Operational Medicine 2001
Hoarseness

Hoarseness is a symptom of many different disorders of the larynx or surrounding tissues.  

It can be caused by: 

• Infections of the larynx itself

• Voice abuse

• Allergic reactions to foods, medications or other substances

• The effects of masses in the larynx or surrounding tissues.  

Each different entity can cause different changes to the volume and pitch of the voice.

The history is important in evaluating any changes in a patient’s voice.  

• A sudden change in voice in association with pain, fever and swollen cervical lymph nodes indicates the likelihood of infection.  

• A gradual change over weeks or months is more concerning and may be due to some underlying mass effect or malignancy.  

• Voice trauma should be clearly evident from the history.

The most common cause of hoarseness is infection.  These include viruses most commonly, but less frequently may also include bacteria.  The typical “laryngitis” is usually due to a viral infection, and may have other associated symptoms, like cough, fever/chills, runny nose or nasal congestion, and headache.  No laboratory evaluation is necessary.  Patients with infectious causes of hoarseness need only symptomatic treatments and may or may not need SIQ time.  Treatments includes:

• Voice rest with avoidance of whispering

• Cough suppressants

• Mucolytics

• Warm sialogogues such as tea with lemon

• Fever control with acetaminophen or ibuprofen

• Humidification of room air as available.  

Any or all of these treatments are purely for symptom relief and in no way alter the time course of the illness.  If there is evidence of bacterial infection, appropriate antibiotics should be employed.

Although it is rare, there have been increasing number of reports of adults contracting bacterial epiglottitis, an infection of the epiglottis caused by Haemophilus influenzae or other bacteria and usually occurring in children.  This rare infection is a medical emergency and needs careful airway management and antibiotics.  Symptoms include:

• Severe sore throat

• Lymphadenopathy

• Tenderness to palpation of the anterior neck overlying the hyoid.  

• Fever may or may not be present

• Hoarseness is not usually present.  

Late symptoms include stridor, drooling and classic “sniffing” posture and may progress rapidly to respiratory compromise.  

The patient should be stabilized and admitted to the intensive care unit with constant airway management and intubation if necessary.  If possible, consultation with otolaryngology staff should be obtained for definitive management recommendations and possible evaluation for MedEvac transfer if epiglottitis is suspected.

Leukoplakia is a form of hoarseness and cough caused by chemical irritation, notably tobacco smoke or alcohol.  There is usually no pain associated with this condition.  It may be premalignant, and should be evaluated by an otolaryngologist at the earliest convenience.  Acute treatment is symptomatic, with the most important step being cessation of smoking.  This condition should be addressed upon return to a treatment facility.

Frequent yelling or shouting causes voice abuse injury.  Many times the abuse is associated with the work environment, such as loud workspaces where personnel are required to speak loudly in order to communicate over background noise.  Treatment is simple and includes resting the voice, along with warm sialogogues for symptom relief.

Allergic reactions include a spectrum of symptoms from rashes to the most dangerous form, anaphylaxis, a potentially life threatening complication of allergies.  Any patient may become allergic to any medication, but it is important to recognize that reactions like nausea or vomiting are not allergic in nature.  Allergic reactions to any substance may present as an urticarial or itchy skin rash, commonly called hives, angioedema or swelling of the face or tongue, and sometimes difficulty breathing.  

If any patient describes symptoms of rapid onset of hoarseness associated with a skin rash and difficulty breathing or stridor, the patient should immediately be treated for anaphylaxis, a medical emergency.  Treatment includes:

• Airway stabilization if compromise is suspected

• Administration of subcutaneous epinephrine

• Antihistamine therapy with diphenhydramine.  

Occasionally, if the patient is unable to be intubated with an endotracheal tube or nasotracheal tube, it is necessary to open a percutaneous airway in order to ventilate the patient.  Common offending agents include many types of antibiotics, shellfish, nuts and inhaled particles.  The key to diagnosis is a history of ingestion of one of these commonly allergenic substances.  After the acute allergic reaction is treated and the offending agent is avoided in the future, there is no reason for transfer of the patient to a medical treatment facility.  No laboratory evaluation is necessary.

Laryngeal edema may also be the result of the inhalation of a chemical or other irritant such as smoke or fumes.  If a chemical ingestion or inhalation is suspected, it is important to consult with hazardous material disposal personnel in order to treat the exposure properly.  Airway management is always the first line of treatment.

In some cases, hoarseness may be a slowly developing symptom.  Oral or laryngeal cancers should be suspected in any case where the patient has a persistent change in voice that does not resolve over days or weeks.  Voice changes are usually a deepening in tone and pitch.  In some cases, the vocal cords themselves may become paralyzed.  These changes could be due to nodules or polyps on the vocal cords themselves, or by masses in the tissue surrounding the larynx, causing distortion of the anatomy, or by vocal chord paralysis via the recurrent laryngeal nerve.  Evaluation of slowly evolving hoarseness should include fiber optic laryngoscopy to assess vocal cord function. 

Head and neck cancers may include cancer of the:

• Throat

• Thyroid gland

• Lymph nodes

• Other soft tissues

Risk factors for oral and laryngeal cancers include use of smokeless tobacco, cigarette or cigar smoking, and pipe smoking.  Those exposed to radiation may be at a higher likelihood for development of blood-borne cancers like lymphoma, which may affect the lymph nodes of the neck, or for thyroid cancers.  

Initial evaluation for a suspected neck tumor is chest x-ray and soft tissue x-ray examination of the neck.  

Laboratory evaluations include complete blood count, blood chemistries and, if available, thyroid functions.  These studies can help delineate a paraneoplastic syndrome or thyroid dysfunction.  Additional evaluation may include examination with a fiber optic laryngoscope.  If a head and neck cancer is suspected in a patient and there is evidence of vocal chord paralysis, they should be transferred immediately to a treatment facility with the capability for magnetic resonance imaging and definitive treatment.

In the military setting, a common cause of upper airway maladies is tobacco smoking.  It is always important to advise patients that it is never safe to smoke, whether the use is occasional or repeated on a daily basis.  Patients should always be advised to quit smoking, and that medical therapy may be employed to reach that end.

References:

• Goroll: Primary Care Medicine, 3^rd Ed., Lippincott-Raven Publishers,1995 

• Rosen: Emergency Medicine: Concepts and Clinical Practice, 4th ed.,  Mosby-Year Book, 1998 

This section provided by LT Scott D. Pennington, MC, USNR

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Operational Medicine 2001
Health Care in Military Settings

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