CHAPTER 44 Laryngitis

(b) Spasm: Inchildren, the larynx is more

Laryngitis is a common condition and it may excitable and may develop spasm very
be classified as follows: easily.
(Ay Acute Larvngitis (c) Cough refler of the child
is comparatively
(1)Non-specific: () Acutelaryngitis. weak, and secretions may not be expelled
(ii) Acute laryngotra- easily.
cheobronchitis. may affect
(2) Infection: Viralor bacterial infection
(ii) Acute epiglotitis. the larynx. The conmmon cold is the commonest
(2) Specific: G) Diphtheric cause of laryngitis.
laryngitis. (3) Exanthemata make the larynx susceptible to

(B) Chronic Laryngitis infection.

(1) Non-specific: ) Chronic non- (4) Other Respiratory Tract Infections like
specific laryngitis. Sinusitis, tonsillitis or bronchitis may spread to
the larynx.
i) Hyperkeratosis
YVocal Misuse and Overuse are common causes
(Leukoplakia)
of acute simple laryngitis.
(2) Specific (rare): () Tuberculosis..
Irritation: Smoking, alcohol and fumes irritate
(ii) Syphilis the larynx.
(ii) Scleroma, leprosy Seasonal Changes may cause acute laryngitis.
(8latrogenic: Intubation _and endolaryngeal
Sugery may cause laryngitis.
ACUTE NON-SPECIFIC LARYNGITIS
It is the commonest cause of temparary SYMPTOMS
hoarseness. (1) Hoarseness: The voice becomes husky initially.
AETIOLOGY Severe infection may lead to aphasia.

(1) Age: It occurs at all ages, but it may take a (2) Rawness: There is a feeling of rawness in the
serious turn in childrem because of the following throat.
reasons: (3) Pain occurs in severe cases.
(a) Small lhumen: Slight oedema in a child (4) Cough of an irritating type may be present.
may narrow the lumen of the larynx
(5) Stridor may be present in children.
considerably, and may lead to dyspnoea
and stridor. (6) Constitutional Symptonus may occur.

274
 Laryngitis
SIGNS (2)Anti-inflammatorydrugs reduce the congestion.
Indirect laryngoscopy is required for diagnosis: (3) Linctus codeine reduces the cough.
Congestion: The vocal cords become (4) Steroids should be given if dyspnoea is present.
congested and the colour may vary from pink
to red. Other parts of the larynx may also be (5) General rest may be advised in severe cases.
congested. (6) Smoking amd alcohol should be avoided
(2) Oedema may be present with severe infection.
)Exudate is sticky and mucoid initially. As the ACUTE EPIGLOTTITis
infection becomes more severe, it becomes
purulent (Septic laryngitis). In acute epiglottitis, the epiglottis gets
(4) Fibrinous Laryngitis: In some cases of inflamed and becomes markedly swollen.
influenza, white plaques may form on the vocal
It usually occurs in children, but can also
cords and the larynx.
affect adults, H. Inftuenza B is usually the causative
(6) Movements of the Vocal Cords may be organism.
hampered
CLINICAL FEATURES
COMPLICATIONS may be quite severe in children.
()Dyspnoea
(1) Spread: The infection may spread to the (2) Pain is the presenting feature in an adult, and
tracheobronchialtree. Swallowing is extremely painful.
(2) Dyspnoea: Children are liable to get dyspnoea (3) Fever is usually present.
and stridor because of the small size of the
laryngeal lumen, spasm and weak cough (4) Stridor can be present due to supraglottic
reflex. congestion and oedema.
(3) Perichondritis: In very severe cases, (5) Radiograph: Lateral view may present
perichondritis of the larynx may develop. Thumb sign'caused by oedematous epiglottis
looking like a thumb.
TREATMENT
TREATMENT
(A)Local1
() Voice rest; The patient should restrict speaking to (1) Steam Inhalation and Voice Rest are
recommended.
the minimum. Forced whisper and shouting are
more strenuous for the vocal cords than normal (2) Antibioties are essential for these cases.
conversation. (3) Steroids should be administered to reduce
2) Steam inhalation is very soothing because of oedema.
fomentation and loosening of viscid secretions. (4) Tracheostomy may be required in ehildren
Tincture benzoin, menthol or eucalyptus oil may with dyspnoea. Intubation may be dificult
be added to boiling water. because of the epiglottic oedema.
6)Lozenges give comfort to the throat.
4) Fomenation of the neck may be helpful. ACUTE
5) Endotracheal intubation may be required
LARYNGOTRACHEOBRONCHITIS
Tor small children with stridor. At times,
racheostomy may be life saving This severe infcction occurs in chiliren, when
(b) General their resistance is low and infection is virulent. The
child appears to be more toxic than a patient with
)dntibiotics are advised to patients with bacterial
diphtheria., because of the severity of infection and
laryngitisAnd to thase having complieations.
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A Short Book of E.N. T. Diseases

dyspnoea due to generalized oedema of the entire (2) Corynebacterium Diphtheriae is the causative
tracheobronchial tree. organism.

AETIOLOGY PATHOLOGY
occurs in the larynx.
(1) Age and Sex: It affects children of both sexes. A membrane formation
The membrane may detach
and hang between
General Debility predisposes to this condition. laryngospasm. A
(3) Causative Organism is usually Streptococcus the vocal cords leading to
cause laryngeal
haemolyticus. large membrane itself may
obstruction.
PATHOLOGY
There is marked congestion and oedema of the CLINICAL FEATURES
be low grade fever
entire respiratory tract, extending from the laryx (1) Constitutional: There may
to the trachea and bronchi. This interferes with and tachycardia with weak pulse. The patient
the pulmonary function. Tenaceous secretions and appears to be toxic.
crusting may be present. be the first
2) Cough: A hoarse, croupy cough may
symptom.
CLINICAL FEATURES
(3) Hoarseness: The child develops hoarseness.
The clinical features have been discussed Stridor and Inspiratory Dyspnoea soon follow,
(4)
in Table 44-I on this page.
which are intermittent initially, but become
continuous later.
DIFFERENTIAL DIAGNOSIS
It is similar to that of laryngeal diphtheria. (5) Diphtheric Membrane may be present on
the tonsils. The diphtheric greyish-white
TREATMENT Table 44-1I
Its treatment is similar to that of laryngeal
Laryngeal Acute
diphtheria except for the following differences:
diphtheria laryngotracheo-
(1) Humidification to liquify the secretions. bronchitis
(2) Antitoxin is not required.
i) History Exposure to Upper respira-
(3) Bronchoscopy may be required to suck out diphtheria. tory infection.
viscid tracheobronchial secretions.
(ii) Toxaemia Present. Severe.
Earlier, tracheostomy was performed in a
(ii) Temperature Low. High.
large number of cases and mortality was very
(iv) Inspiratory Present. Present with
high. But today, due to antibiotics, steroids and
endotracheal intubation, mortality has been reduced stridor expiratory
and tracheostomy is performed in a few cases only. dyspnoea.
(v) Chest Clear. Rales and
LARYNGEAL DIPHTHERIA rhonchi.
(vi) Throat May show Acute follicular
Laryngeal diphtheria has become very rare due diphtheric or ulcerative
to immunisation. It may lead to a serious emergency white patch. tonsillitis.
by causing laryngeal obstruction, in addition to the (vii) Direct Diphtheric Marked
usual toxaemia. It is often the extension of faucial laryngos-
diphtheria. membrane. congestion and
copy oedema of the
AETIOLOGY larynx with or
(1) Age and Sex; Usually it affects children ofboth without white
sexes. patches.

276
 Laryngitis
membrane is seen on the affected parts on (6) Tracheostomy is indicated for persistent
direct laryngoscopy. Removal of the membrane stridor.
results in bleeding.
If a patient is having severe stridor, one
should not waste time for establishing the
DIFFERENTIAL DIAGNosIS diagnosis. Instead, one should start the treatment
(1) Acute Laryngotracheobronchitis: The immediately, and intubation or tracheostomy is
difference between laryngeal diphtheria and performed if required.
acute laryngotracheobronchitis is shown in (7) Fluid-intake should be adequate
Tablc 44-1:
(8) Immunization of other children in the family
2) Laryngeal Foreign Body: There may be a is performed.
history of inhalation of foreign body, and the
onset is very sudden. There may be hoarseness
or aphonia.
CHRONIC LARYNGITIS
(3) Tracheobronchial Foreign Body should Chronic laryngitis is a fairly common condition
be always kept in mind as a differential which is caused by chronic irritation of the vocal
diagnosis. cords.
(4) Acute Simple Laryngitis in children may AETIOLOGY
cause stridor.
(1) Age: Usually it occurs over the age of
(5) Laryngismus Stridulus starts almost
20 years.
immediately after birth and is never severe.
6) Multiple Laryngeal Papillomas produce (2) Sex: It is more common in males.
chronic hoarseness and stridor. (3) Predisposing Factors
(7) Allergic Laryngitis with oedema and stridor Misuse or overuse of voice: Speaking
is rare and sudden.
continuously, loudly, or improperly may
INVESTIGATIONS result in chronic laryngitis.

Bacteriological Examination of the laryngeal ii) Smoking produces chronic inflammation

swab showing corynebacterium diphtheriae in the of the larynx, which is further aggravated
smear and culture confirms the diagnosis, but a by coughing due to chronic bronchitis.
3
negative report does not rule out diphtheria, unless (ii) Atmospheric pollution by dust and
separate samples are negative for it. obnoxious gases may cause chroniec
laryngitis.
TREATMENT
(iv) Sepsis: Chronic tonsillitis, dental sepsis
(1) Antitoxin should be administered after a test and chronie paranasal and nasal infection
dose for sensitivity. Usually 40,000 to 100,000 may lead to chronie laryngitis.
units are required as a single dose therapy.
(v) Hawking and coughing aggravate chronic
(2) Antibiotics: Penicillin or erythronmycin are laryngitis.
adviscd.
(3) Oxygen should be started at the earliest. SYMPTOMS
(4) Steroids reduce laryngeal oedema and toxicity. (1) Hoarseness is the presenting symptom, and it
Endotracheal Intubation may be utilised for is usually severe in the morning. After clearing
(5)
overcoming laryngeal obstruction. the collected seeretions in the throat, the voice

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Short Book of'E.N.T. Diseases
develop
becomes better; but as a result of vocal strain or (5) Granulations or Atrophy may in

advanced cases.
snokig, it gradually worsens in the evening. It
may improve intermittently.
DIFFERENTIAL DIAGNoSIS
(2) Cough: Dry irritating cough is
present.
Benign Tumours
Vocal Nodules, Polyps and
Kawensation in the throatis often experienced (1)
may present with similar
clinical picture.
by the patient, which increases on speaking. by indirect
but these are differentiated
(4) Hawking: Frequent desire to clear the throat laryngoscopy.
is present due to secretions collecting on the
vocal cords. The persistent hawking uggravates (2) Malignancy of Vocal Cords may be
the condition. misdiagnosed as chronic laryngitis. Careful
laryngeal examination and biopsy settle the
SIGNS diagnosis.

Following bilateral changes may be present: (3) Tuberculous Laryngitis is usually secondary
is characterised
(1) Hyperaemia: The vocal cords remain congested. to pulmonary tuberculosis, and
The colour may range from pink to red by pale granulations in the posterior
onc-third of the vocal cords and interarytenoid
(2) Hyperplasia of the vocal cords as well as false region. Biopsy confirms the diagnosis.
cords, arytenoids and the interarytenoid region
may occur. (4) Gumma affects the anterior portion of the
larynx, and may present as a granuloma or deep
(3) Oedema: The vocal cords may become
ulceration of the vocal cords and epiglottis.
oedematous and pale.
VDRL test is positive.
(4) Viscid Secretions from the mucous glands
may stick to the vocal cords, which compel the (5) Vocal Cord Palsy is diagnosed by indirect
patient to clear his throat constantly. laryngoscopy.

Table 44-1I
Differential diagnosis of chronie laryngitis
Laryngeal Lesions Tuberculosis Syphilis Malignancy Non-specific
chronic laryngitis
(1) Pain Severe. Absent. May be present. Insignificant.
(2) Swallowing Painful. Normal. Dysphagia later. Normal.
(3) Emaciation Present. Absent. Present. Absent.
(4) Voice Weak aphonic. Strong, hoarse. Hoarse. Hoarse.
(5) Lesions Posterior 1/3 Anterior /3 Everted edges. Congestion.
aflected. Pale or involved. Decp oedema.
mouse-nibbled ulcers.
appearance.
(6) Radiograph Pulmonary Normal. Secondaries in Normal.
of chest tuberculosis. the late stage.
(7) Sputum A.F.B. present. Nogative. Negative. Negative.
(8) VDRL Negative. Positive Negative. Negative.
(9) Biopsy settles
the diagnosis.

278
 Larngitis
6) Leukoplakia is identified by indirect (2) Leukoplakic Raised White Patches appear
laryngoscopy. Biopsy may be performed by on one or both vocal cords on the anterior and
endoscopy. It may undergo malignant change. middle one-third portions.
(7) Acute Laryngitis is of short duration, and there 3) Movements of the vocal cords are not affected
is congestion of the vocal cords.
DIAGNOSIS
TREATMENT Biopsy rules out a malignant change.
(1) Chronic irritating factors like smoking and
atmospheric pollution should be avoided. PROGNOSIS
(2) Change of emvironment or place of work may The patient must remain under continuous
help. supervision for detection of the malignant change

(3) Voice rest is very helpful. TREATMENT

(4) Speech therapy plays an important role in these (1) Voice rest is recommended.
cases. Smoking should be stopped totaly.
()
(5) Steanm inhalation is soothing.
(3) Steam inhalation is helpful.
(6) Linctus codeine controls the cough. (4) Vitamin A is of doubtful value.
(7) Sepsis: Nasal, pharyngeal and oral sepsis should ) Excision of the leucoplakic patches is performed
be treated. by microlaryngoscopy.
(8) Antibiotics may help early cases, but are not (6) Laser may be useful.
useful for chronic cases.
(7) Stripping: The surface of the vocal cord may be
(9) Stripping: Thickened and oedematous vocal stripped.
cords may be stripped by microlaryngoscopy (8) Evcision of the vocal cord by laryngofissure
may
be performed in advanced cases.
LARYNGEAL HYPERKERATOSIS (9) Radiotherapy has a controversial role in the
(LEUKOPLAKIA) treatment.

White patches develop on the vocal cords in

LARYNGEAL TUBERCULOSIS
this condition. It is considered to be a premalignant
lesion. With improved treatment of tuberculosis.
laryngeal tubereulosis is not common any more. This
AETIOLOGY lesion may occur in 3 forms:
The exact cause is not known. (1) Acute Miliary Tuberculosis with multiple
(1) Age: It occurs usually over the age of 35 to 40 tubercles breaking down to form uleers, is rare.
It is secondary' to pulmonary tuberrulosis.
years.
(2) Sex: It predominantly occurs in males. 2) Lupus is also rare.
Chronic Tuberculosis is not so rare, and
(3) Smoking may be a cause of this condition. ) is
described here:
(4) Syphilis may lead to leucoplakia.
AETIOLOGY
CLINICAL FEATURES
(1) Age: The usual age is between 20 to 40 year
(1) Hoarseness is of long duration, and gradually
1ncreases. (2) Sex: Both sexes are affected.

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A Short Book of E.N.T. Diseases

(3) Pulmonary tuberculosis: The infection reaches DIFFERENTIAL DIAGNOSIS

the larynx with sputum, or it reaches via the
It has been discussed on p. 278.
lymphatics or blood vessels.
TREATMENT
PATHOLOGY
(1) Tubercle formation is seen initially. (1) Antituberculous treatment is started in full
(2) Ulceration of the tubercles occurs soon. vigour.
(3) Perichondritis and cold abscess formation of (2) Voice rest is advised.
the larynx may occur in advanced cases.
3) Analgesics are required for reducing pain.
SYMPTOMS (4) Tracheostomy has now become rare for this
(1) Aphonia: The voice becomes weak with lesion.
intermittent aphonia. (5) Arytenoidectomy or arytenoidopery for crico
(2) Hoarseness: Severe hoarseness is often present. arytenoid ankylosis may be required.
(3) Cough is always present.
4) Pain increases on swallowing. It may be referred
to the ear.

SIGNS
(1) Movements of the vocal cord may be affected
early due to myositis, recurrent laryngeal nerve
palsy or ankylosis of thee crico-arytenoid joint.
(2) Vocal cords are pale initially. They soon become
congested and ulcerated in the posterior one-
third portion. The ulceration produces the
mouse- nibbled'appearance
Fig.44-1: Laryngeal tuberculosis showing
(3) Granuloma may form in the interarytenoid mouse-nibbled appearance
region, and it may arouse the suspicion of
malignancy. SYPHILITIC LARYNGITIS
(4) Pseudo-oedema of the epiglottis and arytenoids
may occur with furban-like appearance. The This condition has become rare today.
false cords become oedematous CONGENITAL AND SECONDARY STAGES are
(5) Perichondritis of the larynx with swelling and very rare.
cold abscess formation may be seen in advanced
cases. TERTIARY STAGE
(6) Inspiratory dyspnoea is present in late stages. Gumma may be encountered. It affects the
epiglottis and the anterior one-thirdofthe vocal cords.
INVESTIGATIONS
and is described here:
(1) Sputum examination may reveal acid-fast
bacilli Clinical Features
(2) Radiograph of the chest shows pulmonary (1) Hoarseness is the presenting symptom.
tuberculosis.
(2) Diffuse infiltration resembling simple
(3) Biopsy clinches the diagnosis. hypertrophic laryngitis may be seen initially

280
 Laryngitis
(3) Ulceration: A typical deep ulcer with wash PERICHONDRITIS OF THE LARYNX
leather slough may develop.
Perichondritis occurs in late stages. AETIOLOGY
(4)
The laryngeal cartilages become inflamed due
(5) Laryngeal stenosis due to scarring and adhesions
to:
may occur.
() Trauma
Treatment (a) Infection of cut throat injuries, and
(1) Antisyphilitic treatment should be given. impactedforeign bodies may cause it.
(2) Tracheostomy is required, if there is laryngeal (b) High tracheostomy may predispose to
obstruction. perichondritis.
(3) Laryngoplasty for stenosis may be performed (c) Irradiation may be the cause.
after active infection is controlled. (2) Infections: Tuberculosis, syphilis and
severe septic laryngitis may give rise to
LARYNGEAL LEPROSY perichondritis.

Leprosy of the larynx is rare. (3) Malignaney: Advanced cases with secondary
infection may lead to it.
(1) Diuse nodular infltration of the epiglottis,
arytenoids and false cords may occur. CLINICAL FEATURESs
(2) Stenosis and deformity of the larynx may result.
(1) Pain is severe, making swallowing very
difficult.
LARYNGEAL SCLEROMA (2) Hoarseness is always present.
Rhinoscleroma of the nose may rarely extend (3) Inspiratory dyspnoea may be present.
down to involve the larynx. Subglottic region is
usually involved. The infiltration in the submucosa (4) Abscess formation may follow.
leads to subglottic stenosis. (5) Stenosis may be the end result.

TREATMENT TREATMENT
() Streptomycin or doxycycline is useful. (1) Antibiotics are essential for these cases.
(2) Steroids reduce fibrosis and stenosis.
(2) Steroids reduce the swelling and searring.
(3) Tracheostomy may be necessary.
(3) Tracheostomy is often required.
(4) Laryngeal dilatation may be required.
(4) Stenosis has to be treated later.
6) Laser excision may be helpful.
Antibiotics and steroids may have to be (5) Laryngectomy is very rarely required if severe
administered for many months. pain and dysphagia persist.

281
 Hoarseness; Speech
CHAPTER 47 and Voice Disorders

LESIONS DISCUSSED IN THIS Muffled Voice is produced by a space-

CHAPTER Occupying lesion in the laryngopharynx without
involving the vocal cords. It is called hot potato
Hoarseness speech', because the patient speaks as if he has a hot
Speech disorders potato in his mouth which is neither being swallowed
Voice disorders nor is being spat out. Patients having malignancy of
the base of the tongue or pyriform fossa may have
Dysphonia plica ventricularis
such a voice.
Spastic dysphonia
Breathy Voice of poor volume is produced by a
Reflux laryngitis
patient having vocal cord paralysis, if there is escape
Phonosurgery of air between the vocal cords.
HOARSENESS Table 47-II
hoarse voice is rough and unpleasant, and it Causes of hoarseness
A
results from lesions of the vocal cords. () Laryngeal and laryngopharymgeal
Congenital
Causes of hoarseness may range from (1)
(2) Traumatic
innocent acute laryngitis to laryngeal diphtheria and
(3) Infections
malignancy. If hoarseness persists for more than
(4) Tumours
2 weeks in spite of conservative treatment, laryngeal
(5) Miscellaneous
examination should be carried out to diagnose the
cause. (1) Oesophageal

MECHANISM OF HOARSENESs (ut) Cervical and mediastinal

(1V) Gener
Interference with the following may lead to
hoarseness:
CAUSES OF HOARSENESS
Movements of vocal cords.
()LARYNGEAL AND LARYNGOPHARYN-
(ii) Approximation of edges of vocal cords. GEAL CAUSES
(ii) Mass of vocal cords. (1) Congenital
(iv) Tension of vocal cords. (i) Large web at the anterior commissure is
rare.
QUALITY OF VOICE (ii) Congenital cysts and tumours are also
Hoarse Voice is rough and unpleasant. rare.

295
A Short Book of E.N.T. Diseases
(c) Leprosy.
(2) Traumatic
(d) Lupus.
) Misuse and overuse of voice: Speaking
continuously or loudly may injure the (e) Scleroma.
vocal cords. This is a common cause of (4) Tumours
hoarseness. Singing in an improper chondroma,
Benign tumours like cysts,
manner and excessive coughing may rare. Haeman-
fibroma and myoma are
produce hoarseness. polypoidal swelling
gioma presenting as a
sometimes seen.
(i) External injuries: Strangulation, cut- on the vocal cords is
occur in
throat or contusional injuries of the larynx Multiple laryngeal papillomas
producing haematoma of vocal cords may children and produce chronic hoarseness
cause hoarseness. accompanied by stridor.
laryngo-pharynx:
(ii) Internal injuries: Inhalation of hot acid (i) Malignancy oflaryx and
fumes produces oedema and inflamma- Malignancy of vocal cords produces
tion of the larynx. hoarseness at the earliest, while other
time
(iv) Irradiation may damage the vocal cords. types of malignant lesions take some
should
(v)ntubation trauma: Use of a large laryngeal to produce hoarseness. This cause
always be ruled out in an elderly patient,
tube, rough intubation or prolonged
intubation may tear a vocal cord or lead whose hoarseness is not relieved by
to granuloma formation and stenosis. conservative treatment within 2 weeks.
(5) Miscellaneous
(3) Infection (Laryngitis)
Acute laryngitis i) Singer's nodes are common causes of
chronic hoarseness, and are characterised
) Non-specific: Viral or bacterial laryngitis by a nodule on the edges of both vocal
produces temporary hoarseness which cords at the junction of anterior-third and
usually follows an attack of common cold. middle-third.
This is the commonest cause of
hoarseness (i) Laryngeal oedema may be due to causes
like:
(ii) Diphtheria with membrane formation
(a) Infection.
on vocal cords may produce hoarseness,
stridor and inspiratory dyspnoea. (b) Neoplasms.
(c) Trauma.
(ii) Acute laryngotracheobronchitis occurs (d) Allergy.
in children and produces hoarseness
with inspiratory as well as expiratory (e) Cardiac lesions, and obstruction
dyspnoea. to superior vena cava. Extensive
oedema may cause inspiratory
Chronic laryngitis dyspnoea with stridor.
(i) Non-specific
(ii) Laryngeal polyp may cause hoarseness.
(a) Chronic non-specific laryngitis.
(iv) Laryngeal stenosis may
(b) Leucoplakia of vocal cords. It is be produced
by prolonged endotracheal intubation.
usually associated with smoking, cut-throat injuries, scleroma,.syphilis
and is a pre-malignant condition. and
perichondritis. The patient has
hoarseness
(ii) Specific (rare) and stridor.
(a) Tuberculosis. (v) Paralysis ofrecurrent laryngeal
(b) Syphilis.
nerve may
present with hoarseness.
296
 Hoarseness; Speech and Voice Disorders

(vi) Functional aphonia: If a female comes (6) Microlaryngoscopy gives a precise diagnoSIS
with sudden loss of voice or with voice with the aid of a surgical binocular microscope.
reduced to a whisper, this condition
should be kept in mind. She does not have TREATMENT
hoarseness. (A) Specific Treatment
One should treat the specific cause of
(vii) Laryngocele (prolongation of the ventricle)
hoarseness.
is rare.
(B) General Treatment
(vi) Prolapse of the ventricle of the larynx is
It is basically similar to the treatment of acute
uncommon. laryngitis:
(ix) Arthritis of the crico-arytenoid joints. (1) Voice rest: The patient should avoid misuse
and overuse of voice. He should speak in
(1I) OESOPHAGEAL CAUSESs relaxed manner.
conversational voice in a
Malignancy may produce recurrent laryngeal Whispering is traumatic to the vocal cords and
nerve palsy. should be avoided. In severe cases, total voice
rest is advised.
(IL) CERVICAL AND MEDIASTINAL CAUSES
(2) Steam inhalation soothes the vocal cords and
These may lead to recurrent laryngeal nerve reduces the congestion. One may add tincture
palsy. benzoin, menthol, camphor or eucalyptus oil to
boiling water for steam inhalation, but the active
(IV) GENERAL CAUSES
ingredient is steam.
(1) Oedema: Myxoedema, cardiac oedema and renal 3) Antibiotics may be preseribed to control the
oedema may cause hoarseness. infection.
(2) Diabetes, syphilis and leadpoisoning may result (4) Anti-inflammatory agen1s reduce the oedema
in recurrent laryngeal nerve palsy. and congestion.
(5) Speech therapy: The patient is taught to speak
INVESTIGATIONS in a relaxed manner without straining the vocal
The investigations for hoarseness are similar to cords.
those for laryngeal nerve palsy (p. 284). (6) Direct laryngoscopy permits examination and
be
The following investigations may also surgery.
advised: (7) Microsurgery of larynx is useful for precise
(1) Thyroid Function Tests and thyroid
scan may diagnosis and surgery.
be required. (8) Phonosurgery has been described on p. 299.
(2) Radiography: Plain radiographs of the larynx,
tomograms and contrast laryngography may be SPEECH DISORDERS
advised. disorder due to a lesion
(1) Dysphasia is a speech
(3) CT Scan may be advised. affecting the cortical speech centre.
can be
(4) Flexible Fibreoptic Laryngoscopy (2) Aphasia is the loss of speech due to a lesion of
pertormed as an out patient procedure under
ihecortical speech centre.
local anaesthesia.
and (3) Dysarthria disorder due to a lesion
is a speech
(5) Direct Laryngoscopy settles the diagnosis
culture affecting the eranial nerves or the museles,
laryngeal swab may be sent for smear,
be joints and ligaments responsible for production
and antibiotic sensitivity. A biopsy may
performed.
of speech.
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 A Short Book of E.N.T.
Diseases
(4) Stammering is a functional speech disorder.
There is a break in the flow of speech, or the
person repeats sounds or syllables. Many
children have minor stammering upto the age
of 5 years which clears up. But if the parents
(b)
repeatedly taunt the child, it may get fixed in (a)
the mind.

TREATMENT
(1) Cause should be treated.
(c)
(2) Speech Therapy is advised.
Fig 47-1:4ppearance ofrima
glottidis in phonaesthesia. (a)
(3) Psychotherapy may be required for stammering (b) Triangular space; (c) Keyhole
appearance.
Bowing:
including counselling of the parents and teachers
cautioning them against over reacting to the
disorder. TREATMENT

(1) Cause should be treated.

VOICE DISORDERS (2) Voice rest: Voice rest is advised. Total voice rest

(1) Rhinolalia has been described on p. 175. is advised initially for phoneaesthesia.

(3) Speech therapy is recommended.

(2) Dysphonia (hoarseness) has been discussed
earlier. (4) Auditory training and speech therapy are
(3) Pubophonía is the cracking of voice in males advised for defective speech due to impaired
which occurs at puberty, as the normal transition hearing.
from the voice ofa child to the voice of an adult (5) Pubophonia: Correction of emotional instability
does not occur. Emotional as well as hormonal speech therapy and reassurance are required.
disturbances can affect this process and lead to
(6) Speech therapy is advised thereafter.
a disorder in voice.

(4) Weakness of Voice results from pulmonary

insufficiency or general debility. DYSPHONIA PLICAE
(5) Phonaesthesia (fatigue of phonatory muscles, VENTRICULARIS
vocal strain) canalso result in weak voice. It is
In this disorder, the ventricular bands are used
characterised by:
to phonate instead of the vocal cords. It is regarded as
(a) Bowing of the vocal cords due to weakness a functional voice disorder developed to compensate
of thyroarytenoid muscles. for the vocal disorder of true cords. The voice is harsh
(b) Triangular space in the posterior glottis due and unpleasant.
to weakness of interarytenoid muscles. On examination, the true cords are obseured by
the thickened ventricular bands.
(c) Keyhole appearance of the glottis if
both muscles are involved. It occurs due
Treatment
to vocal misuse, overuse or following
laryngitis. (1) Voice rest and speech therapy are advised.
(6) Impaired Hearing affects the voice. (2) Organic lesion of true eords must be ruled
out.
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 Hoarseness; Speech and Voice Disorders
SPASTIC DYSPHONIA
The procedure can be supplemented by laser.
This is a stress related voice disorder characterised
(B) TEFLON PASTE INJECTION
by sudden interruptions of speech which may
be
accompanied by respiratory distress or choking. Injection of teflon paste can be given into the
vocal cord for augmentation and medialisation
Treatment is by psychotherapy and speech therapy of
the vocal cord in such cases of recurrent laryngeal
Crushing or sectioning of one of the
recurrent nerve palsy which to not improve with conservative
laryngeal nerves have met with temporary
success. treatment. This procedure also has to be performed
Botulinium toxin injection has been advocated.
by microsurgery.
C) THYROPLASTY (Laryngeal framework
REFLUX LARYNGITIS
surgery)
Aetiology This procedure is performed for improving the
functioning of the vocal cords and has been divided
Acid reflux, particularly in lying position, is into 4 Types (Isshiki):
now increasingly being recognised as a cause of
(1) Type I is the medial displacement of the vocal
hoarseness.
cord by implantation of a prosthesis lateral to
Clinical Features the vocal cord for unilateral vocal cord palsy (p.
285).
Hoarseness occurs and there is redness and
(2) Type II consists of lateral displacemem of the
hypertrophy of interarytenoid region. This may result
in formation of contact ulcers (p. 290). vocal cords to improve the size of the airway for
bilateral vocal cord palsy (p. 285).
Treatment (3) Type IlI: The vocal cords are shortened
(1) Proton Pump Inhibitors (PPI) like rabeprazole (relaxed) by reducing the distance between
and pantoprazole are used to control acidity. anterior and posterior commissures. This is
performed for lowering the pitch of the voice
(2) Gastro-oesophageal Peristalsis improvement for male patients with feminine voice.
can be achieved by using drugs like domperidone, 4) Type IV: Lengthening (tightening) of the vocal
metoclopramide etc. cords is performed by increasing the distance
(3) Head High Position while sleeping reduces between the anterior and posterior commissures
gatric reflux. for raising the pitch of the voice in females
with masculine voice. This can be achieved
by advancing anterior commissure forwards
PHONOSURGERY or approximation of the ericoid and thyroid
cartilages.
Phonosurgery is performed for improving
the quality of voice and it includes a variety of (D) LARYNGEAL REINNERVATION
procedures carried out for different types of lesions. PROCEDURES
These can be classified as: This consists of isolating a part of the anterior
(A) MICROSURGERY belly of the omohyoid muscle with the its blood
vessels and nerve supply ansa hypoglossi. This
Microsurgery is performed by using self-retaining segment is implanted into the thyroarytanoid muscle
direct laryngoscope utilising the magnification and though a window fashioned in the ala of the thyroid
illumination by a surgical binocular microscope. cartilage.
Which permits a very precise surgery for various
procedures like biopsy and/or excision of the polyps. Long term evaluation will demonstrate the
vocal nodules and malignant lesions. eficacy of these procedures.

299