Psychology
Medical History-Medications, Reflux, Smoking, Surgery, Radiation therapy
Vocal use- job, recreational activities
Trauma
Physical Exam
Complete Head and Neck Exam
Listen to the Voice
3 month guideline for laryngoscopy
Laryngoscopy
-Mirror
-Flexible Endoscopy
-Rigid Endoscopy
DDx Dysphonia
If the voice varies widely over a short period of time.. the voice is likely normal
-If the voice is always bad then there is likely some pathology going on here

DDx
Functional voice disorders
Tumors
Chronic noninfective laryngitis
Infection
Benign mucosal abnormalities
Laryngeal Trauma
Neurogenic Voice Disorders
Functional Dysphonias
Everything is anatomically intact
Excessive laryngeal tension
-VOICE THERAPY
Benign Tumors
Laryngeal Papilloma is by far the most common
-pebbly in appearance
-Often there are multiple nodules

HPV types 6 and 11
High rate of recurrence
Treatment is removal to maintain voice/airway
Multiple other benign tumors in small percentages
Malignant Tumors
Squamous Cell Carcinoma almost exclusively
Family Dr's concern in dysphonic patients
Gradual onset of a rough voice in a long time smoker
T1-4
Treatment is surgery or radiation therapy depending on T stage
Infection
The acute cases are viral laryngitis
-rest the voice till you get better

Chronic
-bacterial can follow a viral URTI or other rare infections
-Fungal think steroids or immunocompromised
Chronic Nonspecific Laryngitis
Chronic inflammatory changes in vocal fold structure
Results in stiff, poorly vibrating vocal folds

Causes are multifactorial and include GERD, smoking, allergies, vocal abuse ,occupational and other? factors
-these are what you are going to have to eliminate

Carcinoma and other significant disease must be ruled out
Benign Mucosal Abnormalities
Relatively common-includes nodules, polyps, granulomas, cysts, sulcus
-often they are due to vocal cord overuse and abuse
-intubation and iatrogenic trauma are also common
Vocal Nodules
-Little bumps on the vocal cords

Occur as a result of vocal abuse (yelling, singing or acting)
Maximum trauma occurs at junction of the anterior one third posterior two thirds
Treatment is usually initially voice therapy
Surgery is a last resort
Vocal Granulomas
Secondary to trauma to the posterior glottic mucosa (vocal process)
Area will ulcerate then granulate
Intubation, vocal abuse, coughing, reflux, or iatrogenic manipulation may cause
-the uleraction followed by granulation is critical!!
Treat by preventing trauma, they will usually resolve spontaneously
Vocal Cord Polyps
Unilateral
Most often an isolated event
URI +/- vocal trauma
Vocal hemorrhage
Formation of polyp
Almost all require removal

Bilateral
Superior aspects of anterior vocal cords
Most often heavy smoking, voice using females
Treatment is to stop smoking
Removal will improve voice
Vocal Cord Cyst
These come on suddenly and unexpectedly and give a persistently dysphonic voice
-Essentially it is an obstructed mucus gland
Laryngeal Trauma
AIRWAY IS THE MOST IMPORTANT THING!!
-Start there and then continue the workup
Neurogenic Voice Loss
CVA
Vocal Cord Paralysis
Dystonia
Vocal tremor
Parkinson's
Motor Neuron disease
Other- Tourette's, Myoclonus
Vocal Cord paralysis
This is the most common cause of paralysis
Unilateral vs Bilateral
Remember the anatomy RLN vs SLN vs X nerve
SLN paralysis- minor vocal changes
RLN paralysis- causes much more significant changes
Unilateral paralysis- voice is the issue
Bilateral paralysis- airway is the issue

Etiology:
-Tumor, Trauma, Infection, Surgery

Unilateral
-Breathy voice that gets worse with increased activity
-Initially these people often struggle with aspiration
-You need to medialize the vocal cord if it is really Bad

Bilateral
-THINK AIRWAY
-Always going to be a trade off between voice and airway
Spasmodic Dysphonia
Focal Dystonia
Adductor (95%)-Tight strangled breaking speech
Abductor- Breathy spasmodic breaks in voice
Exact etiology is unknown
Best treatment is currently Botox
Neurologic Vocal Tremor
This is the essential tremor of the voice world
Progressive Tremor of Voice in a more elderly patient (Katherine Hepburn)

Often Familial

Often associated with hand and head tremors

Also called Benign Essential Voice Tremor

Moderate to Severe cases may be Rx with Botox
Dysphonias in kids
Virtually always benign
Nodules(screamers)
Papillomas, hemangiomas
Congenital anomalies-paralysis, webs, stenosis, laryngeal clefts, etc
Key message if a child has significant dysphonia or stridor- see ENT
Subglottic Stenosis
Reasonably common
Biphasic stridor inspiratory more prominent
Most commonly idiopathic
Occaisionally trauma
Typically adult female with remote, routine intubation in the past
Rx is laser/cautery and dilation initially
Most often recurs slowly then repeat? Or resection?
Paradoxical Vocal Fold Motion
May present acutely

More commonly intermittent inspiratory stridor which resolve spontaneously

Often occur when anxious or upset

Sometimes precipitated by severe cough

Usually female

Often patient complains of obstruction at laryngeal level

Diagnosis is by clinical suspicion

Confirmed by endoscopy

In mild intermittent cases, often only reassurance is needed

In persistent cases, behavioural therapy by voice therapist gives relief
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