Evaluation of hoarseness and dysphonia

Fungal laryngitis results in white patches on the vocal folds and/or speckled white spots in the pharynx and larynx.

Fungal laryngitis results in white patches on the vocal folds and/or speckled white spots in the pharynx and larynx.

Characteristic appearance of reflux laryngitis. [Figure caption and citation for the preceding image starts]: Reflux laryngitisFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

Findings occur mostly in the posterior larynx.

The pH is measured as the percentage of time the pH is <4.0. These data are used to classify reflux as acid or nonacid.[80]Dobhan R, Castell DO. Normal and abnormal proximal esophageal acid exposure: results of ambulatory dual-probe pH monitoring. Am J Gastroenterol. 1993 Jan;88(1):25-9. http://www.ncbi.nlm.nih.gov/pubmed/8420269?tool=bestpractice.com [81]Tutuian R, Castell DO. Gastroesophageal reflux monitoring: PH and impedance. May 2006 [internet publication]. https://www.nature.com/gimo/contents/pt1/full/gimo31.html

Reflux is identified by changes in intraluminal resistance determined by the presence of liquid or gas inside the esophagus.[81]Tutuian R, Castell DO. Gastroesophageal reflux monitoring: PH and impedance. May 2006 [internet publication]. https://www.nature.com/gimo/contents/pt1/full/gimo31.html

Bilateral lesions located at the anterior two-thirds junction of the mid-membranous vocal fold.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Unilateral encapsulated lesion in superficial lamina propria. [Figure caption and citation for the preceding image starts]: Vocal fold cystFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

Differential diagnosis is difficult with laryngeal visualization alone.

Findings depend on lesion size and location.​[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Large broad-based or hanging unilateral gelatinous mass in superficial lamina propria associated with enlarged blood vessels or hemorrhage.[82]Sulica L. Polyps and Reinke's edema: distinct laryngeal pathologies with different potential for glottic airway obstruction. Anesth Analg. 2005 Jun;100(6):1863. http://www.ncbi.nlm.nih.gov/pubmed/15920241?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Vocal fold polypFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

Mucosal wave abnormalities depend on vocal fold stiffness and lesion size.​[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Vocal fold stiffness contributes to increased fundamental frequency.​[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.​

Unilateral or bilateral fibrous mass within subepithelial space or near vocal ligament with reactive lesion on opposite vocal fold.

Unilateral or bilateral lesion with or without increased vascularization and sulcus (groove along the partial or complete edge of the medial membranous vocal fold) formation.

Tethering of epithelium to deeper tissues may give the appearance of a superficial lesion in the lamina propria.

High laryngeal position and anteroposterior hyperfunction of the larynx is also visible on examination.

Subglottic pressure depends on lesion size.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Findings depend on lesion size.

Bilateral (sometimes unilateral) gelatinous material present in the superficial lamina propria with edema along the entire vocal fold length.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.[Figure caption and citation for the preceding image starts]: Reinke edemaFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

Findings are secondary to mucosal and muscle atrophy and glottic insufficiency.[14]Pontes P, Brasolotto A, Behlau M. Glottic characteristics and voice complaint in the elderly. J Voice. 2005 Mar;19(1):84-94. http://www.ncbi.nlm.nih.gov/pubmed/15766853?tool=bestpractice.com

Findings may be present during all laryngeal tasks including resting breathing.

Flexible fiberoptic nasendoscopy is preferred for evaluation of neurolaryngeal disorders.[62]Merati AL, Heman-Ackah YD, Abaza M, et al. Common movement disorders affecting the larynx: a report from the neurolaryngology committee of the AAO-HNS. Otolaryngol Head Neck Surg. 2005 Nov;133(5):654-65. http://www.ncbi.nlm.nih.gov/pubmed/16274788?tool=bestpractice.com

Allows detection of electrical activity in the vocal folds.[78]Maronian N, Robinson L. Laryngeal electromyography. In: Merati AL, Bielamowicz SA, eds. Textbook of laryngology. San Diego, CA: Plural Publishing; 2006: 107.

Depending on the size of the lesion, the voice is often preserved and is commonly unaffected, as granulomata do not occur at the mid-membranous vibratory portion of the vocal fold.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Unilateral or bilateral lesions (pale gray to dark red, polypoid, nodular, fungating, or ulcerated), with the latter taking on the appearance of a cup and saucer.[83]Luzar B, Gale N, Klopcic U, et al. Laryngeal granuloma: characteristics of the covering epithelium. J Laryngol Otol. 2000 Apr;114(4):264-7. http://www.ncbi.nlm.nih.gov/pubmed/10845040?tool=bestpractice.com [Figure caption and citation for the preceding image starts]: Granuloma 1From the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].[Figure caption and citation for the preceding image starts]: Granuloma 2From the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

May interfere with glottic closure or symmetry of movement depending on the size of the lesion.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Signal-to-noise ratio is based on lesion size and location.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Other measures are highly variable depending on lesion size and location.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Epithelial growths in the upper aerodigestive tract, frequently found on the vocal fold. [Figure caption and citation for the preceding image starts]: Recurrent respiratory papillomaFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

A staging classification, the Laryngoscopic and Clinical Assessment Scale for Recurrent Respiratory Papilloma, has been developed to identify the nature (surface, raised, or bulky), location (larynx, trachea, nasopharyngeal area, and/or esophagus), and extent of the lesions.[40]Derkay CS, Wiatrak B. Recurrent respiratory papillomatosis: a review. Laryngoscope. 2008 Jul;118(7):1236-47. http://www.ncbi.nlm.nih.gov/pubmed/18496162?tool=bestpractice.com

Level of airflow depends on the stage of disease.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Flexible fiberoptic nasendoscopy is preferred for evaluation of neurolaryngeal disorders.

Severity depends on the position of the immobile vocal fold.

There are no differentiating acoustic signs for unilateral and bilateral vocal fold paralysis or paresis

Some movement may be apparent secondary to muscular imbalance and effort during voicing. On immobile side, the arytenoid may be prolapsed and the vocal folds may appear shortened and off plane.​[Figure caption and citation for the preceding image starts]: Left vocal fold paralysisFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends]. The arytenoid complex may be immobile in the medial, mediolateral, or lateral position. Asymmetry will be apparent with possible vertical phase difference. Glottic closure is incomplete except with paralysis in the medial position.[43]Netterville JL, Billante CR. The immobile vocal cord. In: Ossoff RH, Shapshay SM, Woodson G, et al, eds. The larynx. Philadelphia, PA: Lippincott Williams and Wilkins; 2003: 269.

Flexible fiberoptic nasendoscopy is preferred for evaluation of neurolaryngeal disorders.

Allows evaluation of the innervation status of the immobile vocal fold and differentiation between nerve and structural/mechanical involvement.[43]Netterville JL, Billante CR. The immobile vocal cord. In: Ossoff RH, Shapshay SM, Woodson G, et al, eds. The larynx. Philadelphia, PA: Lippincott Williams and Wilkins; 2003: 269.

CT imaging of the head, neck, and chest is used to identify and locate tumors on the recurrent laryngeal nerve and lung or mediastinal masses.[79]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: head and neck cancers [internet publication]. https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf ​​​

MRI may be used for patients who cannot undergo a CT scan, or as a complementary tool if CT does not provide adequate information.

MRI with contrast gives higher signals, so any pathology shows up brighter.

Severity depends on the position of the immobile vocal folds.

There are no differentiating acoustic signs for unilateral and bilateral vocal fold paralysis or paresis.

Some movement may be apparent secondary to muscular imbalance and effort during voicing. On immobile side, the arytenoid may be prolapsed and the vocal folds may appear shortened and off plane. The arytenoid complex may be immobile in the medial, mediolateral, or lateral position. Asymmetry will be apparent with possible vertical phase difference. Glottic closure is incomplete except for paralysis in the medial position.[43]Netterville JL, Billante CR. The immobile vocal cord. In: Ossoff RH, Shapshay SM, Woodson G, et al, eds. The larynx. Philadelphia, PA: Lippincott Williams and Wilkins; 2003: 269.

Flexible fiberoptic nasendoscopy is preferred for evaluation of neurolaryngeal disorders.

Allows evaluation of the innervation status of the immobile vocal fold and differentiation between nerve and structural/mechanical involvement.[43]Netterville JL, Billante CR. The immobile vocal cord. In: Ossoff RH, Shapshay SM, Woodson G, et al, eds. The larynx. Philadelphia, PA: Lippincott Williams and Wilkins; 2003: 269.

CT imaging of the head, neck, and chest is used to identify and locate tumors on the recurrent laryngeal nerve and lung or mediastinal masses.[79]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: head and neck cancers [internet publication]. https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf ​​​

MRI may be used for patients who cannot undergo a CT scan, or as a complementary tool if CT does not provide adequate information.

MRI with contrast gives higher signals, so any pathology shows up brighter.

Findings vary between patients.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Flexible fiberoptic nasendoscopy is preferred for evaluation of neurolaryngeal disorders.

Allows detection of electrical activity in the vocal folds.[74]Akst LM, Zeitels SM. Historical developments in laryngology. In: Merati AL, Bielamowicz SA, eds. Textbook of laryngology. San Diego, CA: Plural Publishing; 2006: 3.[78]Maronian N, Robinson L. Laryngeal electromyography. In: Merati AL, Bielamowicz SA, eds. Textbook of laryngology. San Diego, CA: Plural Publishing; 2006: 107.

Flexible fiberoptic nasendoscopy is preferred for evaluation of neurolaryngeal disorders.

Allows detection of electrical activity in the vocal folds.[74]Akst LM, Zeitels SM. Historical developments in laryngology. In: Merati AL, Bielamowicz SA, eds. Textbook of laryngology. San Diego, CA: Plural Publishing; 2006: 3.[78]Maronian N, Robinson L. Laryngeal electromyography. In: Merati AL, Bielamowicz SA, eds. Textbook of laryngology. San Diego, CA: Plural Publishing; 2006: 107.

Increase in phonatory airflows depends on lesion size and degree of airway obstruction.

Leukoplakia shows characteristic appearance. [Figure caption and citation for the preceding image starts]: LeukoplakiaFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

Biopsy of the vocal fold lesion shows mild (minimal but demonstrable changes in cellular structure), moderate (undifferentiated cells extend to two-thirds of the thickness of the epithelium), or severe (nonstratified undifferentiated cells occupy two-thirds to full epithelial thickness) dysplastic features.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Conservative therapy (with avoidance of irritants and treatment of laryngeal candidiasis) may be considered prior to biopsy for leukoplakia present on otherwise mobile vocal folds.[3]Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia) (update). Otolaryngol Head Neck Surg. 2018 Mar;158(1 Suppl):S1-42. https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599817751030 http://www.ncbi.nlm.nih.gov/pubmed/29494321?tool=bestpractice.com

Voice changes depend on tumor size and location.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Pitch depends on tumor size and vocal fold stiffness.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Phonatory airflows depends on tumor location and degree of airway obstruction.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Lesion may initially be unilateral but can spread to involve both vocal folds.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.[Figure caption and citation for the preceding image starts]: Vocal fold cancerFrom the collection of the University of Wisconsin School of Medicine and Public Health [Citation ends].

Depth of lesion depends on disease severity.[9]Verdolini K, Rosen C, Branski R, eds. Classification manual for voice disorders: I. Mahwah, NJ: Lawrence Erlbaum Associates, Inc; 2005.

Biopsy is mandatory in any case of suspected vocal fold cancer.[3]Stachler RJ, Francis DO, Schwartz SR, et al. Clinical practice guideline: hoarseness (dysphonia) (update). Otolaryngol Head Neck Surg. 2018 Mar;158(1 Suppl):S1-42. https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1177/0194599817751030 http://www.ncbi.nlm.nih.gov/pubmed/29494321?tool=bestpractice.com

Squamous cell carcinoma is the most common malignancy of the vocal fold.

Laryngeal CT imaging is used for identification of laryngeal anatomy and pathology.[79]National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: head and neck cancers [internet publication]. https://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf

CT images are taken in the axial or horizontal plane and tumor blocks out fat, giving a darker appearance.[84]Curtin HD, Sakai O. Imaging of the larynx: magnetic resonance imaging and computerized tomography. In: Ossoff RH, Shapshay SM, Woodson G, et al, eds. The larynx. Philadelphia, PA: Lippincott, Williams & Wilkins; 2003.

MRI may be used for patients who cannot undergo a CT scan, or as a complementary tool if CT does not provide adequate information.

MRI with contrast gives higher signals, so any pathology shows up brighter.