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  • Differential Diagnosis of Throat Problems

Differential Diagnosis of Throat Problems

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See table 1 for the most common clinical entities

Acute viral laryngitis Viral URTI preceding aphonia +/− of sore throat. Bilateral vocal cord edema and erythema. Improves usually with resolution of URTI Conservative treatment with voice rest. Antibiotic if 2° bacterial infection. Most common infectious cause of hoarseness.
Vocal cord nodules Occurs more frequently in singers, females and children. Aggravated by URTI, sinusitis, smoke and alcohol. Often arise bilaterally at the junction of the anterior and middle 1/3 of the vocal cords. Soft and red, but chronic nodules become fibrotic, hard and white. Voice rest. Speech therapy. Rarely is surgery ever indicated. Caused by sub mucosal inflammation.
Laryngitis 2° to GERD Hx of GERD and its precipitating factors. Erythema and edema of the mucosa lining the arytenoids, may develop ulcers or granulomas in a similar distribution. Treatment as for reflux conservative vs. medications vs. surgery.  
Vocal cord polyp Males, smokers, vocal misuse or abuse or irritant exposure +/- dyspnea, cough. Unilateral, asymmetric, broad based and pedunculated with a smooth, soft appearance (can occur bilaterally). Voice rest. Speech therapy. Surgical excision. The diffuse form is called Reinke’s edema, which is due to fluid accumulation in the loose submucosal space.
Squamous papillomas   Often occur at the anterior commisure and true vocal cord subglottic and supraglottic areas may be involved. Appears as white to reddish verrucous mass. complete surgical excision/laser extirpation. Most common benign tumor.
Glottic carcinoma Predisposing factors: alcohol, smoking, exposure to radiation, HPV and nickel exposure Symptoms include dysphagia, odynophagia, otalgia and hemoptysis. Lesions will vary in appearance dysplasia or CIS may appear as leukoplacia, Often exophytic, ulcerated growth on vocal cord membrane. Due to poor lymphatic supply tumor spread at time presentation is not common. Refer to otolaryngologist. Biopsy. Organ preservation therapy: Radiation therapy or surgery.
Psychogenic Patient will complain of only being able to speak in forced whisper. Normal cough Ability of patient to say ‘Ah’ in their normal voice.   A conversion disorder.
Spastic dysphonia Strained, strangled voice associated with facial grimacing, during singing, crying or laughing the voice is normal. In some onset is related to major life stressor. Hyper adduction of the true and false cords. Botulinum toxin injection. Speech therapy (work if it is psychogenic in nature as opposed to neurological).  
Cord paralysis Breathy voice due to air escape – Bilateral paralysis may lead to airway compromise. Hx of recurrent laryngeal nerve damage (thyroid or CV surgery or disease). Unilateral: Cord abducted in resting position and unable to adduct during phonation.
Bilateral: cords adducted, unable to abduct with little space between.
Unilateral: Manage expectantly, or thyroplasty surgery where the paralyzed cord is medialized. Bilateral – Often needs a temporary trach.  
Trauma Hx of trauma to the larynx. Traumatic induced lesions of the vocal cord 2° to voice abuse (screaming, excessive singing without proper training). Severe trauma can result in fracture, dislocation etc. trauma due to vocal abuse results in benign vocal cord polyps, nodules or contact granulomas. Treatment depends upon the type of injury and treatment as above for polyps and nodules external trauma may require airway control, and surgery. With external trauma assess larynx mucosa, cartilage and joints.

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