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WASHINGTON – If your patient complains of hoarseness, how do you handle it? Although the causes of hoarseness are often obvious, many patients with hoarseness have vocal folds that appear normal, which can create a diagnostic challenge, said Dr. Seth M. Cohen of Duke University Medical Center in Durham, N.C., and Dr. J. Pieter Noordzij of Boston Medical Center.
Some of the most common causes of hoarseness in patients with normal-looking vocal folds are muscle tension/functional dysphonia, spasmodic dysphonia, vocal fold tremor, Parkinson’s disease, presbylaryngis (vocal fold atrophy), and amyotrophic lateral sclerosis. Dr. Cohen and Dr. Noordzij reviewed these conditions and shared cases at the annual meeting of the American Academy of Otolaryngology – Head and Neck Surgery Foundation.
The Work-Up
When evaluating a patient’s hoarseness, start with a history and physical exam. The history should include the duration of hoarseness, how it started, family history of hoarseness, and the patient’s vocal demands that could contribute to overuse of the voice, Dr. Cohen said. Fluid intake (or lack of) can play a role, as can certain medical conditions such as gastroesophageal reflux disease (GERD) and allergies involving postnasal drip, he said.
The complete evaluation of a hoarse patient should include a full head and neck exam and a full cranial nerve exam, as well as an assessment of general appearance, facial expression, and endolaryngeal findings, Dr. Cohen said.
In addition, clinicians can use a perceptual voice analysis to try to characterize the general voice quality in terms of roughness (raspy), breathiness, strain (voice breaking), pitch (may be lower than normal), articulation, and speed, Dr. Cohen said. Techniques to evaluate patients include asking them to whisper, sing, make sustained vowel sounds (aaah, eee, ooo), and count from 60 to 69 and from 80 to 89.
Although some patients with hoarseness may benefit from surgical procedures, voice therapy is usually the first choice for treatment, he noted.
"Listen to the patient, listen to what they tell you, and listen to what they sound like," Dr. Cohen said.
Muscle Tension/Functional Dysphonia
Patients with muscle tension and functional dysphonia have excessive tension or poor coordination of the muscles in and near the voice box. The hoarseness in these patients often occurs after a cold and may be worse at the end of the day, said Dr. Noordzij.
On physical exam, this patient’s voice may be raspy and lower in pitch than normal. Someone who puts heavy demands on their voice might be susceptible to this condition, Dr. Noordzij said. They perceive their voice as strained and lower pitched, and they feel that are talking at the end of a breath. An endolaryngeal exam may show a gap between the vocal folds and squeezing of the larynx above the vocal folds (called a supraglottic constriction).
Spasmodic Dysphonia
Spasmodic dysphonia (SD) most often occurs in adulthood and can be triggered by a major life stress, Dr. Noordzij said. SD is a neurologic problem, not a functional one, he noted. SD is a movement disorder that involves involuntary, repetitive contractions of the laryngeal muscles. SD may be one of two types: adductor (a spasm that pushes the vocal folds together) or abductor (a spasm that causes the vocal cords to pull apart). Adductor spasmodic dysphonia is the most common form. Vocal characteristics include a strained or strangled voice that breaks on voiced syllables. However, voice breaks do not occur when the patient whispers, sings, or speaks in a falsetto, Dr. Noordzij said.
Vocal Fold Tremor
Vocal tremor is a central nervous system disorder that can be associated with other tremor conditions such as Parkinson’s disease, cerebellar ataxia, and spasmodic dysphonia, Dr. Cohen said.
"The hallmark of the condition is a rhythmic alteration in both the pitch and the loudness," he said. Vocal tremor may be exacerbated by stress or fatigue, and there may be a family history of tremor, he added.
On physical exam, patients with vocal tremor also may have tremor of the hands, head, jaw, voice, pharynx, tongue, or palate. Oscillations of pitch and amplitude are most noticeable during sustained vowels.
Parkinson’s Disease
Patients with Parkinson’s disease can present with voice complaints before they have a Parkinson’s diagnosis, although they also may exhibit Parkinson’s symptoms including hand tremor, rigidity, drooling, or a shuffling gait, Dr. Cohen said.
Hoarseness in these patients is characterized by breathy, flat voice, in a monotone, with breaths at inappropriate times. Patients also may have decreased blinking and a lack of facial expression.
Parkinson’s patients may have a history of not realizing the low volume of their voices, and they may take breaths at inappropriate times, Dr. Cohen noted. An endolaryngeal exam may show evidence of vocal fold bowing and a pooling of secretions, he said.
Presbylaryngis
Presbylaryngis, also known as vocal fold atrophy, is caused by age-related changes in the vocal folds, including ossification of laryngeal cartilage, decreased muscle bulk, decreased mucus production, and thickening or thinning of the epithelium.
"This is one of the hardest problems to treat surgically," Dr. Cohen said. Therefore, voice therapy is the first line treatment, he said.
In general, the pitch of men’s voices rises in cases of presbylaryngis, while the pitch of women’s voices decreases, Dr. Cohen noted. Patients perceive their voices as breathy and weak, with vocal fatigue and decreased ability to project their voices.
Amyotrophic Lateral Sclerosis
Approximately 25% of patients with amyotrophic lateral sclerosis (ALS) present with speech and swallowing problems. ALS is a progressive degeneration of the upper and lower motor neurons. Speech in these patients is typically slow, weak, and hypernasal, said Dr. Cohen. ALS patients may have dysarthria (disturbance of articulation) as well as dysphonia, and involuntary twitches of the tongue, he added.
Neither Dr. Cohen nor Dr. Noordzij had any financial conflicts to disclose.
WASHINGTON – If your patient complains of hoarseness, how do you handle it? Although the causes of hoarseness are often obvious, many patients with hoarseness have vocal folds that appear normal, which can create a diagnostic challenge, said Dr. Seth M. Cohen of Duke University Medical Center in Durham, N.C., and Dr. J. Pieter Noordzij of Boston Medical Center.
Some of the most common causes of hoarseness in patients with normal-looking vocal folds are muscle tension/functional dysphonia, spasmodic dysphonia, vocal fold tremor, Parkinson’s disease, presbylaryngis (vocal fold atrophy), and amyotrophic lateral sclerosis. Dr. Cohen and Dr. Noordzij reviewed these conditions and shared cases at the annual meeting of the American Academy of Otolaryngology – Head and Neck Surgery Foundation.
The Work-Up
When evaluating a patient’s hoarseness, start with a history and physical exam. The history should include the duration of hoarseness, how it started, family history of hoarseness, and the patient’s vocal demands that could contribute to overuse of the voice, Dr. Cohen said. Fluid intake (or lack of) can play a role, as can certain medical conditions such as gastroesophageal reflux disease (GERD) and allergies involving postnasal drip, he said.
The complete evaluation of a hoarse patient should include a full head and neck exam and a full cranial nerve exam, as well as an assessment of general appearance, facial expression, and endolaryngeal findings, Dr. Cohen said.
In addition, clinicians can use a perceptual voice analysis to try to characterize the general voice quality in terms of roughness (raspy), breathiness, strain (voice breaking), pitch (may be lower than normal), articulation, and speed, Dr. Cohen said. Techniques to evaluate patients include asking them to whisper, sing, make sustained vowel sounds (aaah, eee, ooo), and count from 60 to 69 and from 80 to 89.
Although some patients with hoarseness may benefit from surgical procedures, voice therapy is usually the first choice for treatment, he noted.
"Listen to the patient, listen to what they tell you, and listen to what they sound like," Dr. Cohen said.
Muscle Tension/Functional Dysphonia
Patients with muscle tension and functional dysphonia have excessive tension or poor coordination of the muscles in and near the voice box. The hoarseness in these patients often occurs after a cold and may be worse at the end of the day, said Dr. Noordzij.
On physical exam, this patient’s voice may be raspy and lower in pitch than normal. Someone who puts heavy demands on their voice might be susceptible to this condition, Dr. Noordzij said. They perceive their voice as strained and lower pitched, and they feel that are talking at the end of a breath. An endolaryngeal exam may show a gap between the vocal folds and squeezing of the larynx above the vocal folds (called a supraglottic constriction).
Spasmodic Dysphonia
Spasmodic dysphonia (SD) most often occurs in adulthood and can be triggered by a major life stress, Dr. Noordzij said. SD is a neurologic problem, not a functional one, he noted. SD is a movement disorder that involves involuntary, repetitive contractions of the laryngeal muscles. SD may be one of two types: adductor (a spasm that pushes the vocal folds together) or abductor (a spasm that causes the vocal cords to pull apart). Adductor spasmodic dysphonia is the most common form. Vocal characteristics include a strained or strangled voice that breaks on voiced syllables. However, voice breaks do not occur when the patient whispers, sings, or speaks in a falsetto, Dr. Noordzij said.
Vocal Fold Tremor
Vocal tremor is a central nervous system disorder that can be associated with other tremor conditions such as Parkinson’s disease, cerebellar ataxia, and spasmodic dysphonia, Dr. Cohen said.
"The hallmark of the condition is a rhythmic alteration in both the pitch and the loudness," he said. Vocal tremor may be exacerbated by stress or fatigue, and there may be a family history of tremor, he added.
On physical exam, patients with vocal tremor also may have tremor of the hands, head, jaw, voice, pharynx, tongue, or palate. Oscillations of pitch and amplitude are most noticeable during sustained vowels.
Parkinson’s Disease
Patients with Parkinson’s disease can present with voice complaints before they have a Parkinson’s diagnosis, although they also may exhibit Parkinson’s symptoms including hand tremor, rigidity, drooling, or a shuffling gait, Dr. Cohen said.
Hoarseness in these patients is characterized by breathy, flat voice, in a monotone, with breaths at inappropriate times. Patients also may have decreased blinking and a lack of facial expression.
Parkinson’s patients may have a history of not realizing the low volume of their voices, and they may take breaths at inappropriate times, Dr. Cohen noted. An endolaryngeal exam may show evidence of vocal fold bowing and a pooling of secretions, he said.
Presbylaryngis
Presbylaryngis, also known as vocal fold atrophy, is caused by age-related changes in the vocal folds, including ossification of laryngeal cartilage, decreased muscle bulk, decreased mucus production, and thickening or thinning of the epithelium.
"This is one of the hardest problems to treat surgically," Dr. Cohen said. Therefore, voice therapy is the first line treatment, he said.
In general, the pitch of men’s voices rises in cases of presbylaryngis, while the pitch of women’s voices decreases, Dr. Cohen noted. Patients perceive their voices as breathy and weak, with vocal fatigue and decreased ability to project their voices.
Amyotrophic Lateral Sclerosis
Approximately 25% of patients with amyotrophic lateral sclerosis (ALS) present with speech and swallowing problems. ALS is a progressive degeneration of the upper and lower motor neurons. Speech in these patients is typically slow, weak, and hypernasal, said Dr. Cohen. ALS patients may have dysarthria (disturbance of articulation) as well as dysphonia, and involuntary twitches of the tongue, he added.
Neither Dr. Cohen nor Dr. Noordzij had any financial conflicts to disclose.
WASHINGTON – If your patient complains of hoarseness, how do you handle it? Although the causes of hoarseness are often obvious, many patients with hoarseness have vocal folds that appear normal, which can create a diagnostic challenge, said Dr. Seth M. Cohen of Duke University Medical Center in Durham, N.C., and Dr. J. Pieter Noordzij of Boston Medical Center.
Some of the most common causes of hoarseness in patients with normal-looking vocal folds are muscle tension/functional dysphonia, spasmodic dysphonia, vocal fold tremor, Parkinson’s disease, presbylaryngis (vocal fold atrophy), and amyotrophic lateral sclerosis. Dr. Cohen and Dr. Noordzij reviewed these conditions and shared cases at the annual meeting of the American Academy of Otolaryngology – Head and Neck Surgery Foundation.
The Work-Up
When evaluating a patient’s hoarseness, start with a history and physical exam. The history should include the duration of hoarseness, how it started, family history of hoarseness, and the patient’s vocal demands that could contribute to overuse of the voice, Dr. Cohen said. Fluid intake (or lack of) can play a role, as can certain medical conditions such as gastroesophageal reflux disease (GERD) and allergies involving postnasal drip, he said.
The complete evaluation of a hoarse patient should include a full head and neck exam and a full cranial nerve exam, as well as an assessment of general appearance, facial expression, and endolaryngeal findings, Dr. Cohen said.
In addition, clinicians can use a perceptual voice analysis to try to characterize the general voice quality in terms of roughness (raspy), breathiness, strain (voice breaking), pitch (may be lower than normal), articulation, and speed, Dr. Cohen said. Techniques to evaluate patients include asking them to whisper, sing, make sustained vowel sounds (aaah, eee, ooo), and count from 60 to 69 and from 80 to 89.
Although some patients with hoarseness may benefit from surgical procedures, voice therapy is usually the first choice for treatment, he noted.
"Listen to the patient, listen to what they tell you, and listen to what they sound like," Dr. Cohen said.
Muscle Tension/Functional Dysphonia
Patients with muscle tension and functional dysphonia have excessive tension or poor coordination of the muscles in and near the voice box. The hoarseness in these patients often occurs after a cold and may be worse at the end of the day, said Dr. Noordzij.
On physical exam, this patient’s voice may be raspy and lower in pitch than normal. Someone who puts heavy demands on their voice might be susceptible to this condition, Dr. Noordzij said. They perceive their voice as strained and lower pitched, and they feel that are talking at the end of a breath. An endolaryngeal exam may show a gap between the vocal folds and squeezing of the larynx above the vocal folds (called a supraglottic constriction).
Spasmodic Dysphonia
Spasmodic dysphonia (SD) most often occurs in adulthood and can be triggered by a major life stress, Dr. Noordzij said. SD is a neurologic problem, not a functional one, he noted. SD is a movement disorder that involves involuntary, repetitive contractions of the laryngeal muscles. SD may be one of two types: adductor (a spasm that pushes the vocal folds together) or abductor (a spasm that causes the vocal cords to pull apart). Adductor spasmodic dysphonia is the most common form. Vocal characteristics include a strained or strangled voice that breaks on voiced syllables. However, voice breaks do not occur when the patient whispers, sings, or speaks in a falsetto, Dr. Noordzij said.
Vocal Fold Tremor
Vocal tremor is a central nervous system disorder that can be associated with other tremor conditions such as Parkinson’s disease, cerebellar ataxia, and spasmodic dysphonia, Dr. Cohen said.
"The hallmark of the condition is a rhythmic alteration in both the pitch and the loudness," he said. Vocal tremor may be exacerbated by stress or fatigue, and there may be a family history of tremor, he added.
On physical exam, patients with vocal tremor also may have tremor of the hands, head, jaw, voice, pharynx, tongue, or palate. Oscillations of pitch and amplitude are most noticeable during sustained vowels.
Parkinson’s Disease
Patients with Parkinson’s disease can present with voice complaints before they have a Parkinson’s diagnosis, although they also may exhibit Parkinson’s symptoms including hand tremor, rigidity, drooling, or a shuffling gait, Dr. Cohen said.
Hoarseness in these patients is characterized by breathy, flat voice, in a monotone, with breaths at inappropriate times. Patients also may have decreased blinking and a lack of facial expression.
Parkinson’s patients may have a history of not realizing the low volume of their voices, and they may take breaths at inappropriate times, Dr. Cohen noted. An endolaryngeal exam may show evidence of vocal fold bowing and a pooling of secretions, he said.
Presbylaryngis
Presbylaryngis, also known as vocal fold atrophy, is caused by age-related changes in the vocal folds, including ossification of laryngeal cartilage, decreased muscle bulk, decreased mucus production, and thickening or thinning of the epithelium.
"This is one of the hardest problems to treat surgically," Dr. Cohen said. Therefore, voice therapy is the first line treatment, he said.
In general, the pitch of men’s voices rises in cases of presbylaryngis, while the pitch of women’s voices decreases, Dr. Cohen noted. Patients perceive their voices as breathy and weak, with vocal fatigue and decreased ability to project their voices.
Amyotrophic Lateral Sclerosis
Approximately 25% of patients with amyotrophic lateral sclerosis (ALS) present with speech and swallowing problems. ALS is a progressive degeneration of the upper and lower motor neurons. Speech in these patients is typically slow, weak, and hypernasal, said Dr. Cohen. ALS patients may have dysarthria (disturbance of articulation) as well as dysphonia, and involuntary twitches of the tongue, he added.
Neither Dr. Cohen nor Dr. Noordzij had any financial conflicts to disclose.
AT THE ANNUAL MEETING OF THE AMERICAN ACADEMY OF OTOLARYNGOLOGY HEAD AND NECK SURGERY FOUNDATION