1. Hoarseness

2. Common referral Hoarseness reflects any abnormality of normal phonation

3. Cartilaginous skeleton

4. Cricoarytenoid Joint True synovial joint

5. Intrinsic Musculature Abductors Adductors Tensors

6. Intrinsic Musculature

7. Innervation

8. Abduction

9. Adduction

10. Tension

11. Vocal Fold Anatomy

12. Laryngeal function Sphincteric function Respiration Phonation Other – Stabilizes the thorax by preventing exhalation during lifting – Compresses abdominal cavity during coughing or straining

13. Phonation Physical act of sound production by means of passive vocal fold interaction with the exhaled airstream Pitch Quality Volume

14. Sound Production – Contraction of expiratory muscles – Rise in subglottic air pressure – Escape through glottis – Closure Bernoulli effect elasticity

15. Phonation Glottal puff – Release of air as upper margins of TVC separate Phase delay – Delay of closure between upper and lower margins of TVC Mucosal wave – Horizontal and vertical components

16. Mucosal wave/Phase delay

17. Body-Cover Theory Changes to mucosal wave – Stiffness – tension

18. Mucosal wave Velocity increases – Increased airflow – Increased subglottic pressure

19. Fundamental Frequency Pitch (measure in Hertz) Changes in vibration frequency – Mass – Stiffness – viscosity

20. Workup “Any patient with hoarseness of two weeks duration or longer must undergo visualization of the vocal cords”

21. Workup History Physical Examination Ancillary tests

22. History URI – Laryngitis – Overuse with edema and inflammation – Paralyses – Granulomas from coughing

23. History Trauma – Arytenoid dislocation – Nerve paralysis – Laryngeal fractures – Mucosal lacerations

24. History Intubation – Arytenoid dislocations – Nerve injury – granulomas

25. History Pulmonary conditions – power source – COPD – Asthma

26. History Gastrointestinal – LPR Autoimmune – RA Endocrine – Hypothyroidism

27. Neurologic disorders

28. Surgical History Skullbase procedures Carotid endarterectomies Thyroidectomies Aortic aneurysm repairs

29. Medications

30. Social History Tobacco Alcohol ?Inflammation ?Drying of secretions ?malignancy

31. Occupational History Voice abuse

32. Associated Symptoms

33. Physical Examination Head & neck examination Laryngeal examination – Physiologic position – Image quality – Magnification – Cost – Required equipment – Time/skill necessary

34. Laryngeal examination Indirect mirror Flexible laryngoscopy Rigid laryngoscopy

35. Indirect mirror examination Advantages – Quick – Inexpensive – Little equipment Disadvantages – Gag – Anatomic features – nonphysiologic

36. Flexible laryngoscopy Advantages – Well tolerated – Complete examination – Video documentation Disadvantages – More time – Expensive

37. Rigid laryngoscopy Advantages – Best images – Magnification – Video documentation Disadvantages – Expensive – Nonphysiologic – Gag – Anatomic features

38. Videostroboscopy Light quasi-synchronized with vocal fold vibrations – Bell microphone – Electroglottography Video recording – Detailed review – Comparison after treatment

39. Videostroboscopy Synchronous = motionless Asynchronous = slow motion

40. Videostroboscopy Vocal fold closure pattern Vocal fold vibratory pattern Mucosal wave of each vocal fold Symmetry

41. Videostroboscopy

42. Radiographic studies MRI CT

43. Laryngeal EMG Myopathy – normal frequency of firing but decreased amplitude Neuropathy – decreased frequency but occasional normal amplitudes Polyphasic reinnervation potentials indicate some loss of function but reinnervation has begun

44. Laryngeal EMG

45. Differential Congenital Inflammatory Neoplastic Traumatic Neurologic Endocrine Iatrogenic Local factors

49. Vocal Cysts

51. Vocal Nodules Usually bilateral Voice rest and speech therapy for 6 months Surgical removal

53. Vocal cord granulomas LPR Intubation Treat medically

57. Vocal Cord Paralysis Lesion at nuclear level – cadaveric Lesion above nodose ganglion – abducted Lesion below nodose ganglion - paramedian

58. Vocal Cord Paralysis Superior laryngeal nerve – subtle voice changes with decreased pitch range, tilting of the larynx with a rotation of the glottis

59. Vocal Cord Paralysis Children – Neurologic – Traumatic – Idiopathic Adults – Iatrogenic – Traumatic – Neoplastic – Idiopathic – neurologic

60. Vocal Cord Paralysis