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DEFINITION Hoarseness is an impairment of the voice, in which the basic sound produced by the glottis has more the character of a rustle or murmur than a tone. Dysphonia includes other voice problems, such as a raspy, quiet or ‘broken’ voice. AETIOLOGY/PATHOGENESIS Hoarseness can have a number of causes. The most common are discussed below. Acute laryngitis usually occurs as the result of an upper respiratory infection, or by heavy overtaxing of the voice during a short period. Chronic laryngit
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  DEFINITION Hoarseness is an impairment of the voice, in which the basic soundproduced by the glottis has more the character of a rustle or murmurthan a tone. Dysphonia includes other voice problems, such as araspy, quiet or ‘broken’ voice. AETIOLOGY/PATHOGENESIS Hoarseness can have a number of causes. The most common arediscussed below.  Acute laryngitis usually occurs as the result of an upper respiratoryinfection, or by heavy overtaxing of the voice during a short period. Chronic laryngitis is mainly caused by smoking. Voice overuse can alsogive rise to irritation and oedema of the larynx. Polyps, cysts and nodules are benign tumours of the vocal cords. Thefirst two occur in people of all ages, and the last is seen particularly inchildren, and is probably caused by improper use of the voice. Laryngeal carcinoma is a rare, but very important, cause of hoarseness.This symptom is an early pointer, and early treatment has a relativelygood prognosis. Paralysis of the vocal cords is caused by damage of the laryngeal nerves.This tends to happen on one side and, in general, the position of theparalysed vocal cord (medial, intermediate or lateral) determines theremaining function. The most common cause of this type of injury isiatrogenic (e.g. thyroidectomy). Other causes include trauma,tumours, neurological disease or muscular disorders. Functional causes are quite common. Psychological stress createsincreased muscle tone in the larynx. This can give rise to symptoms, 271 HEAD HOARSENESS/DYSPHONIA 66 HOARSENESS/DYSPHONIA  such as hoarseness, a sensation of a lump in the throat, the need toclear the throat and a nervous tickly cough. Various medications , such as diuretics, anticholinergics andantihistamines, can affect the function of the vocal cords. The use of inhaled corticosteroids can cause irritation. Hormonal disorders , such as thyroid and growth hormone problems,or the use of anabolic steroids, can affect the larynx and thereby the voice. Intubation (during anaesthesia) can cause damage to the larynx,which can result in short-term dysphonia.  Ageing  can cause the voice to weaken, but account should be taken of the fact that the risk of tumours increases with age.  Anatomical variations can affect laryngeal structure, resulting in aweak or hoarse voice. PRESENTATION The patient attends with the complaint of hoarseness, raspiness orloss of the voice. The GP will sometimes also detect this disorder in apatient presenting with an entirely different complaint. EPIDEMIOLOGY The incidence of hoarseness in general practice is seven per 1000patients per year; women attend with this complaint twice as often asmen. There are about 3670 cases of laryngeal cancer each year in theUK. This means the average GP will see one new case every 8years.It almost always affects those aged 50–70years. HISTORY The GP asks: ã how long the symptom has been present and whether itdeveloped acutely or gradually ã about any connection with an upper respiratory infection ã about smoking habits HEAD HOARSENESS/DYSPHONIA 272  ã whether the patient uses inhaled medications ã about emotional stress and other psychological factors ã about any straining/overtaxing of the voice ã about symptoms of hormonal problems ã whether the patient has recently undergone anaesthesia withintubation ã whether the patient has had problems with hoarseness his entire life. EXAMINATION For acute hoarseness, examination of the vocal cords is not usuallynecessary, at least initially, as the diagnosis can be made based on thehistory and by listening to the voice. The GP can check for signs of anupper respiratory infection.Additional investigations must be carried out if the hoarsenesspersists for longer than 3weeks in patients aged 50years or more, because of the risk of laryngeal carcinoma. Thorough visualization of the larynx will usually require referral to an ear, nose and throat(ENT) specialist. TREATMENT Acute laryngitis is generally viral and can be treated by resting the voice, using steam inhalations and not smoking. Antibiotics (e.g. amoxicillin) may be prescribed if there is secondary bacterialinfection. In young people with gradually developing hoarseness,the cause is almost always chronic laryngitis. The patient should stop smoking and not overuse or force the voice.Long-term hoarseness in children can be successfully treated by aspeech therapist. The vocal nodules that sometimes accompany this are reversible, so referral to an ENT specialist is not essential.Nowadays, primary school children with voice or speech problemsare often directly referred for speech therapy.Hoarseness that is clearly functional in adults can be treated by theGP providing advice about relaxation and stress reduction.In other cases, the treatment will depend on the underlying cause. 273 HEAD HOARSENESS/DYSPHONIA  PREVENTION AND ADDITIONAL INFORMATION As can be seen from the above, much of the treatment is alsopreventive: providing information about proper speech technique,use of medications, smoking and stress management. Literature DaCosta SP,Damsté RH,Gerritsma EJ,et al.Stem- en spraakstoornissen[Voice and speech disorders]. Bijblijven 1992; 4 .Rosen CA,Anderson D,Murry T.Evaluating hoarseness:keeping yourpatient’s voice healthy.  Am Fam Physician 1998; 57 (11):2775–82.Sinard RJ.The aging voice:how to differentiate disease from normalchanges. Geriatrics 1998; 53 (7):76–9. HEAD HOARSENESS/DYSPHONIA 274 Key points ã Laryngeal carcinomais a rare but very important cause of hoarseness.Additional investigations must be carried out if thehoarseness persists for longer than 3weeks in patients aged50years or more. ã Acute laryngitis is generally viral and can be treated by resting thevoice,using steam inhalations and not smoking. ã Long-term hoarseness in children can be successfully treated by aspeech therapist–it does not require the attention of an ENTspecialist.

FMT 111

Jul 23, 2017

GR00002600-23A.pdf

Jul 23, 2017
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