Hoarseness: A Common Problem with Often Serious Causes
Abstract: The Center for Voice and Swallowing Disorders specializes in evaluating and treating dysphonia. Hoarseness that persists for more than three weeks should be evaluated by an otolaryngologist.
From Clinical Update, Spring 2007
Any patient who has been hoarse for three weeks or more should be evaluated by an otolaryngologist,” advises Carter Wright, M.D., assistant professor of otolaryngology and director of the Center for Voice and Swallowing Disorders. “This is our standard recommendation to primary care physicians and other health care providers whose patients have often waited for an extended period of time to seek care for their condition.”
According to Wright, “Hoarseness, also known as dysphonia, will occasionally defy any obvious explanation. Patients frequently and inaccurately attribute their hoarseness to a recent respiratory infection, although months may have passed and all other symptoms of the infection have long since disappeared.”
While respiratory viruses are one possible cause of chronic hoarseness, other causes include:
• Carcinoma, typically a Squamous Cell variety
• Acid reflux, or silent reflux—laryngopharyngeal reflux
• Benign lesions, such as nodules, polyps and cysts
• Aging (presbylaryngis)
• Neuropathy, often from prolonged intubation, surgical trauma, malignancy
• Tumors and arterial abnormalities of the chest, both of which can interfere with the course of the recurrent laryngeal nerve.
Wright explained that a symptom described as ‘hoarseness’ is the tell-tale sign of virtually all laryngeal lesions.
He added, “We now believe that the vocal folds, which are dependent on and densely innervated by two pairs of nerves, are susceptible to any decrease in activity of those nerves. When the neuron is weakened, so, too, is its targeted muscle fiber. As the muscle fibers atrophy, the vocal folds go from being full and robust to atrophic and bowed. They are no longer able to approximate appropriately, resulting in dysphonia.”
The evaluation of a patient experiencing dysphonia begins with a fiber-optic laryngoscopy, which may be coupled with stroboscopy “to capture the intricacies of the vocal fold motion too subtle to appreciate with the naked eye. We can thus identify all phases of the vocal fold mucosal vibration.”
If there is a gap between the vocal cords, Wright said, “We will usually proceed to a laryngeal electromyography (EMG), which is performed in concert with a neurologist. For this procedure, we use a fine electrode and insert it into four representative muscles of the larynx. From these recordings we are able to ascertain the health and strength of each muscle and then infer something about the health and strength of the nerve that drives it.”
The Center for Voice and Swallowing Disorders specializes in evaluating and treating dysphonia. “A full continuum of diagnosis and treatment is one of the things that sets this center apart,” said Wright.
“By the time many patients arrive here, they have already failed some initial therapy. Our goal is to complete a comprehensive evaluation quickly, and treat each underlying condition aggressively.”