Case Challenge: Diagnosing and Managing Dysphonia

Gordon H. Sun, MD, MS

Disclosures

June 19, 2018

Risk Factors for Dysphonia

According to the 2018 American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) clinical practice guideline update for hoarseness/dysphonia, clinicians should consider dysphonia "...in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces QOL [quality of life]."[1] The AAO-HNSF guideline includes an exhaustive list of historical risk factors associated with dysphonia that "might modify management." Examples of such contributing factors include, but are not limited to, the following:

  • Surgical history (endotracheal intubation, head/neck/spine/chest surgery, or both)

  • Smoking (eg, tobacco, e-cigarettes)

  • Frequent use of the voice in occupational settings (eg, teachers, singers, newscasters)

Scope, Image, or Medicate?

A 55-year-old office worker presented to his primary care physician (PCP) for evaluation of intermittent hoarseness and globus sensation for the past 3 years. The patient stated that his symptoms occurred whenever he had to speak for a prolonged period of time. He noted that this sensation was accompanied by a frequent need to clear his throat. He denied sore throat, dysphagia, dyspnea, hemoptysis, halitosis, heartburn, regurgitation, or constitutional symptoms. He has no known medical conditions and no recent acute illnesses. His surgical history was significant for an uncomplicated tonsillectomy 40 years ago. He reported no medication use or environmental allergies. He denied use of tobacco, alcohol, or illicit drugs.

Image from Science Source

Vital signs were within normal limits. The patient appeared comfortable and in no acute distress. There was no audible stridor; however, his voice was notably deep and coarse-sounding, which he asserted was not his baseline. With the exception of a modestly deviated nasal septum, a complete head and neck exam demonstrated no notable abnormalities. The cardiopulmonary and neurologic exams also were unremarkable. The PCP was not able to perform a laryngeal mirror exam and did not have a laryngoscope in her office.

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