41.1 Conditions Associated with Laryngopharyngeal Reflux

• Paroxysmal laryngospasm

• Laryngeal stenosis

• Laryngeal carcinoma

• Vocal cord nodules

• Globus pharyngeus

• Laryngomalacia

41.1.1 Extraesophageal Reflux Scoring Systems

• Reflux symptom index

Validated and highly reproducible

9-item questionnaire

Scores per item vary from 0 (no problem) to 5 (severe problem)

Max score 45

Score > 15 about 90% chance of supraoesophageal reflux

Items:

– Hoarseness or problem with your voice

– Clearing your throat

– Excessive mucous or postnasal drip

– Difficulty swallowing food, liquid, or pills

– Coughing after you ate or lying down

– Breathing difficulties or choking episodes

– Troublesome or annoying cough

– Sensation of something sticking in your throat or a lump in your throat

– Heartburn, chest pain, indigestion, or stomach acid coming up

• Reflux finding score

Validated

8-item scale

Based on fiberoptic laryngoscopic findings

Max score 26

Score more >5 is abnormal

Items:

– Infraglottic oedema: 0, absent; 2, present

– Ventricular obliteration: 0, absent; 2, present; 4, complete

– Erythema: 0, none; 2, arytenoids; 4, diffuse

– Laryngeal oedema: 0, none; 1, mild; 2, moderate; 3, severe; 4, polypoid

– Post-commissure hypertrophy: 1, mild; 2, moderate; 3, severe; 4, obstructing

– Granuloma/granulation tissue: 0, absent; 2, present

– VF oedema: 0, none; 1, mild; 2, moderate; 3, severe; 4, polypoid

– Thick mucus: 0, absent; 2, present

41.2 Laryngitis

• Acute <3 weeks

• Self-limiting

• Erythema and oedema of vocal cord

• Typically affects 18- to 40-year-olds

• Aetiology includes vocal misuse, infection typically viral

• Treatment: humidification, voice rest, Cochrane database showed no evidence for antibiotics

• Chronic >3 weeks

• Fluctuating dysphonia, chronic cough (night>day), laryngospasm secondary to mucous strands

• Consider occupational history including exposure to toxic substances

• Consider drug history: e.g., diuretics may dry mucosa, calcium channel blockers/nitrates may predispose to gastro-eosophageal reflux disease (GORD) secondary to reduction in tone of lower oesophageal sphincter

• Autoimmune causes include:

Granulomatosis with polyangiitis (GPA)

– Hemoptysis

– Stridor

– Upper airway narrowing

Amyloidosis

Relapsing polychondritis

– May have tender larynx and develop tracheomalacia

• Systemic cutaneous causes include:

SLE—nodules, ulceration

Pemphigus

Stevens–Johnson syndrome

Rheumatoid arthritis—paralysis of cricothyroid/arytenoids joint

• Treatment:

Conservative:

– Avoid stimulating/irritating factors, e.g., cigarette smoke

– Treat underlying medical cause

Surgery:

– Biopsy to confirm diagnosis

41.3 Chronic Granulomatous Laryngeal Conditions

• Tuberculosis: posterior one-third larynx may mimic carcinoma

• Sarcoidosis: granulomas, nodules, supraglottic swelling, vocal cord palsy

• GPA: subglottis ± renal involvement

41.4 Angioedema

• With or without anaphylaxis

• Acute allergic histamine-mediated inflammatory reaction

• Acute vascular dilation and capillary permeability

• Oral and laryngopharyngeal structures frequently affected

• Precipitating factors:

Medications:

– Penicillin

– Aspirin

– Other non-steroidal anti-inflammatory drugs

– Angiotensin-converting enzyme inhibitors

Food additives and preservatives

Blood transfusions

Infections

Insect bites

• Hereditary form:

Deficiency of C1 esterase inhibitor

Recurrent attacks of mucocutaneous oedema

• Occult lymphoma leading to C1 esterase inhibitor deficiency can occur

• Associated with pruritus

• Hoarseness present when larynx involved

• Treatment involves:

Adrenaline

Corticosteroids

Antihistamines

Aminophylline

Airway management as required

• Treatment of hereditary form:

Prophylactic danazol

Fresh frozen plasma acutely

41.5 Neurological Disorders Causing Laryngeal Dysfunction

• Upper motor neuron disorders:

Cerebrovascular accident (bilateral vocal cord involvement)

Parkinson disease (soft voice + other features of Parkinson disease)

Progressive supranuclear palsy

Pseudobulbar palsy—vascular and degenerative disease affecting corticobulbar tracts—bilaterally

Multiple sclerosis

Myoclonus

• Lower motor neuron disorders:

Amyotrophic lateral sclerosis

Myasthenia gravis—may have hypernasal speech/nasal regurgitation and dysphagia

Wallenberg syndrome (posterior ICA occlusion)

Postpolio syndrome

41.6 Functional Voice Disorders

41.6.1 Spasmodic Dysphonias (SD)

• Aka laryngeal dystonia

• Categories:

Adductor SD—uncontrolled closing of VFs

Abductor SD—prolonged VF opening for voiceless sounds extending into vowels

VF tremor—modulations in pitch and loudness most evident during prolonged vowels

• Characteristic features:

Onset between 30 to 50 years of age

60% female

Aetiology unknown but believed to be part of a neurological problem with other dystonic features, e.g., blepharospasm, dyskinesias, oromandibular dystonia, or tremor

Reflexive and emotional aspects of voice function unaffected, e.g., coughing, shouting, laughter

Diagnosed by listening to voice, which sounds like patient is straining on the toilet

Consider neurology referral to exclude other dystonias

• Treatment:

Medication—anticholinergics effective in 50% cases

Voice therapy

Surgery—Botox, though often requires multiple procedures

Surgery on recurrent laryngeal nerve including avulsion procedure

• Adduction of VFs during inspiratory phase of respiration leading to total obstruction or stridor

• Categories:

Idiopathic focal dystonia

Part of Meige syndrome

Associated with or masquerading as asthma

Exercise-induced stridor

Psychogenic

Associated with GORD

41.6.3 Disorders of Vocal Misuse

• Muscular tension dysphonia

• Voice fatigue syndrome

• Abnormal loudness—e.g., with poor hearing

• Abnormal pitch

• False-cord phonation

41.6.4 Psychogenic Voice Disorders

• Conversion reaction dysphonia—stressor related to onset of dysphonia

• Malingering dysphonia

• Pyschogenic dysphonia—stressor is in intermediate or distant past

• Elective mutism

• Psychogenic overlay