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Chapter 18 • Headache 231
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blood levels are diagnostic. History may suggest recent
smoke inhalation or similar symptoms in multiple
family members.
Severe hypoglycemia. Hypoglycemia is more
likely to occur in persons with type 1 diabetes but can
occur in anyone taking oral hypoglycemic agents, in
younger persons who experience reactive hypoglycemia, or in persons who have ingested excessive
amounts of alcohol. A dietary and medication history
may lead to a specic causative factor. Headache is
generalized and bilateral and is associated with dizziness and a sense of not feeling well. Some persons with
diabetes may have nocturnal hypoglycemia and report
nightmares and vivid dreams, night sweats, and a headache on awakening. Blood glucose levels can conrm
the presence of hypoglycemia.
Drug withdrawal. Withdrawal from prolonged use
of steroids may cause migrainous headaches. Nitrites
may precipitate headache. Other drugs causing cranial
dilation and an aftereffect of rebound vasoconstriction
include hydralazine, alcohol, histamine, nicotinic acid,
and caffeine.
Dietary ingestion. A mild to moderately severe
generalized headache may occur after ingestion of
tyramines (e.g., aged cheese, red wine), monosodium
glutamate, and nitrites in smoked meats. A headache
diary will help identify the pattern of headache
related to specic foods.
Cerebrovascular Origin
Intracranial tumor. Intracranial tumors are more
common in children than adults. Brain metastases from
primary sites in the lung, breast, or kidney are more
common in adults. Pain is constant and progressive, is
felt in a discrete location, changes with head position,
and awakens the person from sleep. Objective neurological signs are present in 98% of all children with
brain tumors.
Hydrocephalus. Hydrocephalus is a collection
of cerebrospinal uid (CSF) in the ventricles of the
brain and can be caused by tumors or cysts. If fontanels are still open, hydrocephalus will cause an enlargement of the head on measurement. Headache
will be progressive and may be associated with neurological ndings and mental status changes similar
to those observed with dementia. Radiographic techniques are diagnostic, and LP may detect increased
CSF pressure.
Subdural hematoma. Subdural hematoma produces a sudden, severe headache that is associated with
a history of head trauma, exertional physical activity,
or pharmacological anticoagulation. There is transient
loss of consciousness, stiff neck, nausea, vomiting,
photophobia, pupillary dilation, and pain over the eye.
A thorough history of trauma is essential to obtain.
Posttrauma headache can occur hours or a day after
injury.
Pseudotumor cerebri. Teenagers being treated
with topical acne preparations, menopausal women,
and persons ingesting large amounts of vitamin A are
at increased risk for pain from pseudotumor cerebri.
Papilledema will be present in many cases, but, without it, the headache may be diagnosed as mixed type.
A neurology referral is indicated to ensure that no
local obstruction is present before an LP is done to
assess for increased intracranial pressure. LP sometimes leads to herniation of the brainstem.
Brain abscess. Pain is of gradual onset, deep and
aching in nature, often worse in morning, and aggravated by coughing or straining. Other signs of increased
intracranial pressure may be present, such as papilledema and widening pulse pressure. There may be a
recent history of head injury, infection, or assault to the
central nervous system.
Intracerebral hemorrhage. ICH may result in a
stroke or sudden coma and is associated with neurological ndings dened by the site of bleeding. A person may present with a sudden-onset, severe headache,
with or without a history of trauma. The severity of
symptoms from bleeding intracranial aneurysms is correlated to the rate of hemorrhage and graded from I
(asymptomatic to minimal headache with nuchal rigidity) to V (deep coma, decerebrate rigidity). Elderly
persons with AIDS and persons prescribed anticoagulation therapy are at increased risk for ICH. CT scan is
diagnostic.
232 Chapter 18 • Headache
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Headache
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Primary Headaches Without Structural or Systemic Pathology
Tension-type
headache
(muscle)
Migraine without
aura (common)
Migraine with
aura (classic)
Mixed headache Throbbing, constant pain
Cluster
headache
Benign exertional
headache
Secondary Headaches with Structural or Systemic Pathology
Infectious Origin
Sinusitis Frontal, upper molar, or
Dental disorders Localized pain in jaw and top
Pharyngitis Sore throat Fever; infection of posterior
Otitis media Ear pain, pain with swallowing Fever; red, bulging tympanic
Meningitis Severe headache, chills,
Neurogenic Origin
Trigeminal
neuralgia
Optic neuritis Acute onset of pain with
Cervical spine
disorders
Common in adults; bilateral
pain, general or localized in
bandlike distribution; history of
anxiety, stress, or depression
More common in children; uni-
lateral, throbbing pain; nausea
Pain precipitated by environ-
mental stimuli; visual disturbances (scintillating scotoma)
precede pain
during waking hours; muscle
tightness; family history of
migraine
Rare in children; abrupt,
nighttime onset; unilateral
periorbital pain that is severe
Sudden onset related to
physical exertion, Valsalva, or
coitus
periorbital pain; cough,
rhinorrhea
of head
myalgias, stiff neck; toxic child
or adult
Persons .55 yr; bursts of sharp
pain over face innervated by
affected nerve; triggered by
stimulus to affected nerve
extraocular movement (EOM),
followed by blurred vision
May have history of trauma;
occipital pain, muscle stiffness
Normal physical examina-
tion; neck muscle tightness
or fasciculations may be
palpated
Photophobia and
phonophobia
Nausea and vomiting,
photophobia and
phonophobia
Mix of findings related to
tension and migraine
headache pain
Ipsilateral rhinorrhea, nasal
stuffiness, conjunctival
injection, sweating, ptosis
Normal physical examination May need to distinguish
Low to no fever; pain on
palpation of frontal, maxillary
sinuses; purulent nasal or
postnasal discharge
Malocclusion, caries,
abscesses of teeth present,
gum disease
pharynx
membrane
Positive Kernig’s and
Brudzinski’s signs; fever,
photophobia, petechial rash
may be present; mental
status changes
Normal physical examination;
stimulation of triggers may
provoke pain
Diminished visual acuity,
decreased papillary reflex,
hyperemia of optic disc; pain
with EOM
Normal physical examination
or pain associated with neck
motion
None
None
None
None
None
from subarachnoid hemorrhage with CT scan
Radiographs (Waters
view)
Dental referral
Throat culture
None
Lumbar puncture
None
Ophthalmology referral
Cervical spine
radiographs
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DIFFERENTIAL DIAGNOSIS OF Common Causes of Headache—cont’d
CONDITION HISTORY PHYSICAL FINDINGS DIAGNOSTIC STUDIES
Temporal arteritis Age .50 yr; sharp, localized
temporal pain; malaise, anorexia; history of polymyalgia
rheumatica
Metabolic Origin
Carbon
monoxide
poisoning
Severe
hypoglycemia
Drug withdrawal Pattern of headache associated
Dietary ingestion Mild to moderately severe
Cerebrovascular Origin
Intracranial
tumor
Hydrocephalus Progressive headache, vomit-
Subdural
hematoma
Pseudotumor
cerebri
Brain abscess History of chronic ear infection
Intracerebral
hemorrhage
AIDS, acquired immune deficiency syndrome; CT, computed tomography; ESR, erythrocyte sedimentation rate.
History of exposure; throbbing
headache, mild dyspnea
History of diabetes or
medication, alcohol, and food
ingestion; generalized
headache, dizziness, sense of
not feeling well
with stopping medication or
substance use
headache after ingestion of
foods or medication
Sudden-onset headache that is
progressive, exacerbated by
coughing or exercise; worse
in morning; history of trauma
increases risk
ing, irritability
History of head trauma, bleeding
disorders, child abuse; adult
.35 yr; sudden onset of “worst
headache ever,” often over eye;
transient loss of consciousness
Teens, menopausal women;
history of vitamin A or
tetracycline ingestion;
progressive headache
or cyanotic heart disease
Risk factors: persons .50 yr,
with AIDS, taking anticoagulation therapy
Fever, weight loss; tender over
a nodular temporal artery
Nausea, vomiting, change in
mental status, lethargy, loss
of consciousness
Normal physical examina-
tion or pallor, sweating, and
weakness
Normal physical examination Blood chemistry
Normal physical examination Blood chemistry
Papilledema, vomiting,
asymmetrical reflexes,
weakness, sensory deficit, or
other neurological deficit
Rapid enlargement of head,
bulging fontanels
Unequal pupils, photopho-
bia, neurological changes,
seizure
Papilledema may be present CT scan, neurology
Fever, seizures, focal
neurological deficits
If conscious, abnormal
neurological findings correlated with extent of lesion
Elevated ESR (.50);
immediate referral for
treatment
Blood gases and
carboxyhemoglobin
level
Blood glucose level; may
need self-monitoring of
blood glucose to establish pattern
CT scan
CT scan and referral
CT scan and neurosurgi-
cal referral
referral to assess risk related to lumbar puncture
CT scan
Emergency transport for
immediate evaluation
or with hypertension
(CT scan) and possible
surgical treatment
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REFERENCES AND READINGS
American College of Emergency Physicians: Clinical policy: critical
issues in the evaluation and management of patients presenting to
the emergency department with acute headache, Ann Emerg Med
39:108, 2002.
Davenport R: Headache, Pract Neurol 8:33, 2008.
Dodick DW: Pearls: headache, Semin Neurol 30:74, 2010.
Kabbouche M, Cleves C: Evaluation and management of children
and adolescents presenting in an acute setting, Semin Pediatr
Neurol 17:105, 2010.
Kaniecki R: Headache assessment and management, JAMA 289:1430,
2003.
Lewis DW: Pediatric migraine, Pediatr Rev 28:43, 2007.
Lipton RB, Bigal ME, Steiner TJ, Silberstein SD, Olesen J: Classi-
cation of primary headaches, Neurology 63:427, 2004.
Manzoni GC, Torelli P: Headache screening and diagnosis, Neurol
Sci 25: S255, 2004.
Purdy RA: Clinical evaluation of a patient presenting with headache,
Med Clin North Am 85:847, 2001.
Smetana GW: The diagnostic value of historical features in primary
headache syndromes, Arch Intern Med 160:2729, 2000.
Stafstrom CE, Rostasy K, Minster A: The usefulness of children’s
drawings in the diagnosis of headache, Pediatrics 109:460,
2002.
C H A P T E R
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19
Hoarseness
oarseness is a disturbance of the normal voice
pitch by an abnormal vibration of the vocal
H
rough, harsh, or deep voice. Voice is the sound produced
when the vocal folds are approximated and expired airow between the cords causes them to vibrate. The
sound produced by the larynx is amplied by the pharynx, oral cavity, sinuses, and nasal cavity and is modied
by movements of the tongue, uvula, and soft palate.
Hoarseness may be an early sign of local disease or
a manifestation of a systemic illness. Hoarseness is a
cardinal symptom for laryngeal disease.
with a mucous membrane connected to the superior
part of the trachea and to the pharynx inferior to the
tongue and hyoid bone. It is the sphincter that guards
the entrance into the trachea and functions secondarily
as the organ of voice. Nine cartilages connected by
ligaments and eight muscles form the larynx. The
lower portion of the thyroarytenoid muscle forms the
true vocal fold, or folds, which are highly elastic and
account for the extraordinary versatility of the voice
and the wide range of pitch, volume, and quality. The
glottis is the triangular opening between the true vocal
cords. The supraglottic area includes the ventricular
folds (false vocal cords), aryepiglottic folds, and the
epiglottis (Figure 19-1). The epiglottis is the lidlike
cartilaginous structure that overhangs the entrance to
the larynx and serves to prevent food from entering the
larynx and trachea while swallowing.
functional disorders from voice overuse. Functional
causes are unrelated to organic disease and may have a
psychosocial component, such as restraint in expressing anger, or crying, or a history of psychological
trauma.
in an adult and 1 week in a child may indicate secondary
changes to the vocal cords. These changes may be caused
by structural changes resulting from palsies, polyps, or
cords. It is a term used to describe an unnaturally
The larynx is a musculocartilaginous structure lined
Many benign conditions cause hoarseness, such as
However, persistent hoarseness for more than 2 weeks
cysts; laryngeal neoplasm; or congenital disorders of the
larynx. Hoarseness may also be a symptom of systemic
disease, such as hypothyroidism, or a symptom of inammation caused by a variety of processes. Many forms of
laryngitis that appear alike on physical examination have
very different causes; critical clues to the specic etiology of laryngitis depend on a careful history.
DIAGNOSTIC REASONING:
FOCUSED HISTORY
Is the hoarseness acute or chronic?
Key Questions
n How long has the symptom been present?
n Has this happened before? Is it recurrent?
n Is it getting better or worse?
Duration
Symptoms of less than 2 weeks’ duration are considered to be acute; the most likely cause is a viral upper
respiratory tract infection. Inammations secondary to
acute viral infection or voice overuse are the most
common causes of acute laryngitis. Chronic symptoms suggest structural change in the larynx or hoarseness secondary to disorders, such as gastroesophageal
reux disease (GERD) or systemic disease. If the
duration of hoarseness is longer than 2 weeks, referral
to an ear, nose, and throat specialist is indicated to
evaluate for neoplasm, most often squamous cell carcinoma, because chronic laryngitis is rarely of an
infectious etiology.
Recurrence
Recurrent episodes of hoarseness may indicate allergies
or sinusitis with postnasal drip.
Progression
Progressive hoarseness usually indicates a lesion, such
as a laryngeal or hypopharyngeal cyst.
235
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Glottis
Trachea
FIGURE 19-1 Laryngoscopic view of the interior of the larynx. (Modified from Greene MCL,
Mathieson L: The voice and its disorders, ed 5, London, 1989, Wiley. Copyright John Wiley & Sons
Limited. Reproduced with permission.)
Epiglottis
Thyroarytenoid muscle
(true cords)
Ventricular fold
(false cords)
Aryepiglottic fold
What does the onset of hoarseness tell me?
Key Questions
n How did the hoarseness develop?
n Is there any history of trauma to the throat?
n Have you had any recent surgery around the throat
or neck?
Onset
Acute onset of hoarseness is usually the result
of infection or trauma. The trauma can be from
direct injury (foreign body, accidents) or overuse
from screaming. The overuse can be gradual, resulting in progressive hoarseness and vocal cord
changes. This hoarseness is worse in the afternoon
or evening.
Hoarseness from birth may indicate a congenital
problem, such as laryngeal web, cyst, palsy, or angioma. Newborns with aphonia or a hoarse cry that does
not resolve may have a congenital anomaly, papilloma,
or vocal cord paralysis.
Trauma
External trauma to the throat is a rare cause of hoarseness
but can result in hematoma formation in the laryngeal
soft tissues. There can also be mucosal lacerations, arytenoid cartilage dislocation, or fracture of the laryngeal
cartilage. Internal trauma can occur with intubation
associated with surgery, as occurs when an endotracheal
tube catches on laryngeal structures and is pushed against
resistance.
Surgical History
Tonsillectomy, thyroidectomy, or rhinoplasty can
alter the quality of the voice secondary to structural
change and scarring. Cardiac surgery has also been
cited as a cause of injury when the vagus nerve (cranial nerve [CN] X) is damaged in its course around
the aorta.
Does the presence of risk factors help narrow
the diagnosis?
Key Questions
n Have you had a recent cold or upper respiratory
tract infection?
n Do you have allergies or asthma?
n Do you smoke? How long have you been a smoker?
n How much alcohol do you drink?
n Can you describe your voice habits, such as singing,
talking, and shouting?
n Are you frequently exposed to dust, fumes, or loud
noise?
n Are your immunizations up to date?
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Upper Respiratory Infection
Acute laryngitis, epiglottitis, and acute laryngotra-
cheobronchitis (croup) are sequelae from a viral
upper respiratory infection (URI) that can result in
vocal cord inammation. Postnasal discharge that is
thick and purulent may pool around the larynx and
cause chronic secondary edema. Nasal congestion
that leads to mouth breathing produces laryngeal
dryness, with resultant hoarseness on arising in the
morning.
Children who have epiglottitis are not hoarse, but,
as the epiglottis swells, the voice becomes mufed and
drooling is observed.
Allergies and Asthma
Poorly controlled or undiagnosed asthma can result
in a chronic cough with subsequent hoarseness. Allergies can cause chronic or recurrent irritation
and swelling of both the upper and lower airways.
Children who have a history of asthma and or allergies can develop vocal cord edema, inammation,
and hoarseness.
Smoking
Cigarette smoking is the most signicant risk factor
for laryngeal cancer. Smoking is also a risk factor for
acute or chronic laryngitis because smoke irritates
all mucous membranes and impairs ciliary function,
causing pooling of secretions around the larynx.
Alcohol Consumption
Chronic consumption of hard liquor is a direct irritant
to the throat and is associated with laryngeal cancer.
Voice Habits
Voice misuse occurs when the true vocal cords are forced
to vibrate under undue stress and tension. Voice abuse is
exuberant overuse and can lead to inammation of the
larynx and edema, hemorrhage, or vocal cord polyps.
A gradual progression of hoarseness may go unnoticed
by the patient. Often a precipitating incident (such as
shouting, excessive speaking, or singing) produces acute
laryngitis. Specic questions may need to be asked to
make the patient aware of conditions that lead to voice
abuse, such as the following:
n Have others noticed a change in the quality of your
voice?
n Do you talk frequently to persons who are hard of
hearing?
n Do you yell at children?
n Do you work in an environment that is noisy or
contains dust or fumes?
n Have you attended a recent sporting event?
Exposures
Patients who are chronically exposed to work environments that contain dust, fumes, or a high noise level
that leads to chronic voice abuse are at increased risk
for laryngeal cancer.
Immunizations
Laryngeal diphtheria should be considered in patients
who have failed to update their diphtheria immunizations.
Updating the tetanus-diphtheria (Td) immunization is
recommended every 10 years after the primary immunization series is completed. Laryngeal diphtheria usually
develops as a downward progression of the tonsillarpharyngeal membrane.
What other clues will help narrow
the diagnostic possibilities?
Key Questions
n Does the hoarseness change during the day?
n Is it painful?
n What other symptoms are present?
n Do you have a neurological disorder?
Timing
Hoarseness that is altered by a position change suggests a mobile lesion, such as a pedunculated polyp.
Patients with myasthenia gravis have a normal voice
in the morning with progressive hoarseness throughout the day.
Pain
Pain may be associated with an inammatory process,
such as a viral URI or GERD. Pain occurs late in laryngeal cancer. Neurological and hormonal causes do not
usually produce pain.
Associated Symptoms
The presence of cough, shortness of breath, weight
loss, dysphagia, ear pain, or throat pain should raise
concerns about neoplasm, systemic disease, or neurological causes. Hormonal disorders, such as hypothyroidism, will also produce signs and symptoms that
vary in severity, according to the duration and degree
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of hormone deciency. Early symptoms of hypothyroidism include cold intolerance, heavy menses, weight
gain, dry skin, fatigue, and constipation. Later signs
and symptoms include hoarseness, very dry skin, hair
loss of lateral eyebrows, and neurological symptoms,
such as delayed deep tendon reex recovery, depression, and mental confusion.
Neurological Disease
Patients with Parkinson disease, myasthenia gravis,
or amyotrophic lateral sclerosis have progressive
dysarthria and dysphagia. As neurological disease
progresses, patients will develop a chronic cough and
throat clearing caused by microaspiration of pooled
secretions.
Gastroesophageal Reflux Disease
Reux of gastric contents causes inammation of the
posterior larynx, especially the arytenoid mucosa. The
patient may also report a habit of frequent throat clearing
and a sensation of a lump in the throat. Chronic cough or
throat clearing further damages already irritated vocal
folds. Generally patients have hoarseness in the morning
and coughing at night. In children, GERD presents with
dysphagia, vomiting, and failure to thrive.
DIAGNOSTIC REASONING:
FOCUSED PHYSICAL EXAMINATION
Listen to the Quality of Voice
Acoustic evaluation criteria for voice include range
(monotonic to extremely variable), loudness (soft to
loud), pitch (low-pitched voice requires more effort to
produce adequate volume; sudden changes in pitch),
register (temporary loss of voice because of abductor
spasm), and quality (roughness, breathiness, and
hoarseness). Table 19-1 lists common criteria used in
evaluating the voice.
Examine the Respiratory System
Assess the airway. Stridor, a high-pitched inspiratory
sound caused by turbulent airway through a narrowed
glottis secondary to inammation or tumor, indicates
an immediate referral to a specialist. If the patient is
able to cough and laugh but cannot speak, this indicates a functional problem, because coughing and
laughing require total adduction of the vocal cords.
Auscultate the lungs for quality of breath sounds, asthmatic wheezing, and signs of consolidation.
Note any associated stridor in children. Inspiratory
stridor may indicate an extrathoracic problem, such as
supraglottic collapse or vocal fold paralysis. An intrathoracic lesion may cause an expiratory stridor.
Perform a General Inspection
Note hair distribution, especially signs of hair loss over
lateral eyebrows and hair loss on scalp, to assess thyroid function. Look for the placement of the trachea
and thyroid gland. Bulges or asymmetry of the neck
suggest a tumor. A head and neck hemangioma or
lymphangioma increases the possibility of a similar
laryngeal lesion as the source of hoarseness.
Examine the Head and Neck
Examine the oral, pharyngeal, and nasal mucosa for
signs of excessive dryness, inammation, or infection. Excessive mucosal dryness, including the conjunctiva, may be secondary to medication use, such as
decongestants and antidepressants, or may be a symptom of an autoimmune disorder, such as Sjögren
syndrome.
Otoscopy may indicate otitis media with effusion,
contributing to hearing loss, a factor to be considered in voice abuse. Inspect the nasal mucosa for
color, edema, and purulent discharge, and examine
Table 19-1
ACOUSTIC QUALITY MEASUREMENT DISORDER
Range Monotonal to extremely variable Monotonal: Parkinson disease, depression
Loudness Soft to loud Environmental, psychological, systemic disease
Pitch Low to high; glottal, raspy to falsetto Variable: puberty
Register Presence of voice Vocal fatigue, overuse
Quality Breathy to resonant Vocal cord mass, paresis, bowing, atrophy
Diagnostics Used in Evaluating Voice
Low: male gender, overuse
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the nasal septa for deviation that may cause obstruction. Hypertrophic tonsils and severe dental abnormalities (malocclusion, cleft palate) can contribute
to hoarseness.
Any indication of airway obstruction associated
with hoarseness is a potentially life-threatening situation. Do not perform a physical examination of the
pharynx if you suspect acute epiglottitis. Examination may trigger laryngospasms and airway obstruction. Refer immediately for emergency treatment and
airway support.
Examine the larynx indirectly using a laryngeal
mirror. Patient cooperation is critical. Ask the
patient to open the mouth wide and extend the neck
while protruding the tongue. The mirror is advanced
to contact and lift the uvula while the patient breathes
through the mouth. Focus the light on the mirror
after the mirror is angled to visualize the larynx. Ask
the patient to say “e” or “a” to observe movement.
Sometimes the epiglottis obscures visualization.
Direct examination of the larynx with a laryngoscope requires the skill and experience of a
specialist.
Observe the larynx for the presence of secretions
and evidence of ulcers, polyps, masses, edema, or redness. Observe for vocal cord motion, especially adduction and abduction of vocal cords, and the presence of
spasm or tremor.
Assess Cranial Nerve Function
Most of the CNs play a part in speech and voice production, and any disease process that affects neurological function, especially vocal cord paralysis, may
affect the voice. Specically examine CNs V, VII, VIII,
IX, X, XI, and XII.
Assess Hearing (Cranial Nerve VIII)
Voice or whisper testing for hearing acuity is the rst
level of hearing screening. An audible whisper is
approximately 20 decibels (dB), and normal speech is
about 50 dB. Patients with neurosensory hearing loss
may use abnormally loud speech.
Palpate Lymph Nodes
Palpate the cervicofacial lymph nodes. Tender nodes
indicate inammation; nontender nodes may indicate
neoplasm. Enlarged nodes in the deep cervical chain in
the absence of other symptoms may indicate laryngeal
cancer.
Palpate Thyroid
Palpate the thyroid for size, tenderness, and crepitus
by moving the thyroid cartilage across the cervical
spine.
LABORATORY AND DIAGNOSTIC
STUDIES
Flexible Fiberoptic Laryngoscopy
Laryngoscopy allows direct examination of the hypopharynx and larynx. A local anesthetic is applied to the
oral or nasal mucosa, and the instrument is passed
through the nose or oral cavity for excellent visualization of laryngeal structures. Laryngoscopy is also
performed using a general anesthetic.
Radiography
Lateral view radiographs of soft tissues of the neck are
used to evaluate structures for abnormalities.
Barium Esophagography
This contrast radiographic technique can be used to differentiate between mechanical lesions and motility
disorders, providing important information about the
latter in particular. For patients with esophageal dysphagia and a suspected motility disorder, barium esophagoscopy should be performed rst.
DIFFERENTIAL DIAGNOSIS
Acute Laryngitis
Acute laryngitis is a self-limiting condition caused
by a viral infection, environmental irritants, postnasal drainage secondary to poorly controlled allergic
rhinitis, or voice overuse. The loudness and quality
of voice are affected, and the patient may report
a sore throat. Hoarseness often progresses throughout the course of the day. Indirect examination of
the larynx reveals redness and edema of the vocal
cords. Physical pathology may be absent in mild
cases.
Acute Epiglottitis
Adults will report severe and rapidly progressing
symptoms of sore throat, dyspnea, and hoarseness. In
children, there is no cough or hoarseness, and drooling with a forward leaning posture is observed. This
condition is most commonly associated with Hae-
mophilus inuenzae infection. Voice quality is froglike. The patient will also have a high temperature
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and be anxious, fearful, and restless with respiratory
distress.
Trauma
Any swelling in response to trauma, directly to the
larynx or indirectly to the throat, will cause hoarseness.
Swelling might be secondary to head and neck surgery,
such as dental surgery, tonsillectomy, or thyroidectomy. Postintubation trauma may be acute if secondary
to inammation or chronic if neurological or structural
damage is irreversible. Mucosal abrasion or ulcer may
be caused by direct trauma to the larynx and is associated with painful phonation and a breathy voice.
Acute Laryngeal Edema
Laryngeal edema may be one symptom in a generalized allergic response that involves the lips, tongue,
and other hypopharyngeal structures. Drug reactions
and food allergies, especially to seafood and nuts,
often precipitate this response. This condition is a
medical emergency because of the high risk of airway
obstruction.
Laryngotracheobronchitis (Croup)
Subglottic edema is caused by a viral infection, most
often parainuenza 1 virus, that can obstruct the airway.
This condition is most common in children ages
3 months to 3 years of age and is more prevalent in the
fall and winter. It is associated with a barking cough,
dyspnea, wheezing, low-grade fever, and hoarseness.
Inspiratory stridor occurs abruptly because of narrowing
of the passage, causing negative pressures generated
on inspiration. Physical examination can determine
the degree of respiratory distress, such as color, stridor,
nasal aring, and level of consciousness.
Chronic Laryngitis
This condition is associated with a combination of
chronic exposure to working conditions with high levels of dust, fumes, or noise; hard liquor consumption;
cigarette smoking; and a history of frequent and persistent cough. Physical examination reveals edema or
nodules of the vocal cords.
Polyps
Vocal cord polyps develop as a result of chronic
inammation from voice abuse, allergies, or GERD.
The voice quality is breathy. With dependent polyps,
the patient may report that symptoms of hoarseness
change with position.
Neoplasm
Laryngeal cancer usually occurs in patients who
have a long history of cigarette smoking and alcohol
consumption. Hoarseness is characterized by a raspy
or harsh voice. Physical examination may reveal
leukoplakia, or a white scaly appearance of the vocal
cords. Patients do not usually report pain until carcinoma is advanced. Pain secondary to ulceration is
late and is often perceived as ear pain, especially
when swallowing.
Gastroesophageal Reflux Disease
Patients with GERD will report retrosternal burning
(heartburn) that radiates upward. The regurgitation of
gastric acid is exacerbated by consuming large meals,
lying in a supine position, or bending over. Patients
may describe a sour taste, experience salivary hypersecretion, have painful swallowing, or have a chronic
cough or habit of throat clearing. Physical examination
will be normal or epigastric tenderness may be elicited
by abdominal examination. Inammation or ulceration
may be visible on the vocal cords.
Hypothyroidism
One symptom of hypothyroidism is a low, gravelly
voice. The degree of hoarseness depends on the severity of thyroid deciency. Usually the diagnosis of hypothyroidism is suspected when other symptoms are
present, such as cold intolerance; rough, scaly skin
texture; weight gain; and such signs as bradycardia and
prolonged deep tendon reex recovery. Risk factors for
hypothyroidism include increased age, postpartum in
women, and a family history of thyroid disease. The
thyroid gland may be nonpalpable or enlarged. Examination of the larynx may reveal edema or polyps. An
elevated serum thyroid-stimulating hormone (TSH)
level will conrm the diagnosis.
Vocal Cord Paralysis
Paralysis is usually unilateral and produces a weak,
breathy voice. Unilateral abductor paralysis on the left
side is caused by pressure on the vagus or recurrent
laryngeal nerve by a mass of malignant glands in the
superior mediastinum or carcinoma of the thyroid or
esophagus.
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