Dysphonia

Dysphonia
ICD-10	R49.
ICD-9	784.49

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Synonyms and keywords: hoarseness

Overview

Dysphonia is the medical term for hoarseness or other phonation disorders. It is considered much less severe than aphonia. Hoarseness can be a change in pitch, a rough sound of the voice, or an increased effort in speaking.

Classificaiton of Dysphonia

Based Upon Chronicity

• Acute hoarseness has a sudden onset and lasts fewer than 2 weeks
• Chronic hoarseness lasts longer than 2 weeks

Based Upon Pathophysiology

• Organic dysphonia
• Functional dysphonia
• Spasmodic dysphonia

Causes

Common Causes

• Aging
• Cold
• Foreign body in respiratory tract
• Hypothyroidism
• Laryngitis
• Laryngeal cancer
• Overstress of vocal cords (speaking, shouting, singing and crying)
• Sinusitis
• Tracheitis

Causes by Organ System

Cardiovascular	Aortic aneurysm, Aortic dissection, Left atrial enlargement, Wegener's Granulotomosis
Chemical / poisoning	Smoke irritation, Chronic inhalation of chemical irritant agents (professional activity)
Dermatologic	Lipoid proteinosis
Drug Side Effect	Axitinib, Danazol, Dornase alfa, Gestrinone
Ear Nose Throat	Elongated styloid process
Endocrine	Goitre, Growth hormone secreting pituitary adenoma, Hypothyroidism, Parathyroid carcinoma, Riedel thyroiditis, Thyroid carcinoma, Thyroid tumor, Virilization
Environmental	Chronic inhalation of chemical irritant agents (professional activity)
Gastroenterologic	Esophageal tumor, Gastroesophageal Reflux Disease (GERD), Oral submucous fibrosis, Oropharyngeal cancer
Genetic	Diastrophic dwarfism, Distal myopathy 2, Lipoid proteinosis, Muscular dystrophy
Hematologic	No underlying causes
Iatrogenic	Postsurgical
Infectious Disease	Acute viral laryngitis, ,Bacterial tracheitis / laryngitis Chronic sinusitis, Croup, Deep space face and neck infection, Epiglottitis, Laryngitis, Laryngotracheobronchitis, Paracoccidioidomycosis, Quinsy, Sinusitis, Tracheolaryngobronchitis, Upper Respiratory Infection , Laryngeal papillomatosis
Musculoskeletal / Ortho	Diffuse idiopathic skeletal hyperostosis, Muscular dystrophy, Polymyositis, Diastrophic dwarfism, Distal myopathy 2, Myasthenia gravis, Juvenile dermatomyositis, Rheumatoid arthritis
Neurologic	10th cranial nerve disorder, 12th cranial nerve disorder, Acoustic neuroma, Amyotrophic lateral sclerosis, Bulbar palsy, Cerebral palsy, Cerebrovascular accident, Guillain-Barre syndrome, Laryngeal nerve palsy, Motor neuron disease, Multiple sclerosis, Myasthenia gravis, Neural tumor, Parkinson's disease, Posterior inferior cerebellar artery syndrome, Spasmodic dysphonia, Lipoid proteinosis, Neurofibroma, Vocal cord paralysis
Nutritional / Metabolic	No underlying causes
Obstetric/Gynecologic	Menopause
Oncologic	Bronchial carcinoma, Bronchogenic tumor, Chondromas, Glomus jugulare tumor, Neurofibroma, Squamous cell carcinoma, Thyroid carcinoma, Thyroid tumor, Growth hormone secreting pituitary adenoma, Parathyroid carcinoma, Esophageal tumor, Acoustic neuroma, Neural tumor, Laryngeal carcinoma, Lung cancer, Oropharyngeal cancer, Hemangioma
Opthalmologic	No underlying causes
Overdose / Toxicity	Axitinib, Danazol, Dornase alfa, Gestrinone
Psychiatric	Habitual aphonia, Psychogenic aphonia, Spasmodic dysphonia
Pulmonary	Chorditis, Edema of vocal cords, Foreign body in respiratory tract, Hemangioma, Hemorrhage into vocal folds, Laryngeal carcinoma, Laryngeal granuloma, Laryngeal papillomatosis, Laryngocelesventricular prolapse, Laryngomalacia, Lipoma, Lung cancer, Nasal polyps, Oropharyngeal cancer, Papillomas, Reinke's edema, Retention cysts, Spasmodic dysphonia, Ventricular dysphonias, Vocal cord nodules, Vocal cord paralysis, Vocal cord polyps, Vocal fold cyst, Acute viral laryngitis, Bacterial tracheitis / laryngitis, Chronic sinusitis, Croup, Epiglottitis, Laryngitis, Laryngotracheobronchitis, Sinusitis, Tracheolaryngobronchitis, Upper Respiratory Infection , Bronchial carcinoma, Bronchogenic tumor, Squamous cell carcinoma, Allergic rhinitis, Chronic cough, severe cold, Sarcoidosis, Singer nodes
Renal / Electrolyte	No underlying causes
Rheum / Immune / Allergy	Allergic rhinitis, Anaphylaxis, Juvenile dermatomyositis, Rheumatoid arthritis, Rheumatoid disease, Riedel thyroiditis, Polymyositis, Amyotrophic lateral sclerosis, Guillain-Barre syndrome, Multiple sclerosis, Systemic lupus erythematosus, Sarcoidosis
Sexual	No underlying causes
Trauma	Head injury, Trauma
Urologic	No underlying causes
Dental	No underlying causes
Miscellaneous	Aging, Amyloidosis, Chronic cough, severe cold, Excessively dry and warm room coupled with low water intake, Overstress of vocal cords (speaking, shouting, singing, crying), Puberty, Sarcoidosis, Singer nodes, Systemic lupus erythematosus, Virilization, Smoke irritation, Menopause, Foreign body in respiratory tract

Causes in Alphabetical Order

10th cranial nerve disorder 12th cranial nerve disorder Acoustic neuroma Acute viral laryngitis Aging Allergic rhinitis Amyloidosis Amyotrophic lateral sclerosis Anaphylaxis Aortic aneurysm Aortic dissection Axitinib Bacterial tracheitis / laryngitis Bronchial carcinoma Bronchogenic tumor Bulbar palsy Cerebral palsy Cerebrovascular accident Chondromas Chorditis Chronic cough, severe cold Chronic inhalation of chemical irritant agents (professional activity) Chronic sinusitis Croup Danazol Deep space face and neck infection Diastrophic dwarfism Diffuse idiopathic skeletal hyperostosis Distal myopathy 2 Dornase alfa Edema of vocal cords Elongated styloid process Epiglottitis Esophageal tumor Excessively dry and warm room coupled with low water intake Foreign body in respiratory tract Gastroesophageal Reflux Disease (GERD) Gestrinone Glomus jugulare tumor Goitre Growth hormone secreting pituitary adenoma Guillain-Barre syndrome Habitual aphonia Head injury Hemangioma Hemorrhage into vocal folds Hypothyroidism Juvenile dermatomyositis Laryngeal carcinoma Laryngeal granuloma Laryngeal nerve palsy Laryngeal papillomatosis Laryngitis

Laryngocelesventricular prolapse Laryngomalacia Laryngotracheobronchitis Left atrial enlargement Lipoid proteinosis Lipoma Lung cancer Menopause Motor neuron disease Multiple sclerosis Muscular dystrophy Myasthenia gravis Nasal polyps Neural tumor Neurofibroma Oral submucous fibrosis Oropharyngeal cancer Overstress of vocal cords (speaking, shouting, singing, crying) Papillomas Paracoccidioidomycosis Parathyroid carcinoma Parkinson's disease Polymyositis Posterior inferior cerebellar artery syndrome Postsurgical Psychogenic aphonia Puberty Quinsy Reinke's edema Retention cysts Rheumatoid arthritis Rheumatoid disease Riedel thyroiditis Sarcoidosis Singer nodes Sinusitis Smoke irritation Spasmodic dysphonia Squamous cell carcinoma Systemic lupus erythematosus Thyroid carcinoma Thyroid tumor Tracheolaryngobronchitis Trauma Upper Respiratory Infection Ventricular dysphonias Virilization Vocal cord nodules Vocal cord paralysis Vocal cord polyps Vocal fold cyst Wegener's Granulotomosis

In alphabetical order.

Acute

• Acute viral laryngitis
• Aortic aneurysm
• Aortic dissection
• Anaphylaxis
• Bacterial tracheitis / laryngitis
• Cerebrovascular accident (CVA)
• Chorditis
• Croup
• Deep space face and neck infection
• Epiglottitis
• Foreign body
• Head injury
• Laryngitis
• Laryngotracheobronchitis
• Overstress of vocal cords (speaking, shouting, singing, crying)
• Sinusitis
• Smoke irritation
• Surgery
• Trauma
• Upper Respiratory Infection

Chronic

• Aging
• Allergic Rhinitis
• Amyloidosis
• Amyotrophic Lateral Sclerosis
• Aortic aneurysm
• Bronchial carcinoma
• Bronchogenic tumor
• Chondromas
• Chronic cough, severe cold
• Chronic inhalation of chemical irritant agents (professional activity)
• Chronic sinusitis
• Drugs
• Edema of vocal cords
• Esophageal tumor
• Excessively dry and warm room coupled with low water intake
• Foreign body
• Gastroesophageal Reflux Disease (GERD)
• Glomus jugulare tumor
• Guillain-Barre Syndrome
• Habitual aphonia
• Hemangioma
• Hemorrhage into vocal folds
• Hypothyroidism
• Juvenile dermatomyositis
• Laryngeal papillomatosis
• Laryngocelesventricular prolapse
• Laryngeal carcinoma
• Left atrial enlargement
• Lipoma
• Lung cancer
• Menopause
• Multiple Sclerosis
• Muscular Dystrophy
• Myasthenia Gravis
• Neural tumor
• Neurofibroma
• Papillomas
• Parkinson's Disease
• Postsurgical
• Psychogenic aphonia
• Puberty
• Reinke's Edema
• Retention cysts
• Rheumatoid Arthritis
• Sarcoidosis
• Spastic dysphonia
• Squamous Cell Carcinoma
• Systemic Lupus Erythematosus
• Thyroid tumor
• Ventricular dysphonias
• Virilization
• Vocal cord nodules
• Vocal fold cyst
• Vocal cord paralysis
• Vocal cord polyps
• Wegener's Granulotomosis

History and Symptoms

The following should be characterized as part of a full history:

• Onset
• Duration
• Prior history
• Exposure
• Medications
• Voice use
• Associated symptoms
• Medical history
• Surgical history
• Trauma

Physical Examination

• Focus on neck, head, lung, thyroid and cardiac exams
• Evaluate voice quality

Laboratory Findings

• Thyroid function tests to rule out hypothyroidism

X-Ray

• Chest X-ray
• Lateral neck X-ray

MRI and CT

• CT scan of sinuses
• CT scan of head and neck

Other Diagnostic Studies

• Upper gastrointestinal (GI) endoscopy
• Direct or fiber optic nasolaryngoscopy
• Biopsy

Treatment

• Airway, breathing and circulation
• Voice rest
• Diet modification (GERD)
• Stop smoking
• Wear protective clothing or masks (if hoarseness is due to exposure)
• Treat underlying etiologies
• Voice therapy

Pharmacotherapy

Acute Pharmacotherapies

• Antibiotics
• Oral steroids
• H2 blocker
• Proton pump inhibitors
• Intranasal steroids
• Antihistamines

Surgery and Device Based Therapy

• Surgical intervention for abscesses, masses
• Cricothyrotomy or tracheostomy (to establish airway)