(Looking in to the nose and throat (voice box) using a flexible fibreoptic endoscope with a small camera at the end.This patient is having hoarseness of voice for few months.Hoarseness is having difficulty producing sound when trying to speak, or a change in the pitch or quality of the voice. The voice may sound weak, very breathy, scratchy, or husky.This patient has got a lesion on the right vocal cord which is going to be removed for biopsy.)
Abnormal changes in the voice are called “hoarseness.” The voice may sound weak, very breathy or husky.
Hoarseness is usually caused by a problem in the vocal cords. Most cases of hoarseness occur with inflammation of the larynx like in laryngitis.
Hoarseness that continues for more than 3-4 weeks should be checked by an ENT doctor .Most common causes are benign but malignant lesion like cancer of the larynx should be ruled out.
How voice produced
The vocal cords are normally open but make sounds by coming together when you speak, or sing. As air leaves the lungs, it makes the closed cords to vibrate, producing the sound of your voice. When your voice is hoarse, it is an indication that these vibrations of the vocal cords are being hindered by mucus, swellings, obstructions or other changes in the surface of the larynx.
Causes of hoarseness of voice
Acute Laryngitis: The most common cause is acute laryngitis—swelling of the vocal cords that occur during a common cold, upper respiratory tract viral infection, or from vocal strain. Serious injury to the vocal folds can result from strenuous voice use during an episode of acute laryngitis with cough.
Vocal abuse
Very common in teachers, singers and preachers. When they are speaking in noisy situations, using inappropriate pitch (too high or too low) when speaking. It\’s common in children who screams and shout.
Benign Vocal Cord Lesions: like nodules, polyps, and cysts. Vocal nodules (singers\’ nodules) are small nodules on the vocal cords. Vocal cord polyps and cysts also occur in those who misuse their voice, but can also occur in those who do not.
Vocal Cord Hemorrhage: If you experience a sudden loss of voice after yelling or shouting or other strenuous vocal use, you may have developed a vocal cord hemorrhage. Vocal cord hemorrhage occurs when one of the blood vessels on the surface of the vocal folds ruptures and the soft tissues fill with blood.
Gastro esophageal Reflux (GERD): A possible cause of hoarseness is gastro-esophageal reflux, when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal folds. Other typical symptoms of GERD include heartburn and regurgitation. Usually, the voice is worse in the morning and improves during the day. These people may have a sensation of a lump or mucus in their throat and have an excessive desire to clear it.
Laryngopharyngeal Reflux (LPRD): If the reflux makes it all the way up through the upper sphincter and into the back of the throat, it is called LPRD rather than GERD. The structures in the throat (pharynx, larynx, and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of the reflux into this area can result in more damage. Many patients with LPRD do not have heartburn or other classic symptoms of GERD.
Smoking: Smoking is another cause of hoarseness. Because smoking is the major cause of throat cancer, if smokers become hoarse. Early sign is thickening of the vocal cord.
Neurological Diseases : Hoarseness can also appear in those who have neurological diseases such as Parkinson\’s or a stroke, or may be a symptom of spasmodic dysphonia, a rare neurological disorder that usually affects only the voice, but sometimes affects breathing. Paralysis of vocal cord like after thyroid surgery may be the cause of a weak, breathy voice. If the hoarseness persists for more than three months and other causes have been ruled out, a neurologist may be helpful for diagnosis.
Other Causes: These include allergies, thyroid problems like Hypothyroidism and trauma to the voice box.
Laryngeal Cancer:
Very serious conditions such as laryngeal cancer can also cause hoarseness, which is why it is important to have chronic hoarseness evaluated promptly by an ENT Surgeon. Cancer of the throat is cancer of the vocal cords, voice box (larynx), or other areas of the throat. People who smoke or use tobacco are at risk of developing throat cancer. Excessive alcohol use also increases risk. Smoking and drinking alcohol combined lead to an increased risk for throat cancers. Most cancers of the throat develop in adults older than 50. Men are 10 times more likely than women to develop throat cancers.
Diagnosis
See your ENT doctor if you have any of the following symptoms:
and If hoarseness lasts longer than three to four weeks, especially if you smoke
and If you do not have a cold or flu
and If you are coughing up blood
and If you have difficulty swallowing
and If you feel a lump in the neck
and If difficulty breathing accompanies your voice change
and If your hoarseness interferes with your livelihood
and If you are a vocal performer and unable to perform
The ENT doctor will perform a physical examination including voice box and neck. A lump on the outside of the neck present spread of cancer to the lymph node.
Flexible Fibre Optic Laryngoscopy:
The ENT doctor will look in your throat or nose using a flexible tube with a small camera at the end.
Other tests may include:
and Blood work up
and Chest x-ray/CT scan of Neck/MRI
and Microlaryngoscopy of biopsy of the lesion if any.
Treatment
Hoarseness caused by a cold or flu may be evaluated by your GP who have learned how to examine the larynx. Problems with the voice are often best managed by a team of professionals who know and understand how the voice functions. These professionals are ENT surgeons, speech therapist. Vocal nodules, polyps, and cysts are typically treated with a combination of microsurgery and voice therapy. Not smoking and avoiding secondhand smoke is recommended to all patients. Drinking fluids and taking medications to thin out the mucus may help. The speech Therapist may teach patients to alter their methods of speech production to improve the sound of the voice and to resolve problems, such as vocal nodules
(Microlaryngeal Surgery Using Microdebrider for Vocal cord lesions under general anesthesia.Microdebrider is a powered instrument made up of rotating blade with built-in suction channel in a tubular housing. If the circuit activates by pressing the foot pedal, it will suck and cut at the same time.It is used in laryngeal surgery such as removal of vocal nodule and papilloma larynx.This is done in Jubilee Hospital, Trivandrum, Kerala, south India.)
Micro Laryngoscopy
Laryngoscopy is a medical procedure that is used for vocal exam to obtain a view of the vocal folds and the glottis. Direct Laryngoscopy is carried out with the laryngoscope is inserted into the mouth on the right side and flipped to the left to trap and keep the tongue out of the line of sight. This move makes a view of the glottis possible. There are ten different types of laryngoscope used, each with specialized function in otolaryngology and medical speech pathology. Sometimes direct diagnostic Laryngoscopy is done with biopsy. It is extremely uncomfortable and cause pain in larynx and cannot be performed on conscious patients, or on patients with an intact gag reflex. An Operating microscope enhances the view of the larynx.
Micro Laryngoscopy is used as a surgical procedure for the removal of foreign objects in the throat, collect tissue samples, remove polyps from the vocal cords, or perform laser treatment. Micro Laryngoscopy may also be used to help find cancer of the voice box.
Vocal cord polyp removal
Treatment requires modification of voice habits, and a speech therapy may be recommended. Vocal rest for several weeks may permit the nodules to shrink. Children occasionally present with screamer’s voice nodules and these can be treated by voice therapy alone. Inhaled steroid spray may be helpful in some cases. Sometimes biopsy and surgical removal are necessary for the polyp removal.
Some preventive practices include; proper use of the voice to eliminate strain, avoid screaming and loud talking, speak at a normal pitch, reduce the neck tension by gently tipping the head forward and to each side while keeping the shoulders down.
Microdebrider and carbon dioxide laser is the surgical tools available for the treatment of polyps.
(After the initial work up, if the lesion is identified, microlaryngoscopy is performed under general anesthesia. Here a microdebrider is used to shave off the lesion after taking a biopsy.
This is done in Jubilee Hospital Trivandrum Kerala South India.)
Cancer of Larynx
The goal of treatment is to completely remove the cancer and prevent it from spreading to other parts of the body. When the tumor is small, either surgery or radiation therapy alone can be used to remove the tumor. When the tumor is larger or has spread to lymph nodes in the neck, a combination of radiation and chemotherapy is often used to preserve the voice box. Some patients need surgery to remove the tumor, including all or part of the vocal cords (laryngectomy). If you have a laryngectomy, speech therapy can help you learn other ways to talk.
Throat cancers can be cured in 90% of patients if detected early. If the cancer has spread to surrounding tissues or lymph nodes in the neck, 50 – 60% of patients can be cured. If the cancer has spread to parts of the body outside the head and neck, the cancer is not curable and treatment is aimed at prolonging and improving quality of life.
After treatment, patients generally need therapy to help with speech and swallowing.
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