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Hoarseness and Laryngeal Disorders

Elizabeth Guardiani MD, Matthew DeLaney, MD, FACEP, FAAEM, and Neda Frayha, MD
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18:38

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Hoarseness is a common complaint in the primary care setting. Our ENT colleague, Dr. Elizabeth Guardiani, sits down with Drs. Matt DeLaney and Neda Frayha to discuss how we can approach this in primary care as well as when to refer to a specialist. 

 

Pearls:

  • To diagnose hoarseness, patients need to have their larynx evaluated by an ENT with direct laryngoscopy, especially if hoarseness persists beyond 4 weeks or they have risk factors such as smoking.

  • Avoid empiric therapy in the treatment of hoarseness.

 

  • Hoarseness:

    • Not typically a medical emergency

    • History:

      • Clear and inciting event (ie: after URI, trauma)

      • Duration

      • Smoking history

      • Surgery, intubation

      • Occupation (ie: professional voice users - like singers, doctors, lawyers, teachers)

      • Throat pain or dysphagia

    • Most common causes:

      • 1. Viral laryngitis

        • Obvious etiology with symptoms of a URI

        • May last 3-4 weeks

      • 2. Muscle tension dysphonia (10-40% of patients coming into specialist evaluation)

        • Behavioral voice disorder where people use excess laryngeal tension when speaking related to:

          • Stress, anxiety

          • Irritation of larynx

      • 3. Reflux

        • Overdiagnosed in the general ENT community

        • May cause swelling/edema of the larynx

        • Should not empirically treat for reflux without evaluation of their larynx

      • 4. Phonotrauma

        • Stress on vocal cords from speaking

      • 5. Atrophy

        • Common in elderly where the vocal cords lose muscle mass, thin out leading to a softer more raspy voice

      • 6. Smoking - Reinke’s Edema

        • Swelling of vocal cords from smoking that causes the pitch to drop and soften

      • 6. Paralysis or paresis

        • Weakness of a vocal cord that can lead to a hoarse or breathy voice quality

      • 7. Laryngeal cancer

        • Uncommon

        • Best diagnosed with laryngoscopy not CT scan

      • 8. Obstructive sleep apnea

        • Snoring leads to persistent laryngitis

      • 9. Medications

        • Corticosteroid inhalers: associated with fungal laryngitis

        • ACE-inhibitors: cough leading to laryngitis

        • Bisphosphonates: chemical laryngitis

    • Evaluation:

      • If > 4 weeks, refer to ENT or sooner if other concerning symptoms from history

        • Flexible scope through the nose

        • Rigid scope through the mouth

        • Strobe light to visualize vocal cord movement because they move too quickly to the naked human eye

      • X-rays, CT are not helpful in the primary evaluation of hoarseness

    • Treatment:

      • Empiric treatment (antacid, steroids, antibiotics)  is NOT recommended without larynx visualization

      • Phonotrauma, inflammation:

        • Many respond well to voice therapy to learn how to strengthen and use voice muscles appropriately

        • Steroids (not routinely) to help bring inflammation down

      • Cancer or large polyps:

        • Surgery

      • Paralyzed vocal cords:

        • Surgery and voice therapy

 

REFERENCE:

  1. American Academy of Otolaryngology-Head and Neck Surgery. Clinical Practice Guideline: Hoarseness (Dysphonia). https://www.entnet.org/content/clinical-practice-guideline-hoarseness-dysphonia. Published June 24, 2019.

Cohen, SM, Kim, J, Roy, N. Prevalence and causes of dysphonia in a large treatment—seeking population. Laryngoscope. 2012;122:343-348

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Primary Care RAP December 2019 Written Summary 3 MB - PDF

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