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Hoarseness and voice change

Medicine > Endocrine & metabolic

Differential Diagnosis Schema 🧠

Infectious Causes

  • Laryngitis: Acute or chronic inflammation of the larynx, often due to viral or bacterial infection; presents with hoarseness, cough, and sometimes sore throat.
  • Epiglottitis: Inflammation of the epiglottis, usually due to Haemophilus influenzae; presents with sore throat, hoarseness, fever, and stridor; a medical emergency.
  • Viral Upper Respiratory Infection (URI): Common cause of transient hoarseness due to viral infection of the upper airway.
  • Tuberculosis: Can affect the larynx, leading to chronic hoarseness, especially in high-risk populations.
  • Fungal Laryngitis: Typically seen in immunocompromised patients, presenting with persistent hoarseness and possible dysphagia.

Neoplastic Causes

  • Laryngeal Cancer: Presents with persistent hoarseness, especially in smokers or heavy alcohol users; may also present with dysphagia or a neck mass.
  • Vocal Cord Nodules/Polyps: Benign lesions often associated with voice overuse; presents with progressive hoarseness.
  • Recurrent Respiratory Papillomatosis: Caused by HPV infection; presents with hoarseness and may require repeated surgical intervention.
  • Thyroid Cancer: Can invade the recurrent laryngeal nerve, causing hoarseness; may present with a thyroid nodule or neck mass.
  • Metastatic Disease: Secondary tumors affecting the larynx or recurrent laryngeal nerve, often from lung, breast, or esophageal cancer.

Neurological Causes

  • Recurrent Laryngeal Nerve Palsy: Can be due to surgical trauma (e.g., thyroidectomy), malignancy, or idiopathic causes; presents with unilateral vocal cord paralysis and hoarseness.
  • Stroke: May cause hoarseness if the stroke affects the brain areas controlling voice; often associated with other neurological deficits.
  • Myasthenia Gravis: Autoimmune disorder causing muscle weakness, including the vocal cords; presents with fluctuating hoarseness, especially with prolonged speaking.
  • Parkinson’s Disease: Neurodegenerative disorder that can cause voice changes due to rigidity and reduced vocal cord movement; presents with a soft, monotonous voice.
  • Amyotrophic Lateral Sclerosis (ALS): Progressive neurodegenerative disease affecting motor neurons; presents with hoarseness, dysarthria, and eventually dysphagia.
  • Multiple Sclerosis: Demyelinating disease that may cause voice changes due to brainstem involvement.
  • Vocal Cord Paresis: Partial paralysis of the vocal cords due to nerve damage; presents with breathy voice and hoarseness.

Other Causes

  • Gastroesophageal Reflux Disease (GERD): Acid reflux can irritate the larynx, leading to chronic hoarseness, often worse in the morning.
  • Vocal Strain: Overuse of the voice (e.g., in singers, teachers) can lead to hoarseness due to vocal cord edema or nodules.
  • Hypothyroidism: Can cause hoarseness due to mucopolysaccharide deposition in the vocal cords, leading to thickening and reduced mobility.
  • Allergic Rhinitis: Postnasal drip and throat clearing can irritate the vocal cords, leading to hoarseness.
  • Psychogenic Hoarseness: Functional voice disorder often associated with stress or anxiety; physical examination is usually normal.
  • Trauma: Direct trauma to the neck or intubation injury can cause vocal cord damage and hoarseness.
  • Medications: Certain drugs (e.g., ACE inhibitors) can cause hoarseness as a side effect due to cough or throat irritation.

Key Points in History 🥼

Symptom History

  • Onset and Duration: Sudden onset may suggest acute laryngitis or vocal cord trauma, while gradual onset suggests neoplastic or chronic inflammatory causes.
  • Associated Symptoms: Dysphagia, odynophagia, weight loss, and neck mass suggest a possible malignancy.
  • Voice Use: Occupational or habitual voice strain, such as in teachers, singers, or public speakers, may suggest vocal cord nodules or polyps.
  • Smoking and Alcohol History: Important risk factors for laryngeal cancer.
  • Gastrointestinal Symptoms: Heartburn, acid regurgitation, or a history of GERD may suggest reflux laryngitis.
  • Neurological Symptoms: Consider underlying neurological causes if there are symptoms such as weakness, tremor, or dysarthria.
  • Trauma or Surgery: Recent intubation, neck surgery, or trauma can lead to vocal cord injury and hoarseness.
  • Systemic Symptoms: Fever, night sweats, and weight loss may suggest an infectious or malignant cause.
  • Allergies: History of allergic rhinitis or sinusitis can contribute to postnasal drip and voice changes.
  • Medications: Use of ACE inhibitors, anticholinergics, or inhaled corticosteroids, which may contribute to hoarseness.
  • Psychosocial Factors: Consider stress or anxiety as contributing factors in psychogenic hoarseness.

Background

  • Past Medical History: Including any history of recurrent laryngitis, vocal cord lesions, thyroid disease, or neurological disorders.
  • Surgical History: Previous neck surgery, especially thyroidectomy or anterior cervical spine surgery, which could have affected the recurrent laryngeal nerve.
  • Drug History: Review of all medications, especially those known to cause voice changes.
  • Family History: Consider any family history of thyroid disease, neurological disorders, or cancer.
  • Social History: Smoking, alcohol use, and occupational history, particularly in professions requiring heavy voice use.
  • Environmental Exposure: History of exposure to irritants, such as dust, chemicals, or allergens, which could affect the voice.
  • Dietary Habits: High intake of acidic or spicy foods that could exacerbate GERD and contribute to hoarseness.
  • Travel History: Consider exposure to infectious causes of hoarseness, particularly in areas with endemic tuberculosis.
  • Psychosocial Factors: Stress and mental health history, which may contribute to psychogenic hoarseness.
  • Immunization History: Relevant in assessing risk for infections like epiglottitis.
  • Sexual History: Consider if sexually transmitted infections, such as syphilis or HPV, could be relevant to the presentation.
  • Occupational Exposure: Assess for exposure to occupational hazards that may cause or exacerbate hoarseness.
  • Reproductive History: Relevant in women, as pregnancy-related hormonal changes can affect the voice.
  • Previous Investigations: Review any past laryngoscopies, imaging, or biopsies.
  • Immunosuppression: Consider if there is a history of immunosuppressive therapy or conditions predisposing to infections.

Possible Investigations 🌡️

Initial Assessments

  • Laryngoscopy: Direct visualization of the vocal cords to assess for lesions, paralysis, or inflammation; essential in persistent hoarseness.
  • Flexible Nasendoscopy: Allows visualization of the nasal cavity, pharynx, and larynx, useful in assessing for structural abnormalities.
  • Chest X-Ray: To assess for any mediastinal masses or lung pathology that may be affecting the recurrent laryngeal nerve.
  • Thyroid Function Tests: Useful in assessing for hypothyroidism, which can cause voice changes.
  • Full Blood Count (FBC): To assess for infection, anemia, or any hematological cause of hoarseness.
  • Erythrocyte Sedimentation Rate (ESR) or C-Reactive Protein (CRP): To assess for inflammation or infection.
  • Speech and Language Therapy Assessment: Important in cases of vocal strain, psychogenic hoarseness, or after surgical interventions.
  • Sputum Culture: If there is a productive cough or suspicion of infection affecting the larynx.
  • Voice Analysis: In selected cases, a detailed analysis of voice function can be conducted by speech therapists.
  • Videostroboscopy: A specialized laryngoscopy technique to assess vocal cord vibration and function.
  • Allergy Testing: If allergic rhinitis or postnasal drip is suspected as a contributing factor.
  • Barium Swallow: May be indicated if there is dysphagia or suspicion of esophageal pathology contributing to hoarseness.
  • Bronchoscopy: To assess for any airway lesions or foreign bodies, particularly in smokers or those with persistent symptoms.
  • Electromyography (EMG) of the Larynx: Can be used to assess neuromuscular function in cases of vocal cord paralysis.
  • CT or MRI of the Neck and Chest: Imaging to assess for masses, structural abnormalities, or pathologies affecting the recurrent laryngeal nerve or larynx.

Further Investigations

  • Thyroid Ultrasound: To assess for thyroid nodules or goiter that may be impacting the recurrent laryngeal nerve.
  • Endocrine Function Tests: Consider in cases where endocrine disorders like acromegaly or hypothyroidism are suspected.
  • Autoimmune Screen: If there is suspicion of autoimmune causes such as Sjögren’s syndrome or systemic lupus erythematosus (SLE).
  • High-Resolution CT of the Chest: Particularly useful in assessing for mediastinal masses or lung cancer affecting the recurrent laryngeal nerve.
  • Serum Calcium Levels: To assess for hypercalcemia, which can be associated with conditions like parathyroid adenoma, affecting the voice.
  • Biopsy: Indicated if a laryngeal or neck mass is identified and malignancy is suspected.
  • PET Scan: In cases of suspected malignancy, especially if metastatic disease is a concern.
  • Neurological Imaging: MRI of the brain may be indicated if central neurological causes are suspected.
  • Esophagoscopy: To directly visualize and biopsy the esophagus in cases of suspected esophageal cancer or other pathology.
  • Acoustic Analysis: Can be used for detailed voice assessment, often performed by speech therapists or ENT specialists.
  • Pulmonary Function Tests: If there is suspicion that lung disease or obstructive airway disease is contributing to voice changes.
  • Serum Tumor Markers: In cases of suspected malignancy, particularly lung or thyroid cancer.
  • Holter Monitoring: If arrhythmia or cardiac involvement is suspected in the etiology of hoarseness (e.g., due to aortic aneurysm affecting the recurrent laryngeal nerve).
  • ENT Referral: Early referral is crucial for persistent hoarseness, especially if malignancy or significant pathology is suspected.

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Endocrine & metabolic