Practice CMAJ

1520 CMAJ, November 19, 2013, 185(17) © 2013 Canadian Medical Association or its licensors

A40-year-old woman presented to the oto-laryngology clinic with a 7-week historyof hoarseness. The symptom had oc -

curred suddenly, and no upper respiratory tractinfections or history of vocal overuse immedi-ately preceded the onset. Her voice had notimproved during the intervening weeks. Shereported symptoms of potential aspiration whendrinking thin liquids, and she found herself shortof breath when speaking. She had no odynopha-gia or throat pain, or systemic symptoms such asfever, chills or night sweats. She had not experi-enced substantial changes in her voice previously.

Three weeks before the onset of hoarseness,the patient had undergone intubation for removalof a benign soft tissue nodule on her left foot. Hervoice was normal after the surgery. Her medicalhistory was otherwise unremarkable. She was nottaking any medications and had no allergies. Shedid not smoke and had low alcohol consumption.

On examination, the patient was found to havea breathy, hoarse voice with a self-reported lowerpitch than normal. Evaluation of the oral cavity,oropharynx and nasal cavity was unremarkable.Examination of the neck showed no lymphad -enopathy. The thyroid examination was normal.Evaluation of cranial nerve function showed noabnormalities other than the hoarseness. Completeleft vocal cord immobility was identified on laryn-goscopy using a flexible na so pharyngoscope. Nolaryngeal lesions were found. The patient had asubstantial gap between her vocal folds on phona-

tion as a result of the immobility (Figure 1).The cause of the patient’s immobile left vocal

cord was not readily apparent from her historyand physical examination. The 3-week delaybetween intubation and development of hoarse-ness made it unlikely that an intubation injuryhad initially been masked by postoperative laryn-geal edema. Computed tomography (CT) fromskull base to mediastinum, ordered to rule outmalignant lesions along the course of the leftvagus nerve and its recurrent laryngeal branch,was normal. Given the negative clinical andimaging work-up, the patient’s vocal cord immo-bility was considered idiopathic.

Because she had substantial symptoms ofvocal insufficiency from the glottic air leak, thepatient was offered a temporary medializationprocedure with injectable hyaluronic acid underlocal anesthesia by the staff laryngologist. (SeeAppendix 1, available at www.cmaj.ca /lookup/suppl /doi:10.1503/cmaj.112112/-/DC1 for a dia-gram of this procedure.) The goal was to im -prove vocal strength, decrease vocal fatigue anddecrease the risk of aspiration while we waitedto see if the vocal fold would recover over thesubsequent 12 months. The patient underwentthe procedure about 8 weeks after symptomonset, with excellent results (Figure 2). HerVoice Handicap Index-10 score1 (a self-reported,validated scale) decreased substantially from ascore of 31 before the procedure (from a maxi-mum score of 40) to a score of 3 (that of a clini-cal control) 6 weeks later.

The patient was seen for reassessment at 6and 12 months after medialization and had atleast 90% recovery of her left vocal cord mobil-ity. This essentially confirmed a neurapraxicinjury, because other pathologies would gener-ally not recover spontaneously.

Discussion

Hoarseness is a common presenting symptom ofpatients seen by both primary care physiciansand otolaryngologists. The term “hoarse” refersto a symptom rather than a specific diagnosis

Cases

A case of hoarseness and vocal cord immobility

Amy M. Trottier MSc MD, Emad Massoud MB, Timothy Brown MD

Competing interests: Nonedeclared.

This article has been peerreviewed.

Correspondence to:Timothy Brown,tfebrown@dal.ca

CMAJ 2013. DOI:10.1503/cmaj.112112

• Hoarseness is a common symptom with many different causes, most ofwhich are benign and self-limiting, but some can be serious and life-threatening.

• In the absence of a firm diagnosis, the best available evidence does notsupport therapeutic trials of antireflux medications, corticosteroids orantibiotics for hoarseness.

• We suggest referral to an otolaryngologist for visualization of thevocal cords via laryngoscopy within 6 weeks, or as soon as possible ifrisk factors for malignancy are suspected.

• The left recurrent laryngeal nerve extends into the mediastinum;as such, there are a greater number of worrisome causes of left vocalcord paralysis compared with right vocal cord paralysis.

Key points

CM

E

Practice

CMAJ, November 19, 2013, 185(17) 1521

and can be used to describe any alteration of thepatient’s voice from its normal quality. Hoarse-ness can refer to a rough, raspy, breathy, weak orstrained voice, or to changes in pitch and per-ceived effort.

Hoarseness as a presenting symptom has abroad differential diagnosis, including manycauses that are self-limiting or benign, whereasothers may be serious and voice-damaging, oreven life-threatening. Causes include simplevocal overuse or abuse, irritants such as smokeor chemical exposures, various inflammatoryprocesses, neuromuscular conditions, psychiatricconditions, systemic disorders, neoplasms, orvocal cord lesions or hemorrhage2 (Box 1).

The most common cause of hoarseness isacute laryngitis from short-term vocal abuse oran upper respiratory tract infection. Acute laryn-gitis typically has a rapid onset and is usuallyself-limiting with a return of normal voice within1 to 2 weeks.3 Our patient had complete leftvocal cord immobility, most likely from neu-rapraxia, a less common diagnosis. We willdescribe features of unilateral vocal cord immo-bility later in the discussion.

Information gained from the clinical historycan help narrow the differential diagnosis,although direct visualization of the larynx is nec-essary to make the diagnosis. Key elements of avoice history include whether the hoarseness wasgradual in onset or sudden, presence of aggravat-ing or alleviating factors, symptoms of vocalfatigue or throat discomfort when speaking, his-tory of vocal overuse or abuse, antecedent upperrespiratory tract infection, recent surgeries re -quiring intubation and history of similar voicechanges in the past.2,4 One should ask aboutsymptoms of aspiration, as well as the degree towhich the patient uses his or her voice for work,social or sporting activities. Risk factors for headand neck malignancy, such as smoking and heavyalcohol use, or concerning symptoms of dyspha-gia, odynophagia, hemoptysis or stridor, shouldbe elicited, because these will affect the urgencyof further investigation.2,4

Investigations for hoarsenessVisualization of the larynx is an essential investi-gation for the detection of mass lesions, inflam-mation or vocal cord mobility issues.5 In ourpatient, laryngoscopy revealed an immobile leftvocal cord.

The timing of referral for direct laryngoscopyis controversial. In its clinical practice guidelinefor hoarseness, the American Academy of Oto-laryngology — Head and Neck Surgery Foun-dation recommends laryngoscopy within a 3-month window.5 However, critics have noted the

Figure 2: (A) Closure immediately after left vocal cordinjection with hyaluronic acid. Other than a minorposterior gap (white arrow), full glottic closure wasachieved. (B) Closure 1 month after left vocal cordinjection. Full glottic closure is maintained.

Figure 1: Larynx of a 40-year-old woman with com-plete left vocal cord immobility (black arrow) showingmaximum closure. Note the large glottic gap (whitearrow). The grey arrow shows the right vocal cordhidden under the vestibular fold (false vocal cord).

A

B

Practice

1522 CMAJ, November 19, 2013, 185(17)

relative lack of evidence (Grade C) that supportsthis recommendation and have expressed con-cern that the guideline does not emphasize thecritical importance of early laryngeal examina-tion in ruling out serious causes.6 Based on ourexperience, we suggest that laryngoscopy beperformed within 6 weeks of symptom onset ifhoarseness persists. (Please consult your localotolaryngologist as to timing.) During this wait-ing period, a several-week trial of conservativevoice use and vocal hygiene measures is sug-gested.2,4 Conservative voice use refers to theavoidance of shouting, excessive voice use andfrequent throat clearing or coughing. Vocalhygiene measures include avoiding irritants suchas smoke and dust, reduction in alcohol and caf-feine intake, and adequate hydration.2,4 A patientwith a hoarse voice presenting with risk factorsfor head and neck malignancy or concerningsymptoms should be referred more urgently fordirect visualization.2,4

The guideline recommends against radiologictests such as CT or magnetic resonance imaging(MRI) before laryngoscopy.5

Initial management of hoarsenessIn the absence of concerning risk factors, initialmanagement should include a trial of up to sev-

eral weeks of conservative voice use and vocalhygiene measures before laryngoscopy, as men-tioned above. The guideline recommends againsttherapeutic trials of antireflux medications in theabsence of signs or symptoms of gastroesoph -ageal reflux disease, corticosteroids or treatmentwith antibiotics.5

For patients using an inhaled corticosteroid, abrief trial of dose reduction or cessation may beconsidered, because hoarseness occurs with bothshort- and long-term inhaled corticosteroid useand may be dose-dependent.7,8

Based on our experience and after review ofthe literature, we have developed a simplifiedflow chart to guide Canadian primary care physi-cians in the initial management of patients pre-senting with hoarseness (Figure 3).2,4–8

Box 1: Differential diagnosis of hoarsenessas a presenting symptom

Inflammatory or irritant

• Allergies

• Upper respiratory tract infections (e.g., virallaryngitis)

• Gastroesophageal/laryngopharyngeal reflux

• Environmental irritants

• Vocal overuse or misuse

• Inhaled corticosteroid

Neoplastic

• Laryngeal papilloma

• Squamous cell carcinoma

• Benign salivary gland malignancies

• Laryngeal dysplasia

• Other laryngeal neoplasms

Neurologic

• Vocal cord paralysis

• Multiple sclerosis

• Myasthenia gravis

• Parkinson disease

• Spasmodic dysphonia

• Essential tremor

• Muscle tension dysphonia

Psychiatric

• Conversion aphonia

Systemic disorders

• Acromegaly

• Amyloidosis

• Hypothyroidism

• Sarcoidosis

• Rheumatoid arthritis with cricoarytenoidjoint involvement

Miscellaneous

• Benign vocal cord lesion (e.g., nodule, polyp,cyst, fibrous mass, hyperkeratosis)

• Vocal cord hemorrhage

• Trial of conservative voice use and vocal hygiene measures (2–4 wk) and reassess

• If taking inhaled corticosteroid, consider brief trial of dose reduction or cessation

Hoarseness present > 2 wk

Risk factors for head and neck malignancy (e.g., smoking, heavy alcohol use, dysphagia, hemoptysis or stridor)?

No Yes

Refer to otolaryngology

for laryngoscopy

Hoarseness resolved?

No Yes

No further treatment

Refer to otolaryngology

for laryngoscopy*

Figure 3: Initial management of patients with a hoarse voice.2,4–8 *The ideal tim-ing of laryngoscopy is controversial. (We suggest no more than 6 wk aftersymptom onset.) Please consult your local otolaryngologist.

Practice

CMAJ, November 19, 2013, 185(17) 1523

Unilateral vocal cord immobilityIn our patient, we diagnosed complete leftvocal cord immobility, most likely from neu-rapraxia. Symptoms and signs of unilateralvocal cord immobility are due to glottic insuffi-ciency and air escape resulting from a laterallydisplaced, immobile cord.9 This is usually per-ceived as a breathy, weak voice with variablechanges in pitch. The patient’s voice may varyfrom mild hoarseness with vocal fatigue toalmost complete aphonia.9 Compensation fromthe opposite vocal cord and false cords can leadto improvement but rarely to complete normal-ization of the voice.

Aspiration or near aspiration of thin liquidsis common. Perceived shortness of breath dur-ing conversation and inability to achieve suffi-cient vocal volume are other common com-plaints. These symptoms can occur with bothvocal cord paralysis and fixation. Vocal cordparalysis indicates a disruption at any pointalong the path of motor innervation of the lar-ynx, whereas fixation can result from any non-neurologic cause that reduces movement of thecricoarytenoid joint.10

Causes Any process interrupting the electrical conduc-tion along the recurrent laryngeal nerve or itsproximal origin, the vagus nerve, results inparalysis of the ipsilateral vocal cord. The rightand left recurrent laryngeal nerves have differentcourses (Appendix 2, available at www .cmaj .ca/lookup/suppl /doi:10.1503 /cmaj .112112/-/DC1).The right recurrent laryngeal nerve loops underthe right subclavian artery and then ascendstoward the larynx, whereas the left extends intothe mediastinum and loops under the ligamen-tum arteriosum before travelling back to thelarynx.10 Because the left recurrent laryngealnerve dips into the mediastinum, there are agreater number of causes of left unilateralvocal cord paralysis.11,12 In a retrospectivestudy, the most common cause of unilateralvocal cord paralysis was found to be iatrogenicinjury from nonthyroid surgeries (e.g., anteriorcervical approaches to the spine and carotidendarterectomies).13 Thyroid surgery is thenext most common cause. Malignancy wasalso found to be a substantial cause of leftrecurrent laryngeal nerve injury.13 Intubationcan cause injuries to the cri co ar y te noid jointand, in rare cases, paralysis of the recurrentlaryngeal nerve.

In many cases, a specific cause is not identi-fied and the paralysis is labelled “idiopathic.”Many of these cases are believed to be due topostviral neuropathy.11

InvestigationsAfter a unilateral vocal cord immobility is identi-fied on laryngoscopy and in the absence of anobvious cause identified on history and physicalexamination, additional investigations may bearranged.5 The use of imaging studies and theirurgency depends on the suspected cause. Incases with a clear temporal relation betweensymptom onset and preceding trauma, iatrogenicinjury or prolonged intubation, imaging is notnecessarily warranted.5,11 Clinical judgmentshould always be used to determine the need forimaging on a case-by-case basis.

Imaging must be done from the base of theskull to below the aortic arch so that the fullcourse of both recurrent laryngeal nerves can bevisualized.5 A CT scan with contrast or MRI areappropriate imaging modalities.5 If a more prox-imal vagal injury is suspected because of find-ings of palatal paralysis or additional cranialnerve palsies, MRI of the brainstem is war-ranted.9 To differentiate paralysis from fixation,laryngeal electromyography or direct palpationin the operating room are potentially usefulinvestigations.

Thyroid ultrasonography may be a usefuladditional imaging modality to search for thyroidneoplasms impinging on the recurrent laryngealnerve. It is generally thought to be a more sensi-tive technique than CT for the detection of thy-roid tumours.14,15

TreatmentThe goal of treatment for unilateral vocal cordimmobility is to reduce the risk of aspiration andimprove vocal quality and strength. Treatment ofthe underlying cause, if identified, should beundertaken as soon as possible.

Traditional teaching in cases of idiopathicvocal cord paralysis was to wait 1 year beforeconsidering intervention to medialize the immo-bile vocal cord. With the advent of temporaryinjectable agents such as collagen and hyaluronicacid, temporary medialization of the cord is pos-sible during the waiting period for potentialspontaneous recovery.11 If no long-term recoveryoccurs, a permanent surgical implant can beplaced in the operating room to medialize thevocal cord and improve glottic closure.11

References1. Rosen CA, Lee AS, Osborne J, et al. Development and valida-

tion of the Voice Handicap Index-10. Laryngoscope 2004; 114:1549-56.

2. Feierabend RH, Malik SN. Hoarseness in adults. Am Fam Physi-cian 2009;80:363-70.

3. Dworkin JP. Laryngitis: types, causes, and treatments. OtolaryngolClin North Am 2008;41:419-36.

4. Syed I, Daniels E, Bleach NR. Hoarse voice in adults: an evidence-based approach to the 12 minute consultation. Clin Oto lar yngol2009;34:54-8.

5. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Oto-laryngol Head Neck Surg 2009;141:S1-31.

6. Johns MM, Sataloff RT, Merati AL, et al. Shortfalls of the American Academy of Otolaryngology–Head and Neck Surgery’s clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head NeckSurg 2010;143:175-7.

7. Yang IA, Fong K, Sim EHA, et al. Inhaled corticosteroids for stable chronic obstructive pulmonarydisease. Cochrane DB Syst Rev 2007;(2):CD002991.

8. Adams NP, Bestall JC, Jones P, et al. Fluticasone at different doses for chronic asthma in adults andchildren. Cochrane DB Syst Rev 2008;(4):CD003534.

9. Sulica L, Blitzer A. Vocal fold paralysis. Berlin: Springer- Verlag; 2006.10. Lalwani AK. Current diagnosis & treatment in otolaryngology head & neck surgery. 2nd ed. New York

(NY): McGraw Hill; 2008.11. Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin North Am 2007;40:1109-31.12. Plastiras SC, Pamboucas C, Zafiriou T, et al. Ortner’s syndrome: a multifactorial cardiovocal syn-

drome. Clin Cardiol 2010; 33: E99-100.13. Rosenthal LHS, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over

20 years. Laryngoscope 2007;117:1864-70.14. Vazquez BJ, Richards ML. Imaging of the thyroid and parathyroid glands. Surg Clin North Am

2011;91:15-32.15. Wang CP, Chen TC, Lou PJ, et al. Neck ultrasonography for the evaluation of the etiology of adult uni-

lateral vocal fold paralysis. Head Neck 2012;34:643-8.

Affiliations: Division of Otolaryngology — Head & Neck Surgery (Massoud and Brown),Department of Surgery, Faculty of Medicine, Dalhousie University; and Faculty of Medicine(Trottier), Dalhousie University, Halifax, NS

Contributors: All the authors were involved in the patient’s care. Amy Trottier drafted thearticle, which all the authors revised. All the authors approved the final version submitted forpublication.

Acknowledgements: The authors thank Alison Martin for her illustrations, shown in Appen-dices 1 and 2.

1524 CMAJ, November 19, 2013, 185(17)

Practice

Change of addressWe require 6 to 8 weeks’ notice to ensure uninterruptedservice. Please send your current mailing label, newaddress and the effective date of change to:

CMA Member Service Centre1870 Alta Vista Dr., Ottawa ON K1G 6R7tel 888 855-2555 or 613 731-8610 x2307 fax 613 236-8864cmamsc@cma.ca

Changement d’adresseIl nous faut de 6 à 8 semaines d’avis afin de vous assurerune livraison ininterrompue. Veuillez faire parvenir votreétiquette d’adresse actuelle, votre nouvelle adresse et ladate de la prise d’effet du changement, à l’attention du

Centre des services aux membres de l’AMC1870, prom. Alta Vista, Ottawa ON K1G 6R7tél 888 855-2555 ou 613 731-8610 x2307 fax 613 236-8864cmamsc@cma.ca