Primary care exam

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What can a primary care doctor infer about hoarseness?

If we recall Faith’s illness in Part I of Foundations, she lost her voice suddenly and went to her primary care physician’s office for advice. He performed a number of typical medical tests and looked into her mouth, but as best we can tell, he never looked at her larynx or her vocal cords. On what basis did he make a diagnosis and on what basis did he offer her treatment advice?

Dr. Marcus’ evaluation must have been largely based on a hunch or a guess, since there is no evidence that he ever saw the vocal cords. That guess might have been based on some sense of whether the hoarseness could be due to a common transient illness – a cold. Perhaps colds have been common for a few weeks in his office. Perhaps some symptoms Faith described matched a cold. 

Let’s consider another patient similar to one we have seen before. Amelia reports annual hoarseness for 30 years that typically starts up in both April and in November. It lasts two to five weeks and often goes away on its own. Her voice fades out as she uses it and she reports discomfort in her neck if she speaks very long. She rates herself as a 4 on the 7-point talkativeness scale. Many times she sees her primary care physician and reports that two courses of antibiotics often seem to make the hoarseness resolve. However, this year the hoarseness persisted after two different antibiotics. Her PCP then tried a course of steroids “to reduce the swelling,” but her voice did not improve. He then tried a one month course of a proton pump inhibitor since she does have a sense that acid comes up into the back of her throat. This treatment helped reduce the sensation of acid in her throat, but her hoarseness persisted. Then, since her hoarseness seems to often coincide with the springtime allergy season, he tried a steroid nasal spray and an antihistamine. Her voice remained hoarse and she was referred to me for an evaluation.

I listen to Amelia and when she speaks, her speaking voice is at a very low pitch for a female yet occasionally breaks into a high pitch. When she laughs, her voice is normal. When I ask her to yell, she hesitates at this vocal task. When I have her sing a high pitch, her voice is very clear and she smiles, somewhat inappropriately. I examine Amelia’s vocal cords with an endoscope and her vocal cords are normal in appearance, though she is often holding them apart during phonation. She happens to be speaking with her thyroarytenoid muscles relaxed and her surrounding neck muscles very tight. She has a nonorganic dysphonia. She can speak with a clear voice at the higher pitches, so I start there and then gradually move her speaking pitch lower until she has a clear voice at her normal speaking pitch. Within a half hour she can even change from a hoarse voice to a clear voice on command. Her hoarseness has resolved in the office.

Since her husband is present during the exam, I discuss how muscle tightness causes her voice problem and how stress often aggravates muscle tightness and plays a role in the problem. I also discuss how the muscle tightness becomes a habit and that the voice problem is quite likely to return again in the future, especially if there is any stress in her life (she volunteers that she has plenty of stress in her life.) Stress frequently causes muscle tension. Finally, I focus on how this disorder could spontaneously resolve and how the assumption that it went away in the past with an antibiotic was an erroneous interpretation of coincidence representing causation. I caution that two courses of antibiotics twice a year, steroids, anti-reflux medication and anti-allergy medication are not only a non-necessary use of her time and her money, but over many years, she is at risk for antibiotic resistance, fungal infections or other medication side effects. I had her work with a voice therapist to solidify the gains she has made today in the office. 

 

Now, let’s dissect the approach taken to hoarseness in Amelia.

Bacterial infections of the larynx are rather uncommon. Some may cause severe swelling and even airway narrowing as well as rather significant pain. Occasionally I see low grade chronic staphylococcal infections that cause a dry crust to form on the vocal cords. Consequently, antibiotic treatment of hoarseness is quite low on my list of treatment options for acute laryngitis.

What about steroids? Steroids do reduce swelling very effectively. Typically prednisone or methylprednisolone taken as a pill will reduce swelling on the vocal cord within two hours. If a patient has swollen vocal cords (and a corresponding deep pitch from that swelling) these symptoms can be temporarily alleviated with steroids. 

The steroid effect of reducing swelling is typically to reduce edema or fluid build up, but is otherwise fairly non-specific. Whether the swelling is from a general enlargement and stiffening of the vocal cord, such as from a viral infection, or whether it is from a discrete swelling along the margin of the vocal cord, such as a nodule and overuse, steroids will reduce the swelling. The improvement in the voice is rapid, but temporary. In this manner, treatment with a steroid can almost be used as a test. If Faith’s voice improves within a day of taking a steroid and her pitch rises, her hoarseness is likely due to swelling.

In practice, Dr. Marcus has heard from his otolaryngology colleagues that reflux is the main cause of hoarseness, so he prescribes an anti-reflux medication (occasionally the newest and most expensive one). Since nearly every prior referral to an otolaryngologist of a patient with a complaint of hoarseness came back to his office with a pill and a diagnosis of reflux, Dr. Marcus (not unjustifiably) hopes to preempt the wait to get in to the otolaryngologist and prescribes an anti-reflux medication from the start of the symptoms. As for this reflex to treat reflux, with proton pump inhibitors or other anti-reflux measures, I will defer a more complete discussion for later, but I would encourage Dr. Marcus to hold onto his pen for now before putting ink on the script. 

Do allergies cause hoarseness? Presumably there could be a histamine reaction along the edge of the vocal cord causing swelling similar to what happens so often in the nose. Yet the lining of the membranous vocal cord is a very different epithelium than the lining of the nasal turbinates. If there were edema of the vocal cord from allergies, presumably the patient would be complaining of a lowered pitch. Given that the nose is the principle filter of air entering the lungs, and the large number of people experiencing nasal symptoms from allergens without a corresponding change in their vocal pitch, I again suspect that allergen effect on the vocal cords is minimal or infrequent, at least relative to the nose. While allergy treatment is relatively benign – many allergy medications are available over the counter – patients are paying for Dr. Marcus’ judgment, so I would cautiously put allergy treatment low on my differential diagnosis.

Using a pulmonary steroid inhaler with the thought that steroids applied topically to the larynx will reduce assumed allergic laryngitis is fraught with an increased incidence of hoarseness as these patients may develop a fungal infection on the vocal cords, stiffening and thickening the vocal cords from the fungal growth. There is no reason to want to participate in iatrogenic hoarseness. I would save inhaled steroids for patients with asthma and even then I would use the lowest possible maintenance dose to avoid giving them a hoarse voice from fungal growth on the vocal cords. With the increasing strength of inhaled steroids, the incidence of fungal laryngitis from steroids has become more frequent.

 

If Dr. Marcus should keep all these potential medical treatments low on his list of things to do for hoarseness, what can he do to be helpful to his patients? Let’s think about how he could improve his hunches.

Dr. Marcus should first ask himself if he is hearing a speech or a voice problem. If the patient has a difficult time forming words, the problem is likely coming from within the mouth – above the speech line. I would think first about neurologic problems that could be impairing motion of the lips, tongue and palate or conditions that involve the area of the brain that controls these muscles.

Then ask, is the problem a quality of sound or lack of volume issue. Is this either a husky voice or a rough voice or a mixture of both? Is this a weak voice? If the answer is yes to any of these, the problem lies on the vocal cords.

I would next determine if the hoarseness likely belongs to one of the behavioral hoarseness categories. Is the patient either a vocal overdoer (they give a high score on the 7-point talkativeness scale) or a vocal underdoer? A patient with hoarseness who rates herself a 6 or a 7 on the 7-point scale has at least an 80 percent probability that her hoarseness is due to a swelling on the edge of the vocal cord just based on this information alone.

Did the patient lose her voice rather immediately after loud vocal use and then suffer from sustained hoarseness? Think of the likely probability of a hemorrhage or other vocal cord edge swelling. Patients with these disorders are quite likely to experience a temporary improvement with steroids. I seldom use steroids for these disorders as I feel the hoarseness responds best to long-term behavioral changes. Steroids are more like a crutch to get the patient through some temporary vocal requirement such as an upcoming performance or presentation. However, if you use steroids and the voice improves rapidly, then some type of swelling is likely the underlying cause of the hoarseness.

Is the patient an underdoer and complaining of hoarseness as well as neck discomfort with episodes of prolonged vocal use? Think about bowing or muscle atrophy that is often accompanied by neck pain from neck muscle tightness. People with thin vocal cords compensate by using the accessory muscles in the neck and, in general, bilateral neck pain with voice use is a very frequent complaint.

Ask the patient to make a few different types of sounds – low pitch, high pitch, loud and soft. Is there an inconsistency where some sounds are clear and others very rough? Does the patient have no sound production at all, but appears to be holding back or not putting effort in toward making a sound? Think about nonorganic voice disorders or inappropriate vocal muscle use.

Behavioral voice disorders such as overuse, underuse or inappropriate use are very common. If the hoarseness resolves quickly – days to a week or two – no further treatment is needed unless the patient desires a more accurate diagnosis.

Next in the line of query, did the patient just have a surgery? Injuries to the nerves supplying the larynx are the most frequent disorder I see in my practice. Surgery in the neck or in the chest can injure the vocal nerve supply directly. Thyroid surgery, parathyroid surgery, anterior cervical fusion, carotid surgery, lung surgery or heart or aortic vessel surgery are all frequent culprits of recurrent laryngeal nerve injury. Even the breathing tube placed in the lungs during any general anesthetic surgery can put pressure on the nerve from inside the airway and cause a vocal paresis. 

While “watch and wait” for spontaneous recovery is the most frequent paradigm in use for nerve disorders, I find that intervention to immediately restore the voice is often appreciated by patients, especially those who are innately talkative or whose voice is important for work. So if the history were suggestive of a possible nerve injury, I would send the patient on to a laryngologist. Let the patient make an informed decision on whether early treatment is appropriate for her amount of voice use.

Voice disorders that come on gradually, have none of the above more obvious explanations for their etiology, and/or persist for more than a week or two probably warrant an examination to determine their etiology - structural or behavioral. I really know no other way to diagnose tumors, fungal infections or paresis without a visual examination of the vocal cords. If Faith has a need to know the cause of her hoarseness, she has a need for an endoscopic examination.

However, Dr. Marcus can utilize the concepts here to take an educated guess at the probable cause of hoarseness and determine whether the expense of a laryngeal examination is warranted. The doctor and patient can weigh the cost of being off work and the cost and risks of inappropriate treatment and delayed accurate diagnosis against the cost of a thorough endoscopic examination. My hope is that Dr. Marcus tells his patient that since he cannot see the vocal cords, his diagnosis is an educated guess, and if the patient needs a more precise diagnosis or fails to improve in a brief period of time, then a referral to a laryngologist would be appropriate.