Hoarseness
Hoarseness, also referred to as dysphonia, is the most common symptom of laryngeal diseases and often indicates that the lesion has affected the vocal cords. Its severity can vary significantly, ranging from a slight change in voice quality or pitch reduction in mild cases to severe hoarseness or even complete loss of voice in severe cases. The common causes of hoarseness are as follows:
Nerve Damage Affecting Vocal Cord Movement
Recurrent Laryngeal Nerve Damage
This is the most common cause and can result from cervical trauma, thyroid surgery, malignant thyroid tumors, malignancies of the cervical esophagus, mediastinal tumors, and other conditions that damage this nerve.
Vagus Nerve Damage
The recurrent laryngeal nerve is a branch of the vagus nerve. Damage to the vagus nerve prior to the branching of the recurrent laryngeal nerve can also impair the recurrent laryngeal nerve itself. Causes include cervical trauma, vagal nerve schwannomas, and nasopharyngeal carcinoma invading the parapharyngeal space where the vagus nerve resides.
Superior Laryngeal Nerve Damage
Although relatively rare in clinical settings, trauma and other causes may weaken vocal cord tension by affecting this nerve, leading to a reduction in vocal pitch.
Intrinsic Laryngeal Pathologies
When lesions of the larynx impact the vocal cords, hoarseness may occur.
- Congenital malformations of the larynx, such as congenital laryngeal webbing or vocal cord hypoplasia (e.g., vocal cord sulcus).
- Inflammatory diseases of the larynx, including nonspecific and specific inflammations such as acute laryngitis, chronic laryngitis, laryngeal tuberculosis, laryngeal diphtheria, or laryngeal syphilis.
- Benign proliferative lesions of the vocal cords, such as vocal cord polyps, nodules, cysts, or contact granulomas.
- Precancerous lesions of the larynx, such as vocal cord leukoplakia, keratosis, or pachydermia.
- Benign laryngeal tumors, such as papillomas, fibromas, or hemangiomas.
- Malignant laryngeal tumors, including laryngeal carcinoma or sarcoma.
- Laryngeal trauma, including injuries to cartilage and soft tissues or dislocation of the cricoarytenoid joint.
- Metabolic diseases of the larynx, such as laryngeal amyloidosis.
Hysterical Hoarseness
Other Causes
Changes in hormone levels can lead to hoarseness during voice changes, menstrual cycles in women, and aging.
Inspiratory Dyspnea
The respiratory process consists of an inspiratory phase and an expiratory phase. Inspiratory dyspnea refers to difficulty in inhalation and is characterized by increased effort during inspiration and prolonged inspiratory time. Because air cannot easily enter the lungs during inspiration, negative pressure within the thoracic cavity increases, causing retraction of soft tissues around the chest wall, such as suprasternal, supraclavicular, and subxiphoid depressions. Clinically, this phenomenon is referred to as the "three-retraction sign." In severe cases, intercostal spaces may also show retractions. Inspiratory dyspnea is commonly caused by obstructive lesions of the larynx and trachea, as well as occasionally by obstructive lesions of the hypopharynx and oropharynx.
When difficulty occurs during exhalation, it is referred to as expiratory dyspnea. This is characterized by increased expiratory effort, prolonged expiratory time, and labored exhalation. Patients often adopt a sitting position with their head leaning forward to alleviate the degree of expiratory dyspnea, which is commonly seen in individuals with bronchial asthma.
If difficulty occurs during both inhalation and exhalation, it is referred to as mixed dyspnea. This is often associated with diseases that reduce the area available for pulmonary respiration, such as pneumonia, pleural effusion, and pneumothorax.
The common laryngeal conditions that cause inspiratory dyspnea include the following:
Congenital Diseases of the Larynx
Examples include congenital laryngeal webbing, congenital laryngeal cartilage malformations, and laryngomalacia.
Inflammatory Diseases of the Larynx
These include acute epiglottitis, acute laryngitis in children, acute laryngotracheobronchitis in children, laryngeal diphtheria, and laryngeal tuberculosis.
Laryngeal Tumors
Benign laryngeal tumors, such as papillomas, fibromas, or hemangiomas, and malignant laryngeal tumors, such as laryngeal carcinoma.
Other Laryngeal Conditions
These include laryngeal edema, foreign bodies in the larynx, laryngeal spasms, large vocal cord polyps or giant epiglottic cysts, closed or open laryngeal trauma, and bilateral recurrent laryngeal nerve paralysis.
Laryngeal Stridor
Laryngeal stridor refers to a distinct sound produced when air is forcefully inhaled through a narrowed larynx or trachea due to obstruction. In clinical settings, the presence of inspiratory laryngeal stridor often indicates laryngeal obstruction and is frequently associated with inspiratory dyspnea.
Common conditions that cause laryngeal stridor include congenital laryngeal stridor, congenital laryngeal web, acute laryngitis or acute laryngotracheobronchitis in children, acute epiglottitis, laryngeal spasm, traumatic laryngotracheal stenosis, bilateral vocal cord paralysis, laryngeal edema, benign laryngeal tumors such as laryngeal papillomas, and malignant laryngeal tumors such as advanced laryngeal carcinoma.
Laryngeal Pain
Laryngeal pain (laryngalgia) can range from mild discomfort to severe pain. The common causes of laryngeal pain include:
- Acute laryngeal inflammations, such as acute epiglottitis, acute laryngitis, and laryngeal perichondritis (often secondary to trauma or radiation therapy).
- Joint pathologies of the larynx, such as cricoarytenoid arthritis.
- Laryngeal trauma or foreign body presence.
- Advanced malignant laryngeal tumors.
- Nonspecific laryngeal inflammations, such as laryngeal tuberculosis.
Hemoptysis
Hemoptysis refers to bleeding from the larynx or lower respiratory tract (trachea and lungs) that is expelled through the mouth. The quantity of blood can vary, ranging from blood-tinged sputum to significant amounts of bright red blood. Hemoptysis is often preceded by symptoms such as throat irritation and coughing. Its differentiation from hematemesis, which originates from gastrointestinal bleeding, is clinically important.
Table 1 Key points for differentiating hemoptysis and hematemesis
Common laryngeal causes of hemoptysis include laryngeal carcinoma, laryngeal tuberculosis, laryngeal hemangiomas, and laryngeal trauma or foreign bodies. Hemoptysis caused by laryngeal diseases needs to be distinguished from conditions of the lower respiratory tract, such as bronchiectasis, lung cancer, and pulmonary tuberculosis, which are often accompanied by associated bronchial or pulmonary symptoms.
Dysphagia
Dysphagia refers to difficulty in the process of swallowing food or liquids from the oral cavity to the stomach. Its primary causes include:
- Structural abnormalities affecting swallowing function.
- Laryngeal pain that worsens during swallowing, causing patients to avoid swallowing.
- Neurological diseases affecting the larynx, leading to impaired airway protection, which may result in choking, aspiration, or mis-swallowing during meals.
The laryngeal conditions that can cause dysphagia include the following:
- Acute Epiglottitis: This can cause severe laryngeal pain that intensifies during swallowing, leading to patients avoiding swallowing altogether.
- Laryngeal Perichondritis and Abscesses: These conditions are often secondary to laryngeal trauma or radiation therapy and may cause swallowing difficulties due to pain.
- Laryngeal Herpes: Ulceration caused by ruptured lesions can lead to severe laryngeal pain and swallowing difficulties.
- Laryngeal Tuberculosis: Ulceration in areas such as the epiglottis or the arytenoid region may result in significant laryngeal pain and subsequent swallowing difficulties.
- Cricoarytenoid Arthritis: Severe inflammation can lead to pain-induced swallowing difficulty.
- Advanced Laryngeal Carcinoma: Tumor ulceration and tissue necrosis may cause laryngeal pain and dysphagia. Structural abnormalities due to tumor invasion of the hypopharynx can also lead to swallowing obstruction.
- Laryngeal Nerve Paralysis: This can be divided into central and peripheral causes:
- Central Causes: Conditions such as vertebrobasilar artery atherosclerosis, posterior inferior cerebellar artery thrombosis, multiple sclerosis, and brainstem tumors can damage the nucleus ambiguus and other brainstem structures.
- Peripheral Causes: Conditions such as nasopharyngeal carcinoma, vagus nerve schwannomas, and jugular paragangliomas can damage the vagus nerve, leading to laryngeal nerve paralysis. Cervical surgeries, trauma, or damage to the recurrent laryngeal nerve or superior laryngeal nerve can also result in laryngeal nerve paralysis, allowing food and saliva to enter the trachea during swallowing, causing coughing and swallowing difficulty. Structural damage may also lead to swallowing obstruction.
- Laryngeal Trauma: Open or closed laryngeal injuries, laryngeal burns, or scalding injuries can cause swallowing difficulties due to pain or structural damage.