Evaluation of the Hoarse Patient

1. Evaluation of the Hoarse Patient Herve� LeBoeuf, MD

3. Anatomy - Vagus Jugular foramina - superior ganglion, nodose ganglion (inferior) Meningeal branches, auricular branch Phar. Constrictors, soft palate (most) SLN - int.- sensation to supraglottic larynx - ext- over inf const to cricothyroid RLN - all other laryngeal muscles Branches to carotid bulb, heart, others

4. Anatomy - Vagus Right - ant to subclavian, RLN loops SA and ascends in TE groove to C-T membrane May branch with sensory fibers to glottis and subglottis, some variability Left - RLN in thorax, loops aorta post to L.A. Ascends in TE groove Non-recurrent nerve in 1% ?

5. Anatomy - skeleton Cartilages - thyroid, cricoid, arytenoid, epiglottic Inferior thyroid horns - cricoid�synovial Arytenoids articulate with upper lateral border of the cricoid lamina Pyramidal - base = synovial, slide , rock, or rotate on cricoid, laterally = muscular process, anteriorly = vocal process to cords

7. Anatomy - Intrinsic Musculature Post C-A - only aBductor of the cords, opens glootis by rotary motion on arytenoids, tenses cords during phonation Lat C-A - Closes glottis by rotating on aryt. Medially Transv C-A - unpaired, approximates arytenoid bodies to close post glottis Obl. Aryt - Closes laryngeal introitus during swallowing

8. Anatomy - Musculature Thyroarytenoid - three parts: Vocalis - adductor and major tensor of cord Thyroarytenoideus externus - major adductor Thyroepiglotticus - shortens vocal ligaments Cricothyroid - extrinsic as innervated by ext br of SLN, increases tension of cords, esp at upper range of pitch and loudness

9. Histology Outermost layer - pseudostratified squamous epithelium superior and inferior to contact margin Contact surface - non keratinizing squamous Lamina propria - 3 layers - Reinke�s space - few fibroblasts, scant elastic and collagenous fibers - Intermediate - mainly elastic fibers, mod. Fibroblasts - Deep layer - collagenous fibers Thyroarytenoid muscle

11. Physiology Hoarseness: Sx, not Dx Laryngeal functions: - Respiration - Phonation - Airway protection - Fixation of the chest during respiration Hoarseness = problem with phonation

12. Physiology - Speech Pulmonary phase - lung inflation and air expulsion into trachea Laryngeal phase - column of air vibrate cords according to proximity and tension = fq Oral phase - sound fq amplified by resonating O/P, O/C, N/P, then modified into speech by lips, pharynx, tongue, teeth Hoarseness = pathology of laryngeal phase

13. Physiology Intr. adductors tense and approximate cords Arytenoids remain immobile/ approximated Air escapes through hiatus from increased subglottic pressure generated from lungs Mucosal margins everted, then elasticity causes them to return to midline - thyroarytenoid and cords don�t move Sustained subglottic pressure causes rapid repetition = �mucosal wave�

14. Physiology Frequency = speed of mucosal vibration Glottic hiatus size/ shape = differing fq If disrupted (cord lesion, incomplete cord adduction), causes hoarseness If mucosa elasticity decreased by edema, thickening, then changes fq = hoarseness FVC flatten laterally, if not then alters air column, alters fq, and causes hoarseness (dysphonia plica ventricularis)

15. Physiology Pitch - altered by fq of mucosal vibration As TVCs lengthened and tightened, vibration fq increases, and pitch increases Damping - Cricothyroid compresses cords further together until vibration ceases, post to ant, decreasing hiatal size, and increasing force of air column = vibration fq increases, and pitch increases Pitch break = neurologic disruption of damping, may cause hoarseness

16. History Hoarseness - rough, scratchy sound - mucosal irregularity Breathiness - incomplete closure, air hisses through TVC gap - paralysis, large mass, CA joint problem Distinguish from articulation/resonance (oral phase), and volume (pulmonary phase)

17. History Geriatric - vocal atrophy, poor conditioning of abdominal and pulmonary musculature Toxic exposure - tob, etoh, pollutants, pollens directly toxic, increase mucus/ throat clearing Voice use/ abuse - occupation, poor posture during abuse, compensatory mechanisms injurious Chronic - nodules - voice rehab Acute severe - polyps/cysts - surgery

18. History Respiratory Hormonal - thyroid, estrogen - edema of lamina propria = decreased elasticity Medications - androg hormones - permanent Asprin, NSAIDS, antihistamines, diuretics Food products - milk - casein GERD - mucosal edema = hoarseness, halitosis, dry mouth�.worse in am heartburn absent in half pts

19. History Neurologic Psychiatric Surgical history - laryngeal, abdominal, thoracic

20. Exam Complete ENT exam for every new patient with emphasis on IDL, Neck 1854 - larynx examined in vivo - IDL 1980s - fiberoptics = machida flex end v. rigid end v. strobe (v. IDL ) IDL not always able to see piriforms to apex

21. Exam - Larynx Evaluate changes in cord mucosa, and appearance of cord in aBd, and aDd Est glottic gap, (mass, atrophy, poor mobility) Arytenoid mobility - hypermobile, paretic, paralyzed �..Cancer, CA joint, RLN lesions, masses, neurologic diseases, etc.

22. Ancillary Testing Labs: TSH, LFT Plain films: CXR, Lat neck CT scan: cancer, unk dx, persistent or recurrent pain and hoarseness, trauma, foreign body? MRI - multiple cranial neuropathies - evaluate skull base and brainstem Modified Ba, Ba swallow,

25. Consultations Speech, Speech, Speech GI med - ph probes Pulmonary Neurology Psychiatry

26. Strobe Oertel - 1878 Late 1980s - fiberoptics, video Mechanism Allows recording of voice and video together = good for f/u to tx and patient education Glottic closure/gap, precise cord motion, supraglottic funxn, better look at ? masses, mucosal elasticity, cord stiffness, functional disorders, ��fewer DLs

27. EMG/ EGG EGG: whether cords open or closed and rapidity of cord closure limited if cords don�t approximate well EMG: determine if paralyzed cord permanent, assisting surgical planning, guiding botox injections for spasmodic dysphonia, CA joint fixation/dislocation v TVC paralysis, RLN paralysis v. complete vocal cord paralysis

28. Panendo Indications Biopsy suspicious lesion Laryngeal cancer - tumor extent, second primary Hoarse patients without dx at end of w/u Persistent or recurrent vocal symptoms �..may need to repeat Patients with prior cancers with new onset hoarseness