hoarse voice

cortical areas for speech

-dominant hemisphere (L usually) -primary motor cortex: area for laryngeal & oral musculature -Broca's area -Wernicke's area

Reinke's oedema

-extensive swelling of superf lamina propria of vocal folds -bilat -v deep voice -cause multifactorial: smoking, GORD -Rx: >smoking cessation >anti-reflux meds >pre-op speech & language therapy >surg

VF nodules

-fibrovascular tissue -2ndary to inappropriate vocal use/abuse -between ant & mid 1/3 of VFs -bilat -videolaryngostroboscopy assessment -Rx: >SLT (soft nodules) >surg last resort (<5%) (hard nodules)

VF polyps

-from trauma to superf lamina propria & microvasculature -mid-cord -size/shape/composition varies >pedunculated/sessile >vascular/fibrotic/myxoid -contralat damage to opposing VF common -excision with microinstruments during microlaryngoscopy

VF granuloma

-hypertrophic infl reaction from traumatic mucosal disruption in post commisure -GORD -endotracheal intubation -assymetric arytenoid movement/tension -Rx: >SLT >anti-reflux meds >surgical resection

intracordal cyst

-in superf lamina propria -most from obstructed mucus ducts -confused with polyps -Rx: excision glottoplasty -must retrieve entire cyst wall to prevent recurrence

neoplastic causes

-laryngeal ca -thyroid ca -lung ca -lymphoma

cord adduction muscles

-lat cricoarytenoid -transverse arytenoid -vocalis & thyroarytenoid: shortening/relaxation of cords

vocal cord palsy causes

-malignant (30%) e.g. thyroid tumour, mets from bronchial ca -iatrogenic (25%) e.g. thyroid surg -external trauma (15%) -idiopathic (15%) -other (15%) e.g. ventricular hypertrophy -> aortic arch unfolds -> traction on L recurrent laryngeal n

dysarthria

-motor speech disorder -> difficulty articulating speech -PD -cerebral palsy -damage to motor cortex e.g. CVA -CN V, VII, IX, X, XII

chronic laryngitis

-persistent dysphonia -assoc >GORD >airborne irritants >sinonasal disease Rx: -voice hygiene -treat underlying cause -rule out malignancy

idiopathic causes

-presbyphonia -vocal cord palsy

nerve supply below vocal folds

-recurrent laryngeal n (CNX) -motor to all muscles in larynx except cricothyroid (adductors & abductors of folds) -sensory to laryngeal mucosa below vocal folds

vocal cord palsy treatment

-speech & language therapy -vocal fold medialization >Isshiki thyroplasty >injection thyroplasty -laryngeal reinnervation

vocal fold microstructure

-stratified epithelium -lamina propria: superf, intermed, deep layers -vocalis lig -vocalis muscle

nerve supply above vocal folds

-sup laryngeal n (CNX) -ext branch motor to cricothyroid muscle (tenses & adducts vocal chords) -int branch sensory & secretomotor to area between lower pharynx-vocal folds

vascular causes

-thoracic aortic aneurysm -arteriovenous malformation

iatrogenic causes

-thyroid/parathyroid surg -neck dissection -cardiothoracic surg -tracheal intubation

benign causes

-vocal cord nodules (professional voice users) -Reinke's oedema (smoking assoc) -vocal cord polyps (voice exertion e.g. matches) -laryngeal papillomatosis (HPV) -functional dysphonia -spasmodic dysphonia -muscle tension dysphonia (-> nodules)

endocrine cause

hypothyroidism

hoarseness/dysphonia

impaired voice quality, harsh, rough, breathy

laryngeal carcinoma

-1% of all cancers RFs: -male 4:1 -incr age (rare <40yo) -smoking -EtOH -HPV 16 & 18 inf -FHx 1st deg relative Presentation: -hoarseness -cough -palpable lymph node -referred otalgia (CNX) -stridor

neurological causes

-CVA -PD -motor neurone disease

inflammatory causes

-GORD/laryngopharyngeal reflux (LPR) -chronic cough -chronic rhinosinusitis (postnasal drip) -airborne irritants (smoking) -autoimmune

VF papillomatosis

-HPV 6 & 11 -in epithelium -ant 2/3 of fold, can extend anywhere in resp tract -surgical Rx: >microdebrider >microspot CO2 laser >helica >adjuvant cidofovir -high recurrence rate -incidence decr due to quadrivalent vaccine (Gardasil) -assoc with head & neck ca

acute laryngitis

-URTI Hx -short duration -aphonia -sore throat Rx: -voice rest -hydration -humidification - +/- abx

Hx & [red flags]

-age: malignancy more common in older pts -occupation & hobbies: professional voice use (teacher, singer), football matches -> vocal fold nodules from straining -[smoking/EtOH]: up malignancy risk -onset: gradual/sudden -duration: [unexplained hoarseness for >3wks] -> 2ww referral for suspected cancer -persistence: constant/intermittent, triggers -assoc symp: [dysphagia], [wt loss], [referred otalgia], acid reflux, sinonasal/chest disease, aspiration -prev surgery/radiotherapy

phonation requirements

-air supply: lungs -vibratory source: vocal folds -resonating chamber: vocal folds to lips/nostrils

larynx functions

-airway protection: elevation in 2nd stage of deglutition -resp -phonation -valsalva: forced expiration against closed glottis (defaecation, childbirth)

dysphasia

-central impairment of language -expressive: Broca's aphasia -receptive: Wernicke's aphasia

congenital causes

-congenital vocal cord palsy -glottic web

O/E

-direct ENT exam >oral cavity >oropharynx >nasal cavity >neck nodes >thyroid >voice quality -indirect >flexible nasolaryngoscopy >rigid videostroboscopy: records phonatory cycle

investigations in vocal cord palsy

CT: skull base -> diaphragm

infective causes

acute viral/bacterial/fungal laryngitis

glottis in phonation

closed

glottis in inspiration

open

cord abduction muscles

posterior cricoarytenoid