Infectious inflammatory
- Acute viral laryngitis.
- Bacterial tracheitis/laryngitis.
- Laryngotracheobronchitis.
- Gastro–esophageal reflux disease (GERD).
- Smoke irritation.
- Chronic cough.
Neoplasia
- Benign: Cysts (retention cysts, laryngoceles, ventricular prolapse). Tumors (vocal cord polyps, papillomas, chondromas, neurofibromas, hemangiomas).
- Malignant tumors (squamous cell carcinoma).
- Endocrine (hypothyroidism, virulization).
- Rheumatoid arthritis, SLE, sarcoidosis, wegner’s granulotomosis, amyloidosis.
- Central lesions (CVA, Guillain barre, head injury, MS, neural tumors).
- Peripheral lesions
Tumors: Glomus jugular, thyroid, bronchogenic, esophageal, neural tumors.
Surgery: Thyroid surgery, cardiovascular or thoracic/esophageal surgery (iatrogenic).
Cardiac: Left atrial enlargement, aneurysm of aortic arch. - Neuromuscular: Myasthenia gravis, spastic dysphonia.
- Psychogenic aphonia (hysterical aphonia).
- Habitual aphonia.
- Ventricular dysphonias.
History: Take a full history keeping in mind the differential diagnosis to guide your questions
- Ascertain the nature, onset and duration (acute or chronic) of the voice abnormality. Acute is usually considered to be less than two weeks.
- Are there times when the voice returns to normal? This would decrease the suspicion of a fixed lesion as the cause of hoarseness.
- Does the voice fluctuate throughout the day? This often is seen in patients with hoarseness 2° to GERD, with hoarseness worse in the am (lying supine).
- Precipitating Factors and Past medical history: Was the hoarseness preceded by a viral URTI? Is there any history of trauma or recent screaming or yelling? Has the patient had thyroid, esophageal or cardio thoracic surgery? Does the patient have a history of hiatus hernia, GERD or hypothyroidism?
- Associated symptoms: Dysphagia, odynophagia, hemptoysis, stridor, heartburn or symptoms of GERD, allergy symptoms, post–nasal drip, chronic cough, symptoms of hypothyroidism or airway compromise.
- Social history: Smoking, alcohol use, vocal demands on the patient, their environment (level of noise, smoke or irritant toxins, do they use their voice excessively?).
- Medication history: Medicines which dry the mucous membranes, cardiac medicines producing a cough or hormones?
- Do a complete ENT exam on the patient who presents hoarseness.
- One should always attempt to examine the larynx using either direct or indirect laryngoscopy, especially in the patient presenting with chronic dysphonia.
- Indirect laryngoscopy involves examining the larynx with a mirror, whereas direct laryngoscopy entails using a scope, either a rigid Hopkins scope or a fibroptic flexible laryngoscope.
- On laryngoscopy try to examine the vallecula, epiglottis, pyriform sinuses, false vocal cords, growths protruding from the ventricle, true vocal cords and immediately subglottic.
- Examine the aforementioned areas for the color and character of the mucosa, look for any lesions and their location, examine the vocal cords, and their resting position, demonstrate normal and symmetric abduction and adduction.
- Stroboscopy (commonly not seen in a primary care office) can help the specialist increase detection of small undiagnosed lesions.
- If you are unable to adequately view the larynx or its surrounding anatomy in a patient with a history that is not suggestive of a benign cause or a patient with chronic dysphonia, obtain an ENT consultation.
