Head and Neck A12


Management of dysphonia

Phonation (voice production) is a complex process. The biomechanics behind phonation involve the expelled pulmonic air from the lungs travelling between the adducted vocal folds (larynx), vibrating the vocal folds. This vibration of the vocal folds creates a sound, and this sound is further shaped and modulated by the articulators and resonators in the supralaryngeal tract.

The following changes will produce a hoarse voice (dysphonia) at the level of the larynx:

  • Pathology affecting the mucosa of the vocal folds:
    • Benign (e.g. vocal fold nodule, fibrous mass, granulomata, papilloma)
    • Pre-malignant / malignant lesion
    • Inflammation (infectious, e.g. viral, bacterial, fungal; irritative)
    • GORD (reflux laryngitis)
    • Smoking Radiation
    • Reinke’s oedema
  • Pathology affecting the intrinsic laryngeal muscles that move the vocal folds:
    • Neuromuscular disorders
    • Neurodegenerative disorders
    • Mass compressing on the recurrent laryngeal nerve (head & neck cancer, lung cancer)
    • Iatrogenic (surgical trauma damaging the recurrent laryngeal nerve)

Red flag symptoms and signs for patients presenting with dysphonia include:

  • Persistent hoarseness (>3 weeks)
  • Dysphagia
  • Odynophagia
  • Haemoptysis
  • Otalgia with normal otoscopy
  • Neck lump
  • Weight loss
  • Loss of appetite
  • Strong history of smoking and/or alcohol consumption

Careful history must be taken, and examinations should include head and neck examination, neurological examination, and a respiratory examination. 

NICE guidelines recommend that any patient over 45 years of age with unexplained, persistent hoarseness (>3 weeks) should be referred for further investigation. Should you suspect airway obstruction, the patient must be sent to hospital immediately.

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