Makindo Medical Notes

General Assessment of Patients with Hoarseness and Voice Changes

History Taking

• Duration of Symptoms: Assess whether the hoarseness is acute (days to weeks) or chronic (lasting more than 3 weeks). Chronic hoarseness may require more thorough investigation.
• Associated Symptoms: Ask about associated symptoms such as dysphagia (difficulty swallowing), odynophagia (painful swallowing), cough, or hemoptysis (coughing up blood).
• Voice Use History: Investigate the patient's occupational or recreational use of their voice. For example, professional voice users (singers, teachers) are at higher risk of vocal cord damage.
• Smoking and Alcohol Use: These are risk factors for laryngeal cancer. A detailed smoking and alcohol history should be taken, particularly in older adults with persistent hoarseness.
• Gastroesophageal Reflux Symptoms: Enquire about symptoms of GERD, such as heartburn or regurgitation, which can cause irritation of the vocal cords.
• Recent Upper Respiratory Tract Infection: Viral infections can cause laryngitis and acute hoarseness.
• Neurological Symptoms: Investigate for signs of neurological disorders such as muscle weakness, changes in speech, or difficulty swallowing, which may suggest vocal cord paralysis or neurodegenerative diseases like Parkinson's or ALS.
• Thyroid Disease Symptoms: Investigate any history of thyroid disease, such as swelling in the neck, changes in weight, or a family history of thyroid problems.

Physical Examination

• Head and Neck Examination: Assess for any visible swelling, neck masses, or tenderness. Palpate the thyroid gland for goiter or nodules.
• Oral Cavity and Pharynx: Look for any signs of infection, lesions, or masses in the oral cavity or pharynx that might cause hoarseness or voice changes.
• Laryngeal Examination (if available): Using a laryngoscope, examine the vocal cords for any abnormalities such as nodules, polyps, or signs of vocal cord paralysis. Direct visualization is crucial for a definitive diagnosis.
• Neurological Assessment: Examine for signs of cranial nerve involvement or other neurological deficits, especially if vocal cord paralysis is suspected.

Investigations

• Laryngoscopy: A key investigation to visualize the vocal cords and assess for lesions, inflammation, or paralysis.
• Imaging: Depending on clinical suspicion, a CT or MRI scan may be required to investigate potential tumours, neurological causes, or structural abnormalities. A chest X-ray can also be useful if lung cancer or mediastinal pathology is suspected.
• pH Monitoring: If gastroesophageal reflux is suspected as a cause, pH monitoring can confirm acid reflux contributing to vocal cord irritation.
• Thyroid Function Tests: If thyroid pathology is suspected, assess thyroid function via blood tests, and perform a thyroid ultrasound if a nodule or mass is detected.
• Biopsy: For suspected malignancies or persistent lesions seen on laryngoscopy, a biopsy may be required for histopathological examination.

Red Flags to Be Aware Of

• Hoarseness lasting longer than 3 weeks, especially in smokers or those over the age of 40.
• Unexplained weight loss, dysphagia, or odynophagia.
• Persistent cough, hemoptysis, or neck mass.
• Neurological symptoms such as muscle weakness, dysarthria (difficulty speaking), or progressive speech changes.

5. Management Considerations

• Voice Rest and Speech Therapy: Patients with vocal cord strain or nodules may benefit from voice rest and referral to a speech therapist for vocal training and rehabilitation.
• Medical Management: Treat underlying conditions such as GERD with proton pump inhibitors (PPIs), or laryngitis with appropriate antibiotics if bacterial infection is suspected.
• Surgical Intervention: Patients with persistent lesions such as polyps, nodules, or suspected malignancies may require surgical removal. Vocal cord paralysis may also need surgical intervention, such as vocal cord medialization.
• Multidisciplinary Care: In cases of suspected malignancy or complex neurological conditions, collaboration with specialists (ENT surgeons, oncologists, neurologists) is essential for comprehensive management.