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Aetiopathology and clinical profile of patients with hoarseness.

BACKGROUND

The voice is a natural medium well adapted to communicate emotional contact, whereas speech is a cultural medium that is suitable to convey intellectual contact. Speech is the main skill, which separates human beings from other animals. [1] Hoarseness is a term used to describe change in voice quality and defined as a perceived rough, harsh or breathy quality to voice. The diseases causing hoarseness range from simple benign to the most malignant conditions. [2] Advent of microlaryngoscopy and endolaryngeal microsurgery as well as the recently introduced fibreoptic telescope have reduced our dependence on mirror examination and have greatly improved the diagnostic ability, especially in the cases of hoarseness. In India and other developing countries, the prevailing lower economic status, poor nutrition, poor general health of the population, different food habits, vocal habits, smoking and drinking habits, unhealthy environment and different social customs definitely influence the incidence of hoarseness. [3] Though the common cause of hoarseness is benign lesion than malignant disease, opportunity for the cure has often been lost by delay under a benign diagnosis. [4] Kleinsasser (1961) revolutionised the diagnosis and treatment of a laryngeal lesion using micolaryngoscopy. [2] Killian in 1932 described the surgical and optical properties of stroboscopic light. In 1961, Van Laden described use of electronic stroboscope. [5] In 1968, flexible fibreoptic laryngoscopy was introduced by Sawashima and Hirose. [6] In the early 1970s, Jako Strong and Vaughan described coupling of CO2 laser to surgical microscope and this provided greater precision and facility for endolaryngeal surgery. [7,8] As the aetiology of hoarseness is diverse and aetiological causes varies from country to country and centre to centre, the need for a study was felt to determine the aetiological distribution of the causes of hoarseness and the clinical profile of patients attending ENT outpatient department in T. D. Medical College, Alappuzha.

Objectives

To study the various causes of hoarseness of voice; to study the associated clinical features; to study various treatment modalities and outcome.

MATERIALS AND METHODS Study Setting

This study was conducted in the Department of ENT, T. D. Medical College, Alappuzha.

Study Duration

The study was conducted during a period of one and a half years, starting from April 2010 to September 2012. Study design: The study was a prospective descriptive study.

Study Population

Patients attending ENT OPD with complaints of hoarseness were studied. A total of hundred patients were studied.

Inclusion Criteria

Patients more than twelve years of age complaining of hoarseness for more than three weeks' duration.

Exclusion Criteria

Patients not willing to be part of study; Patients with Congenital disorders like cleft lip and cleft palate; patients presenting with nasal, nasopharyngeal, oropharyngeal diseases; patients who are already under treatment of a speech therapist.

Methods of Data Collection

This is a descriptive study of 100 patients who came to ENT outpatient department with complaints of hoarseness, meeting the aforementioned criteria. A detailed and careful history was taken with reference to the onset, progression, duration, age, occupation, habits and associated symptoms. A detailed proforma for clinical examination was made. A detailed ENT examination including indirect laryngoscopy was done according to the proforma. Flexible laryngoscopy was done when there was difficulty in visualising larynx with a mirror. Routine blood investigations and TSH were done whenever necessary. Chest x-ray PA view and x-ray soft tissue neck lateral view were taken when required. CT scan of neck was taken when indicated. Direct laryngoscopy followed by biopsy or microlaryngoscopy biopsy was taken whenever suspicious looking areas were seen. Biopsy specimens were sent for histopathological examination and results were reviewed. CT scan of neck was taken when indicated. Further treatment was given according to biopsy results. Patients were sent for speech therapy when indicated.

Analysis of Data

The data collected from the study was analysed using SPSS software version 16.

RESULTS

This is a descriptive study of 100 patients who came to the ENT outpatient department with complaints of hoarseness for more than three weeks' duration. Patients belonging to the seventh decade were the most common group affected with a total of 24 cases (24%). Fifth and sixth decades were next most prevalent groups constituting 18 cases each (18%). Younger age groups were less frequently affected with the least subjects coming from the second decade 6 cases (6%), (Table 1). Patients with hoarseness were males with a 72% incidence and the male-to-female ratio was found to be 2.5: 1.

Most of the patients in the study group were manual labourers (26). The next prominent group was constituted by the unemployed (17 cases). There was one singer in our study group. Housewives constituted (15) fifteen cases. Other jobs which normally do not use much voice including drivers, businessmen, etc. contributed fifteen cases (Table 2).

History of smoking was present in 38 cases. All 38 cases were males.

Malignant lesions were more common in patients who had a history of smoking. Of the total thirty-eight cases (38) that had a history of smoking, 26 (68.42%) developed malignancy; nineteen cases were diagnosed to have malignancy of larynx (19 - 50%) and seven cases developed malignancy of Hypopharynx (07 - 18.42%) and the remaining patients showed benign lesions (12 - 31.57%). Of the total sixty-two cases belonging to the non-smoking group, benign lesions were more common contributing 41 patients (35 - 56.45%); 16 cases of the non-smoking group did not need a biopsy during the study period. Malignant lesions of the larynx and Hypopharynx were seen in eleven cases (17.74%), (Table 4).

History of alcohol use was present in 38 cases (Table 5).

There was a history of alcoholism in 38 of the 100 patients. Malignant lesions were more commonly seen in patients who had a history of alcoholism. There were 26 (68.42%) patients among the 38 with history of alcoholism developed malignancy. Patients with benign lesions constituted 12 (31.87%). Among the alcoholic patients, 19 developed malignant lesions of the Larynx (50%) and 7 (18.42%) developed hypopharyngeal carcinoma. Among the 62 nonalcoholic patients, 38 (62.29%) showed benign lesions of the Larynx. Biopsy was not required in 16 cases of the nonalcoholic group and in 12 cases of alcoholic group; 16 (26.22%) patients among the non-alcoholic group were presenting with non-specific laryngitis (Table 5).

History of tobacco use (e.g. pan chewing, use of gutkha, etc.) was present in 16 cases (Table 6). Malignant lesions were seen in eleven cases out of the sixteen (68. 75%). Among the non-tobacco users, twenty-six cases developed malignancy (30.9%). Majority of this group were having benign lesions (Thirty-nine cases) contributing 46.4%.

A positive history of voice abuse was present in 22 cases. Benign lesions were more common in voice abusers contributing to 16/22 (72%). Of the twenty-two cases, 10 cases had vocal cord polyp and 5 patients had vocal cord nodule and 1 patient with vocal cord cyst (Table 7).

A positive history of GERD was assessed based on the symptoms of the patients; history was present in 20 percent cases like heartburn, retching, frequent hawking and sudden spasm, etc. (Table 8).

A positive history of pulmonary tuberculosis was present in one case. He had already taken 6 months ATT and was declared cured (Table 9).

Cough was the most common associated clinical feature and was present in 29 cases (Table 10).

Sore throat was the next most frequently associated symptom and was present in 16 cases (Table 11).

Nine patients presented with fever in the study (Table 12).

A positive history of dysphagia was present in ten percent cases. Of the 10 cases, 8 patients were diagnosed to have malignancy of Hypopharynx and two patients had malignancy of Larynx (Table 13).

Eight patients presented with neck node enlargement at the time of reporting to the OPD; 4 patients were diagnosed to have malignancy Larynx and the rest four had malignancy Hypopharynx (Table 14).

History of haemoptysis was present in three cases. All patients were diagnosed to have malignancy of larynx. Haemoptysis was present in ten percent cases of laryngeal malignancies (Table 15).

Associated noisy breathing was present in seven cases. All patients were having laryngeal malignancy. All patients who had stridor underwent tracheostomy during the study period (Table 16).

Benign lesions of larynx (63) were more common than malignant lesions (37). Indirect Laryngoscopy finding of a proliferative lesion in the larynx was the most common finding. Vocal cord polyp was seen in 26 cases, which was the next most common single finding; 12 patients showed a congested vocal cord and fourteen cases showed a vocal cord nodule. Benign lesions altogether constituted 63 cases. Hypopharyngeal malignancy was seen in 12 cases. Histopathological finding of a malignant lesion of larynx was the most common single finding in the study (25 cases). Vocal cord polyp was the next constituting 26 cases (Table 17).

The most common single modality of treatment used was microlaryngeal surgery, which was done in 35 cases. Outcome of treatment was measured subjectively at the end of treatment and more than half of the patients had a good result at the end of treatment; 52 cases reported that they got their original voice after treatment. In 21 cases, the quality of voice improved but they never attained the same quality as before. One patient reported a worsening of voice after treatment; 7 cases lost their normal voice, because of tracheostomy. In nineteen percent cases, there was no relief with treatment.

DISCUSSION

Hoarseness is obviously not a disease, but only the manifestation of a disease. The causes vary from self-limiting conditions like acute laryngitis to severe life-threatening malignancies. Benign conditions are more common than malignant lesions. Hoarseness lasting more than three weeks' duration obviously needs detailed evaluation and visualisation of larynx to rule out malignancy. Adults are more commonly affected with seventh decade being most commonly affected. In our study, the age of patients with hoarseness ranged from 13 - 82 yrs. (Mean 50.18 yrs.) and most patients (59%) were in the group of 21 - 60 yrs., which is considered as the most active period of life. Further patients in the 7lh decade (24%) constituted the single largest group. Our observation is supported by Clark AR, [9] Robert TS, [10] Malzahn K [11] and Shambu Baitha. [12] Praveen B [13] also reported the incidence in the age group of 20 - 50 yrs. to be 63.1%, 67.2% and 61.8% respectively. A male: female ratio of 2.57:1 was observed in this study. Other studies by Harmit M, [14] Sumith M [15] and Harold P [16] also showed male predominance. As far as occupation is concerned, manual labourers constituted the single largest group of patients (26%) in our study followed by jobless old age patients (17%) and housewives comprising of 15 cases. The high incidence of hoarseness among labourers in our study may be explained by the fact that our hospital being rural based caters mostly to the village population comprising of farm labourers. Brock [17] has mentioned that inhaled irritants, especially cigarette smoke as the most important predisposing factors for hoarseness. In the present study, a positive history of smoking was seen in 38 cases and alcoholism in 38 cases. Voice abuse was seen in 22 cases and a history of tobacco chewing in 16 cases; 20 cases had a positive history of GERD. In the study by Kameswaran S [18] and Chakravarthy A, [19] vocal abuses was noted in 72% of cases and in Kasim B [20] study smoking was noted in 25.45% of cases, chewing tobacco preparation was noted in 17.27% and alcohol drinking in 12.72%. James et al [21] have found vocal abuse in 56%. In this study, among males 64% were smokers and among females 38.24% had history of vocal abuse. The most common associated feature was cough followed by sore throat (16) and fever (9). Other associated features included difficulty in swallowing (10 cases) haemoptysis (3 cases) and neck swelling (8 cases). On indirect laryngoscopy examination (IDL) commonest finding was growth of vocal cords, consisting of 30 cases followed by vocal cord polyp which was seen in 27 cases. In the study by More PL, [22] congestion of vocal cords was noted in 34.54% and growth in only 9% of cases on IDL examination. In our study, biopsy was done in 80 cases and histopathological finding most commonly encountered was squamous cell carcinoma in 28 cases. Next most common histopathological finding was a vocal cord polyp seen in 26 cases. Fifty-two cases reported that they got their original voice after treatment. In 21 cases the quality of voice improved, but they never attained the same quality as before. Seven cases lost their normal voice because of tracheostomy. In nineteen cases, there was no relief with treatment.

CONCLUSION

Hoarseness usually affects older age groups. Males are more commonly affected than females. Manual labourers constitute the main occupational group of hoarse patients. Malignant lesions are more common in hoarse patients who have a history of smoking or alcoholism. Benign lesions are more common in patients with history of voice abuse. Cough was the most common associated clinical feature. Associated neck swelling or a history of dysphagia or haemoptysis is seen more commonly in malignant cases. Indirect laryngoscopy findings usually correlate well with histopathological findings. Majority of patients with malignant lesions have a poor outcome.

Elderly patients with hoarseness should be examined carefully to rule out malignancy, especially when there is a history of smoking or alcoholism. Biopsy need to be taken in a hoarse patient, if suspicious lesions are seen on indirect laryngoscopy. Public should be made aware that voice abuse is a common cause of hoarseness.

REFERENCES

[1] Alan GK, John H. Scott browns otolaryngology. 6th edn. Butterworth -Heinemann 1997:1-25.

[2] Cohen SM, Kim J, Roy N, et al. Prevalence and causes of dysphonia in a large treatment-seeking population. The Laryngoscope 2012;122(2):343-8.

[3] Nimish PP. Aetiological study of 100 cases of hoarseness of voice. Indian journal of otorhinolaryngology 1991;43(2):71-3.

[4] Chevalier J. Jackson diseases of ear nose and throat. 2nd edn. WB Sounders Company 1959:p 576.

[5] Dimitrios A, George P, John L. Highlights in the evolution of diagnosis and treatment of laryngeal cancer. Laryngoscope 2003;113(3):557-62.

[6] Alfio F. Neoplasms of larynx. 1st edn. Churchill Livingstone 1999:369-400.

[7] Alfio F. Neoplasms of larynx. 1st edn. Churchill Livingstone 1999:1-26.

[8] Lakshmi V, Singh PP, Manish G. Efficacy of video laryngostroboscopy in management of hoarseness. Asian journal of ENT 2004;2(4):9-16.

[9] Clarke AR, Thomas M. Nomenclature of voice disorders and vocal pathology. Otolaryngologics clinis of north 2000;33(5):1035-45.

[10] Robert TS. Evaluation of professional singers. Otolaryngologic Clinics of North America 2000;33(5):923-56.

[11] Malzahn K, Dreyer T, Glanz H, et al. Autofluorescence endoscopy in the diagnosis of early laryngeal cancer and its precursor lesions. Laryngeoscope 2002;112(3):488-93.

[12] Baitha S, Raizada RM, Singh AKK, et al. Predisposing factors and aetiology of hoarseness of voice. Indian journal of Otolaryngology and Head and Neck Suregry 2004;56(3):186-90.

[13] Pravin B, Lamartine D, Mesquite AM, et al. Primary tuberculosis of larynx. Indian journal of Tuberculosis 1997;44(4):211-2.

[14] Harney M, Timan C, Donnehey M, et al. Laryngeal tuberculosis: an important diagnosis. The jounal of Laryngeology and Otology 2000;114(11):878-80.

[15] Sumit M, Arunava S, Joydeep C. Laryngeal tuberculosis in MDR-TB presenting as laryngeal carcinoma. Indian journal of Otolaryngeology 2001;53(4):321-2.

[16] Brass LS, White JA. Granulomatous diseases of the larynx. J La State Med Soc 1991;143(1):11-4.

[17] Broek P. Acute and chromc laryngms. In: Scott brown's otolaryngology. 6th edn. Hlbbert J (edr). Oxford, Butterworth Hememann 19975;5:1-20.

[18] Kameswaran S, Mohan K. ENT disorders in a tropical environment. 1st edn. MERF publications 1979:39-45.

[19] Chakaravarti A, Shashidhar TB, Sahni JK. Primary amylodosis of larynx. Asian journal of ENT 2005;3(1):13-5.

[20] Kasim BA, Ali AB, Anitha B, et al. Laser in Treatment of laryngeal amyloidosis: a case report. Indian journal of Otolaryngeology 2001;53(2):152-4.

[21] James AK, Allen JB. The etiology and pathogenesis of laryngeal carcinoma. Otolaryngological clinics of North America 1997;30(1):1-19.

[22] More PL, Kim D, Selby G, et al. Detection of laryngeal carcinoma and epithelial hyperplastic laryngeal lesions via rapid-access dysphonia clinic. The journal of Laryngology and Otology 2004;118(8):633-6.

Susan James (1), Sunil S. Menon (2), K. Sasi Kumar (3), Dilip Das (4)

(1) Assistant Professor, Department of ENT, Government Medical College, Thiruvananthapuram.

(2) Assistant Professor, Department of Paediatric Surgery, Government Medical College, Thiruvananthapuram.

(3) Professor, Department of ENT, Government Medical College, Thiruvananthapuram.

(4) Postgraduate Student, Department of ENT, TD Medical College, Alappuzha.

Financial or Other, Competing Interest: None.

Submission 28-01-2017, Peer Review 21-02-2017,

Acceptance 27-02-2017, Published 06-03-2017.

Corresponding Author:

Dr. Susan James, Associate Professor, Department of ENT, Government Medical College, Thiruvananthapuram. E-mail: drsusanjames@gmail.com

DOI: 10.14260/jemds/2017/336
Table 1. Showing the Age Distribution of Patients (n = 100)

 Age Group    Frequency   Percent %

12--20 Yrs.       6          6.0
21- 30 Yrs.      11          11.0
31--40 Yrs.      12          12.0
41--50 Yrs.      18          18.0
51--60 Yrs.      18          18.0
61--70 Yrs.      24          24.0
71--80 Yrs.       9          9.0
81--90 Yrs.       2          2.0
   Total         100        100.0

Table 2. Showing the Occupations of the Patients (n = 100)

                     Frequency   Percent

    1. Singer            1         1.0
    2. Teacher           7         7.0
    3. Hawker           13         13.0
   4. Housewife         15         15.0
5. Manual Labourer      26         26.0
 6. No Occupation       17         17.0
    7. Others           15         15.0
    8. Student           6         6.0
      Total             100       100.0

Table 3. Showing Incidence of Smoking (n = 100)

                             Frequency   Percent

History of Smoking Present      38         38.0
History of Smoking Absent       62         62.0
          Total                 100       100.0

Table 4. Showing the Distribution of Laryngeal
Lesions in Smokers and Non-Smokers (n = 100)

      Observations          Non-Smokers 62   Smokers 38

   Carcinoma of Larynx        06--9.67%       19--50%
      Carcinoma of            05--8.06%      07--18.42%
       Hypopharynx
Benign Lesions of Larynx      35--56.45%     08--21.05%
 Non-Specific Laryngitis      16--26.22%     04--10.52%

Table 5. Showing the Incidence of Alcohol Intake (n = 100)

                                       Frequency    Percent

Valid History of Alcohol use Present       38         38.0
   History of Alcohol use Absent           62         62.0
               Total                      100        100.0

Table 6. Showing the Incidence of Laryngeal Lesions
among Alcoholic and Non-Alcoholic Groups (n = 100)

   Observation       Alcoholics--38   Non-Alcoholics--62

  Malignancy of         19--50%           06--9.67%
      Larynx

  Malignancy of        07--18.42%         05--8.06%
   Hypopharynx

Benign Lesions of      08--21.05%         35--56.45%
      Larynx

   Non-Specific       04--10. 52%         16--26.22%
    Laryngitis

Table 7. Showing the Incidence of Laryngeal
Disease in Patients using Tobacco (n = 100)

                                 Frequency   Percent

History of Tobacco use Present      16        16.0
History of Tobacco use Absent       84        84.0
            Total                   100       100.0

Table 8. Showing the Incidence of Voice Abuse (n = 100)

    Voice Abuse        Frequency   Percent

Voice Abuse Present       22        22.0
 Voice Abuse Absent       78        78.0
       Total              100       100.0

Table 9. Showing the Incidence of
History of GERD (n = 100)

                          Frequency   Percent

History of GERD Present      20        20.0
History of GERD Absent       80        80.0
         Total               100       100.0

Table 10. Showing the Incidence of
History of Tuberculosis (n = 100)

                                  Frequency   Percent

History of Tuberculosis Present       1         1.0
History of Tuberculosis Absent       99        99.0
             Total                   100       100.0

Table 11. Showing the Incidence of
Cough among the Patients (n = 100)

                  Frequency   Percent

 Cough Present       29        29.0
 Cough Absent        71        71.0
     Total           100       100.0

Table 12. Showing the Incidence of Sore
Throat among the Patients (n = 100)

                       Frequency   Percent

Sore Throat Present       16        16.0
 Sore Throat Absent       84        84.0
       Total              100       100.0

Table 13. Showing the Incidence of
Fever among the Patients (n = 100)

                        Frequency   Percent

Valid   Fever Present       9         9.0
        Fever Absent       91        91.0
            Total          100       100.0

Table 14. Showing the Incidence of Dysphagia (n = 100)

                     Frequency   Percent

Dysphagia Present       10        10.0
 Dysphagia Absent       90        90.0
      Total             100       100.0

Table 15. Showing the Incidence of Neck Swelling (n = 100)

                         Frequency   Percent

Neck Swelling Present        8         8.0
 Neck Swelling Absent       92        92.0
        Total               100       100.0

Table 16. Showing the Incidence of Haemoptysis (n = 100)

                       Frequency   Percent

Haemoptysis Present        3         3.0
 Haemoptysis Absent       97        97.0
       Total              100       100.0

Table 17. Showing the Incidence of Stridor (n = 100)

                  Frequency   Percent

Stridor Present       7         7.0
Stridor Absent       93        93.0
     Total           100       100.0

Table 18. Showing the Incidence of Benign
and Malignant Lesions of the Study (n = 100)

                                      Frequency   Percent

1. Normal                                 1         1.0
2. Congested Vocal Cord                  12        12.0
3. Vocal Cord Polyp                      26        26.0
4. Vocal Cord Nodule                     14        14.0
5. Proliferative Lesion Larynx           25        25.0
6. Proliferative Lesion Hypopharynx      12        12.0
7. Impaired Vocal Cord Mobility           5         5.0
8. Vocal Cord Keratosis                   2         2.0
9. Vocal Cord Cyst                        3         3.0
Total                                    100       100.0

Table 19. Showing the Treatment
Outcome among the Patients (n = 100)

               Frequency   Percent

  Relieved        52        52.0
  Improved        21        21.0
 No Change        19        19.0
  Worsened         1         1.0
Tracheostomy       7         7.0
   Total          100       100.0
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Title Annotation:Original Research Article
Author:James, Susan; Menon, Sunil S.; Kumar, K. Sasi; Das, Dilip
Publication:Journal of Evolution of Medical and Dental Sciences
Article Type:Report
Date:Mar 6, 2017
Words:3539
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