International Journal of Otorhinolaryngology and Head and Neck Surgery

Munjal M et al. Int J Otorhinolaryngol Head Neck Surg. 2016 Oct;2(4):220-223

http://www.ijorl.com

pISSN 2454-5929 | eISSN 2454-5937

Original Research Article

DOI: http://dx.doi.org/10.18203/issn.2454-5929.ijohns20163469

Hoarseness of voice – an institutional study

Manish Munjal, Bindia Ghera*

Department of ENT, Dayanand medical college and hospital, Ludhiana, Punjab, India

Received: 30 June 2016

Revised: 22 July 2016

Accepted: 28 July 2016

*Correspondence:

Dr. Bindia Ghera,

E-mail: bindiaghera@yahoo.com

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Hoarseness is one of the earliest signal of local and systemic disease. It should be emphasized that hoarseness is not a disease in itself but a symptom of disease or disturbance of larynx or laryngeal innervation. The aim of the study was to analyse various causes and conditions associated with hoarseness of voice.

Methods: We studied 150 patients in a prospective randomised study with inclusion criteria of hoarseness of voice, attending otolaryngology outpatient department of Dayanand medical college and hospital, Ludhiana, irrespective of their age, sex and duration of disease. No exclusion criteria were applied. All the routine investigations like Hb, BT, CT, TLC, DLC, urine-for albumin and sugar were carried out in all patients. X-ray chest- PA view and X-Ray soft tissue neck- AP and lateral view were done when required. Larynx was examined by flexible fibreoptic laryngoscopy followed by biopsy if suspicious looking area was seen. 4% lignocaine spray was used orally and nasally to provide local anaesthesia.

Results: In the present study of 150 cases 87 were males and 63 were females with M:F ratio of 1.4:1 and age ranged from 10–90 years with majority of cases in 4th and 6th decade of their life. All patients had history of hoarseness of voice with most of patients having duration of disease between one month to one year. On flexible fibreoptic laryngoscopy 27% of cases showed normal study, vocal nodule was most common, seen in 20% of cases, 10% showed vocal cord palsy and 10% had laryngopharyngeal reflux disease. Bilateral lesion (72.6%) predominated overall, with left sided (15.2%) of larynx affected more as compared to right side (12%).

Conclusions: Flexible fibreoptic laryngoscopy is an effective alternative for diagnosis of laryngeal lesions and various causes of hoarseness of voice. Vocal nodule has been found as the commonest cause of hoarseness of voice followed by vocal cord palsy and laryngopharyngeal reflux disease.

Keywords: Hoarseness, Voice, Flexible fibreoptic laryngoscopy, Vocal nodule, Vocal cord palsy, Laryngopharyngeal reflux disease

INTRODUCTION

Hoarseness is one of the first and only signal of serious local and systemic disease.1 It is commonest symptoms in ENT practice. It is one of the earliest manifestations of conditions directly or indirectly affecting the voice apparatus as voice being the primary means of communication socially and professionally. Hoarseness is defined as perceived, rough, harsh or breathy quality of voice.2 In children vocal abuse in the form of screaming and shouting is quoted as one of the most widely quoted factor associated with hoarseness.3 It should be emphasized that hoarseness is not a disease in itself but a symptom of disease or disturbance of larynx or laryngeal innervation. The purpose of the study was to assess various causes and conditions associated with hoarseness of voice.

METHODS

In this prospective randomized study, 150 patients were selected with inclusion criteria of hoarseness of voice, attending otolaryngology outpatient department of Dayanand medical college and hospital, Ludhiana, irrespective of their age, sex and duration of disease. No exclusion criteria were applied. Duration of study was of 14 months (2015-2016). All the routine investigations like Hb, BT, CT, TLC, DLC, urine for albumin and sugar were carried out in all patients. X-ray chest- PA view and X-Ray soft tissue neck- AP and lateral view were done, when required. Larynx was examined by flexible fibreoptic laryngoscopy followed by biopsy if suspicious looking area was seen. 4% lignocaine spray was used orally and nasally to provide local anaesthesia. Statistical method used was SPSS version 17.

RESULTS

In the present study of 150 cases 87 were males and 63 were females with M:F ratio of 1.4:1 and age ranged from 10–90 years with majority of cases in 4th decade of their life. All patients had history of hoarseness of voice with most of patients having duration of disease between one month to one year.

On flexible fibreoptic laryngoscopy 27% of cases showed normal study, vocal nodule was most common, seen in 20% of cases, 10% showed vocal cord palsy and 10% had laryngopharyngeal reflux disease. Bilateral lesion (72.6%) predominated overall, with left sided (15.2%) of larynx affected more as compared to right side (12%).

Table 1: Age and gender distribution of hoarseness of voice (n=150).
Age groupMaleFemalePercentage
1 - 10-10.6
11 - 20546
21 - 3091013
31 - 40101617
41 - 50201020
51 - 6014714
61 - 7021819
71 - 80769
81 - 90111.3
Total8763100
Figure 1: Haemorrhagic cyst right TVC, anterior part, superior surface.
Figure 1: Haemorrhagic cyst right TVC, anterior part, superior surface.
Figure 2: Bilateral TVC nodules on anterior one-third.
Figure 2: Bilateral TVC nodules on anterior one-third.
Figure 3: left TVC palsy and right TVC mobile.
Figure 3: left TVC palsy and right TVC mobile.
Figure 4: Bilateral arytenoids congested.
Figure 4: Bilateral arytenoids congested.

DISCUSSION

The larynx is a complex structure that serves protective, respiratory, deglutition, and vocalization functions. Sounds are produced by air flow from the lungs which vibrates the vocal cord epithelium. The resultant fluctuations in air pressure produce sound waves. The vocal cord edges must be brought close enough together to vibrate from the flow of air through the larynx. The arytenoid cartilages along with attached muscles are responsible for movement and tension of the vocal cords. Various lesions of vocal cords causing hoarseness include pathologic changes from allergies, irritants and inflammatory processes, neuromuscular and psychiatric conditions, systemic disorders, and neoplasms. With increase in age mucous membranes of vocal cords become thin and become more dry, which leads to hoarseness of voice. Banjara et al mentioned age range to be 11-78 years in their study and majority of patients presented in 4th and 6th decades of life (22.31% each). 2 Similar results are seen in our study with maximum number of patients seen in the 4th and 6th decade.

Figure 5: Percentage of various causes of hoarseness seen in this study. | Normal 30 Vocal nodule Ulceration of arytenoids Growth Pyriform sinus Growth Post- cricoid area Supraglottic mass Subglottic mass Phonatory Gap Leukoplakic patch Post Radiotherapy 25 20 15 10 5 0 Carcinoma Larynx Laryngopharyngeal reflux disease Vocal cord Palsy Congested arytenoids Laryngitis % Vocal Polyp False vocal cord hypertrophy Vocal cord growth Vocal cord cyst Vallecular cyst Hyperaemic vocal cord
Figure 5: Percentage of various causes of hoarseness seen in this study.
Table 2: Findings on FFL in patients with hoarseness of voice (n=150).
Table reproduced from source PDF page 3

Male:Female ratio in our study was 1.4:1. Khavasi and Prabhu, Kumar and Seth reported male:female ratio of 2:1.4 The gender differences can be attributed to the effect of hormones.

In present study 27% of cases showed normal study, vocal nodule was most common, seen in 20% of cases , 10% showed vocal cord palsy and 10% had laryngopharyngeal reflux disease. Bilateral lesion (72.6%) predominated overall, with left sided (15.2%) of larynx affected more as compared to right side (12%). Baitha (2004) documented chronic nonspecific laryngitis (43.63%) as the most common pathology of hoarseness followed by acute laryngitis (23.63%), carcinoma larynx (14.54%), vocal cord palsy(9.09%) and tubercular laryngitis (5.45%).5 Banjara et al mentioned functional lesions (16.33%) to be most common etiology followed by vocal nodule (11.95%), vocal palsy (11.16%), cancer and chronic laryngitis (9.56% each).2 Ghosh et al (2001) mentioned vocal nodule as the commonest finding in disease of larynx, as seen in our study.6 Epstein et al reported that bilaterality was about four times as common in nodules as compared to polyps. 7 Our study also showed similar findings. Vocal abuse was the most common predisposing factor for vocal nodule and vocal polyp. Smoking and tobacco chewing was the predisposing factor for carcinoma larynx. Progressive hoarseness of voice more than 15 days should be evaluated by otolaryngologist. Education about vocal hygiene and voice therapy is effective in improving the quality of voice in patients with hoarseness of voice.

Table 3: Gender distribution of aetiology of hoarseness (n=150).
Table reproduced from source PDF page 4

CONCLUSION

Flexible fibreoptic laryngoscopy is an effective alternative for diagnosis of laryngeal lesions and various causes of hoarseness of voice. Vocal nodule has been found as the commonest cause of hoarseness of voice followed by vocal cord palsy and laryngopharyngeal reflux disease.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

  1. 1. Von Leden H. The clinical significance of hoarseness of related voice disorders. Lancet. 1958;78:50-3.
  2. 2. Banjara H, Varsha M, Singh D, Gupta A. Hoarseness of voice: A Retrospective Study of 251 Cases. International journal of phonosurgery and Laryngology. 2011;1(1):21-7.
  3. 3. Kay NJ. Vocal nodules in children-aetiology and management. Journal of Laryngol and Otology. 1992;96:731-6.
  4. 4. Khavasi PS. Aetiopathological study of hoarseness of voice. A thesis submitted for master of surgery (otorhinolaryngology) Rajiv Gandhi University of Health sciences, Bangalore, Karnataka. 2005.
  5. 5. Baitha S, Raizada RM, Kennedy AK, Puttewar MP, Chaturvedi VN. Predisposing factors and etiology of hoarseness of voice. Indian journal of Otolaryngology and Head and neck surgery. 2004;56(3):186-90.
  6. 6. Ghosh SK, Chattopadhyay S, Bora H, Mukherjee PB. Microlaryngoscopic study of 100 cases of hoarseness of voice. Indian Journal of Otolaryngology and Head and Neck Surgery. 2001;53(4):270-2.
  7. 7. Epstein SS, Winston E. The vocal cord polyp. Journal of Laryngol and Otology. 1957;71:673-88.