flow chart- hoarseness

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CLINICAL PROFILE OF HOARSENESS OF VOICE

Sambhu Baitha1, R. M. Raizada

2, A. K. Kennedy Singh

3, M. P.

Puttewar3, V. N. Chaturvedi

4

Key Words : Hoarseness, Clinical profile.

INTRODUCTION

The human voice is an extraordinary attainment, which is

capable of conveying not only complex thought but also

subtle emotion. At every child birth the most singularly

and universally awaited sign of life is the infant’s cry. Thecry signals a fulfilled physiological capability required for

the infant’s survival. Probably no other human organ

system need work so immediately and effectively after

birth. “Although the voice is not visible to the eyes during

speech production but its absence or malfunction is

obvious”(Colton et al, 1990).

Hoarseness is the term used to describe a change in normal

voice quality. It is non-specific term, similar to patient's

complaint of dizziness when describing symptoms from

lightheadedness to true vertigo. Hoarseness may imply

breathiness, roughness, voice breaks or unnatural changes in pitch. Term dysphonia is used by laryngologists to

describe abnormal voice quality. Complaints of hoarseness

may represent serious disease, therefore, should not be

ignored (Garrett et al, 1999). In the words of Chevalier

Jackson “Hoarseness is a symptom of utmost significance

and calls for a separate consideration as a subject because

of the frequency of its occurrence as a distant signal of

malignancy and other conditions” (Parikh, 1991).

MATERIALS AND METHODS

The present study, comprising of 110 cases of hoarseness,

was carried out in the Dept. of Otolaryngology - HNS ,MGIMS, Sevagram, Wardha (Maharashtra) between Jan.

1998 to Sept. 1999.

All the cases presenting to Otorhinolaryngology department

with history of hoarseness were included in this study

except for the cases with change in voice due to (i)

Fig-1

Flow chart for clinical study of hoarseness

1Registrar, 2Addl. Professor, 3Lecturer, 4Lecturer, 5Professor & Head, Dept. of Otolaryngology-HNS, M. G. I. M. S. Sewagram - 442 102,

India.



Clinical Profile of Hoarseness of Voice

Congenital disease (ii) Nasal & Nasopharyngeal pathology

(iii) Oral and oropharyngeal pathology and (iv) Speech

defects produced due to CNS lesions.

Methodology used for working up patients presenting with

hoarseness has been depicted in a “Flow Chart” (Fig - I)

OBSERVATIONS

I. Incidence of Hoarseness of Voice

A total of 34081 cases attended the ENT OPD (16472

new and 17609 old) between Jan 1998 to Sept. 1999. Out

of these 110 patients presented with hoarseness of voice.

Thus the incidence was noted to be 0.32% of all cases

and 0.66% of new OPD cases.

II. Clinical Profile of Hoarseness

1) Age: Majority of patients was seen in age group of 21-50

yrs. (61.81%) and most commonly in 4lh

decade of life(28.18%). The age of patients ranged from 6 yrs. to 71 yrs.

(Mean - 40.4 yrs. ) (Table-I).

2) Sex: Male predominance was observed, with Male:

Female ratio of 2: 1 (Table - I).

3) Occupation: Labourer class constituted single largest

group of patients (36.36%) followed by housewives

(21.81%), students (14.54%) and teachers (10%).

4) Rural / Urban distribution: Patients with hoarseness of

voice were predominantly from the rural areas comprising of 83 cases (75.5%). Only 27 (24.5%) patients were from the

urban area giving a rural : urban ratio of 3:1.

5) Duration of hoarseness: It was recorded in days, weeks,

Table I : Age & Sex wise distribution of patients with

Hoarseness

months and years. Duration of hoarseness ranged from 1

day to 5 years. (Mean - 3 months). Half of the patients

(50%), presented with duration in months.

6) Clinical presentation :

Symptoms : A part from the symptom of change in voice

(100%) other common presentations were cough, fever

and vocal fatigue in descending order of frequency. Other

symptoms which were noted are shown in Table -II. None

of the patients had aspiration or regurgitation.

Signs : a) Septic foci : Were noted in oral cavity &

oropharynx in 41.8% cases.

b) In dir ect laryngoscopy: The most frequently

encountered laryngoscopic picture was congestion of true

vocal cords - seen in 27 (34.54%) patients followed by

presence of a nodule and thickening of vocal cord in 14

(12.72%) cases each and unilateral vocal cord paralysis in

paramedian position in 10 (9%) patients. Growth inlarynx was seen in 9 (8.18%) and polyp in 5 (4.54%)

cases . Congestion and edema of epiglottis, A. E. Folds,

interaytenoid area and false cords was also found on

indirect laryngoscopy.

c) Direct Laryngoscopy / Microlaryngoscopy: It was done

in 40 patients. Neoplastic lesions (Sq uamo us cell

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. I, January - March 2002

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Table III : Incidence, Age & Sex distribution and Occupation of Patients as per different conditions causing

hoarseness of voice

carcinoma of larynx and laryngopharynx) were most

commonly encountered in 16 (40%) cases, followed by

vocal nodule in 9 (22.5%) cases. (Five cases of vocal

nodule either did not agree for direct laryngoscopy and

surgical treatment or were treated conservatively). Chronic

hyperplastic laryngitis was encountered in 6 (15%) cases.

Incidence, Age and Sex distribution and occupation of

different condition leading to hoarseness of voice are

shown in Table - III

DISCUSSION

In our study the incidence of hoarseness among total OPD

patients was 0.32% and incidence among new cases was

0.66%. The incidence of individual lesion leading to

hoarseness is shown in Table III. In the literature available to

us, incidence of hoarseness among patients attending

ENT OPD could not be found. This problem has been

encountered by some other workers also like - Mehta(1985) who has mentioned that a search of available

literature on laryngology for the comparative incidence of

causes of hoarseness of voice was unfruitful Parikh (1991)

also comments – “It’s strange that hoarseness as a subject

has not attracted the attention of many workers”.

In our study the age of patients with hoarseness ranged

from 6 - 7 1 yrs. (Mean 40.4 yrs.) and the majority of

patients (61.81%) were in the group of 21-50 yrs. which is

considered as the most active period of life. Further,

patients in the 4lh decade (28.18%) constituted the single

largest group. Our observation is supported by Deshmukh

(1976) and Mehta (1985) who also reported the incidence

in the age group of 20 - 50 yrs. to be 63.1% and 67.2%

respectively.

Chopra and Kapoor (1997) reported the incidence of

benign glottic lesions undergoing microlaryngeal surgery

in the age of 20 - 50 yrs. to be 73.14%. Contrary to this, a

low incidence of 58% in the above age group was noted by

Saxena and Gode (1975) in their study on cases

subjected to Microsurgery of the larynx. Both these studies

involve a limited group of patients in whom focus of

attention is benign glottic lesions or microsurgery of

larynx, which is not the case with our study.

A male : female ratio of 2:1 was observed in this study.Our finding is exactly in confirmation with that of Parikh

(1991). Other studies by Deshmukh (1976), Vrat et al

(1981) and Mehta (1985) also showed male predominance.

As far as occupation is concerned, Labourers constituted

the single largest group of patients (36.36%) in our study

followed by housewives comprising 21.81% cases.

According to Chopra and Kapoor (1997) only 5.97% their

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 1, January - March 2002

16




pat ients presenting with benign glot tic lesions (for

microlaryngeal surgery) were farmers. The high incidence of

hoarseness among labourers in our study may be

explained by the fact that our hospital being rural based

caters mostly to the village population comprising of farm

labourers.

Mehta (1985) and Hirschberg et al (1995) have reported

higher incidence of voice disorders among the urban

population. However in our study hoarseness of voice

was predominantly seen in rural inhabitant with rural :

urban ratio of 3:1. (Reason already mentioned above).

Duration of hoarseness ranged from 1 day (acute onset

cases) to 5 yrs. and 50% patients had duration of

hoarseness in months. Chopra and Kapoor (1997) have

noted 68.65% patients with duration of hoarseness of less

than one year.

The present study on hoarseness of voice included all the

patients with symptom of change in voice (100%). Mehta

(1985) and Parikh (1991) have also done similar studies

and noted that 100% cases presented with hoarseness.

As in our study the other associated symptoms like cough,

dyspnoea, dysphagia, throat pain, weight loss etc. were

noticed by Parikh (1991) also.

In the study by Shah (1973) on patients with benign

growths of larynx incidence of hoarseness was reported to

be 93% and the other symptoms were cough, painful

swallowing, difficulty in swallowing, fever, lump in throatand respiratory distress.

Among signs on clinical examination septic foci in the

oral cavity and oropharynx were observed in 41.8% of

our cases. This is in agreement with Mehta (1985) and

Parikh (1991) who reported oral and oropharyngeal septic

foci in 43% of their patients with hoarseness. Kaluskar

(1971) reported a higher incidence of septic foci (59%) in

patients with hoarseness of voice. Indirect laryngoscopy

findings have already been mentioned before.

Parikh (1991) reported vocal cord nodule as the most

common finding (50%) among patients with chronic

laryngitis and the nodules were bilateral in 91% cases. In

our series vocal cord nodules were seen in 12.72% patients

and they were bilateral in all the cases (100%). Mehta

(1985) also reported bilateral vocal cord nodule in 100%

cases. Further, both the authors reported vocal cord polyp

to be more common on the right vocal cord (72.67% and

64% cases respectively). We have found vocal cord polyp

(4.5%) on right side in 40% patients and left side in 60%

patients. Probably it requires study on large number of

cases to arrive at any conclusion. It is already mentioned

earlier that direct laryngoscopy and / or

Microlaryngoscopy were done in 40 patients.

As per Table III, the most common condition accounting

for slightly less than half of all cases with hoarseness

(49%) was found to be chronic laryngitis followed by

acute laryngitis (26.3%). Others were neoplasms (14.5%),

vocal cord palsy (9%), trauma and senile larynx (1.8%

each).

Summary

Incidence of hoarseness of voice was observed to be

0.32% of all OPD cases and 0.66% of all new case

attending Otolaryngology and Head and Neck SurgeryOPD. Patient's age ranged from 6-71 yrs. (Mean 40.4%

yrs.) Male: Female ratio was noted to be 2:1. Labourers

constituted the single largest group of patients comprising of

about 36% cases. Three fourth of patients were from the

rural area. Duration of hoarseness ranged from 1 day

(Acute onset) to 5 yrs. (mean - 3 months). Septic foci in

oral cavity and oropharynx were noted in 41.8% cases.

Apart from change in voice other common symptoms

were cough, fever and vocal fatigue. Signs of chronic

laryngitis were noted in roughly half of the cases.

REFERENCES1 Chopra H, Kapoor M (1997) : Study of Benign Glottic lesions

undergoing Microlaryngeal Surgery. Indian Journal of

Otolaryngology and Head and Neck Surgery , 49 (3) : 276 -

279.

2 Colton RH, Casper JK, Hirano M (1990): Understanding voice

problem. Edited by John P Butter, Baltimore, Williams and

Wilkins , 1 - 9 .

3 Deshmukh (1976): Clinical study of hoarseness of voice: A thesis

submitted for Master of Surgery (Otorhinolaryngology), Gujarat

University .

4. Garrett CG, Ossoff RH( 1999): Hoarseness. Medical Clinics of

North America , 83 (1) : 115 - 123.

5. Hirschberg J, Dejonckere PH, Hirano M et al (1995): Voice

disorders in children. International Journal of Pediatric

Otorhinolaryngology 32 (suppl) : S 109 - S 125.

6. Kaluskar (1971) : Study on hoarseness of voice : A thesis

submitted for Master of Surgery (Otorhinolaryngology), Gujarat

University.

7. Mehta AS (1985) : An Aetiological Study of hoarseness of

voice. A thesis submitted for Master of Surgery

(Otorhinolaryngology), Gujarat University.

Indian Journal of Otolaryngology and Head and Neck Surgery Vol. 54 No. 1, January - March 2002

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flow chart- hoarseness

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