|Year : 2015 | Volume
| Issue : 2 | Page : 69-73
Pattern of persistent hoarseness at the University of Benin Teaching Hospital
AL Okhakhu1, NH Emma-Nzekwue2
1 Department of Ear, Nose and Throat, University of Benin Teaching Hospital, Benin, Nigeria
2 Department of Surgery, Delta State University Teaching Hospital, Oghara Delta, Nigeria
|Date of Web Publication||16-Jun-2015|
Dr. A L Okhakhu
Department of Ear, Nose and Throat, University of Benin Teaching Hospital, Benin City
Source of Support: None, Conflict of Interest: None
Background: Hoarseness refers to a change in voice quality that can impair a patient's quality of life and is usually subject to misdiagnosis. It is sometimes a pointer to a more sinister pathology especially when it is unremitting. This study seeks to establish the pattern of hoarseness as seen at the University of Benin Teaching Hospital, Benin City, Nigeria.
Patients and Methods: A prospective review of all new consecutive patients who presented with complaints of hoarseness to the Ear, Nose, and Throat Department of the University of Benin Teaching Hospital from January 2012 to September 2013. The instruments used were a proforma, laryngoscopy, and biopsy where applicable. Histopathological examination of biopsied specimens and treatment outcome were the variables.
Results: A total of 75 patients, 51 (68%) males and 24 (32%) females giving M:F ratio of 2:1, were seen during the period of the study. Their age ranged from 7-78 years with a mean age of 47 years. A large proportion of the patients presented for otolaryngologic review more than 24 months after the onset of symptoms. Thirty-three (44%) patients used alcohol while 14 (18.7%) smoked cigarettes. Malignant conditions were responsible for hoarseness in 25 (33.3%) while benign 22 (29.3%) and inflammatory or infective conditions 24 (32%) and vocal cord paralysis 4 (5.3%) were also common.
Conclusion: The causes of hoarseness vary from benign to malignant lesions. The observed delay in laryngoscopy portend poorer outcome for patients with malignant diseases.
Keywords: Causes, hoarseness, laryngeal tumor, laryngeal, malignancy, presentation, vocal cord paralysis
|How to cite this article:|
Okhakhu A L, Emma-Nzekwue N H. Pattern of persistent hoarseness at the University of Benin Teaching Hospital. Arch Int Surg 2015;5:69-73
| Introduction|| |
Hoarseness or dysphonia refers to a change in the voice quality of an individual that impairs social and professional communication. Hoarseness can significantly affect a person's means of livelihood and in general terms, one's quality of life. It is estimated that about 1/3 of the population has experienced impaired voice production at one point in their lives. , Hoarseness is said to be commoner among people who tend to be more talkative for example teachers, salesmen, mothers of young children, preachers, and voices-over users. , Teachers have been found to have a high incidence (58%) of dysphonia. 
Transient hoarseness is common and usually associated with infectious processes affecting the upper respiratory tract. Persistent, unremitting, progressive hoarseness on the other hand carries a more sinister connotation. Most cases of hoarseness are remitting and do not progress. This group of patients with acute onset hoarseness may never require a laryngoscopic evaluation. However, hoarseness persisting for more than 3 weeks and with features of no remittance requires a laryngoscopic evaluation.  Guidelines have emerged mandating laryngoscopy for dysphonia that fails to resolve within 3 months.  There are delays to the attainment of this guideline due to late presentation of patients and the relative unavailability of personnel trained in the art of laryngoscopy. Patients with chronic laryngeal symptoms were more likely to be referred to otolaryngologists than those with acute conditions which usually resolve.  Many factors have been found to affect the referral rates to otolaryngological care by primary care physicians and these include the patient's age, gender, and geographic location.  These factors can result in a delay in the diagnosis and subsequently treatment of patients with malignant laryngeal pathology.
Laryngeal tuberculosis is a cause of hoarseness that appears to be re-emergent because of the increasing prevalence of Acquired Immune Deficiency Syndrome.  It is usually secondary to active pulmonary tuberculosis and presents with non-specific symptoms such as hoarseness, odynophagia, and dysphagia.  It is an important differential as it is often confused with laryngeal carcinoma on laryngoscopy. , Laryngeal tuberculosis is contagious and this poses a risk of transmission of the bacillus to health care providers.  Common causes of hoarseness persisting beyond 3 weeks include inflammatory processes, systemic disorders, neuromuscular, psychiatric disorders, and neoplasms. Recurrent respiratory papillomatosis is a rare but potentially dangerous cause of hoarseness especially in children.  It is the most common benign laryngeal neoplasm in children and it is a result of infection with the human papilloma virus types 6 and 11.  If undetected, it can lead to upper airway obstruction. , Thyroid disease is prevalent in our setting. Hoarseness can occur following thyroid surgery because of injury to the recurrent laryngeal nerve.  An often overlooked cause of hoarseness is laryngopharyngeal reflux disease (LPR). Laryngopharyngeal reflux and gastroesophageal reflux disease (GERD) are highly prevalent in the general population. It is estimated that 10% of Americans have heartburn daily while 60% have heartburn occasionally. There is now a growing awareness about these diseases among physicians. ,,,,,
There is a need to know the pattern of presentation of patients with persistent hoarseness in order to evaluate the attendant morbidity associated with predictors of unfavorable outcome. The present study seeks to establish the pattern of hoarseness as seen at the Department of Otorhinolaryngology, University of Benin Teaching Hospital, Benin City, Nigeria.
| Patients and Methods|| |
This was a prospective descriptive study of consecutive patients presenting with change in the quality of their voice to the services of the Otorhinolaryngology Department, University of Benin Teaching Hospital between January 2012 and September 2013. Information obtained from these patients after a written consent and ethical clearance from the Hospital's ethics and research committee, included age, sex, occupation, duration of symptoms, history of alcohol or tobacco use, previous diagnosis and treatment if any, physical examination findings at presentation, laryngoscopic findings, histology result of tissue biopsy taken for those who had mass lesions, treatment given, and outcome. This information was prospectively entered into a proforma specifically designed for the study. The data obtained was analyzed using statistical package for social sciences (SPSS R ) version 16.
| Results|| |
A total of 75 patients, 51 (68%) males and 24 (32%) females were seen during the period of the study. Male: Female ratio 2:1. Their age ranged between 7-78 years with a mean age of 47 ± 17.75 years. A large proportion of the patients (25.3%) had been hoarse for over 24 months before presentation to otolaryngologists [Figure 1]. All of our patients had sought medical care at a peripheral health center and have also used over the counter medications prior to presentation at the ear, nose, and throat clinic. The main diagnosis at these peripheral centers was asthma in 65 (86.7%) while only 10 (13.3%) had correct diagnosis at the peripheral center. Final diagnoses at the otolaryngology clinic revealed 50 (66.7%) were inflammatory or benign lesions and 25 (33.3%) malignant lesions [Figure 2]. The commonest diagnosis made at the peripheral health facility was asthma and many of the patients had been on anti-asthma medication for several months without improvement. Thirty-three (44%) of the patients used alcohol while 14 (18.7%) smoked cigarettes. The 14 patients who smoked used on average between 10 sticks to a packet a day with varying duration of tobacco use. Some had smoked for more than 20 years and only stopped on account of ill health. Of the 25 patients with malignancy, 16 drank alcohol while 9 smoked cigarettes regularly. The 9 patients with malignancies who smoked tobacco also drank alcohol regularly. The occupation of the patients showed that 40 (53.3%) were professionals requiring the use of the voice including teachers and lecturers while 35 (46.7%) were artisans.
The causes of hoarseness are shown in [Table 1]. A total of 18 patients presented with upper airway obstruction necessitating tracheostomy. Two of these were secondary to recurrent respiratory papillomatosis while 16 were for malignant upper airway obstruction. Cervical lymphadenopathy was present in 7 (9.3%) of the patients while 68 (90.7%) had no palpable nodal disease. Findings on laryngoscopy showed a laryngeal mass lesion in 54 (72%) of the patients. The infective and inflammatory causes of hoarseness included chronic laryngitis and laryngopharyngeal reflux. The malignant lesions were predominantly squamous cell carcinoma of the larynx 20 (80%). Others were Hodgkin's lymphoma 1 (4 %) and hypopharyngeal carcinoma 4 (16%). All the patients in the malignant group presented with advanced stage disease. A total 16 patients with squamous cell carcinoma presented with upper airway obstruction necessitating emergency tracheostomy.
The treatment included antibiotics, anti-inflammatory agents, vocal hygiene, and voice rest with resolution of symptoms in the infective group and some with benign lesions. Voice therapy was also instituted with varying degrees of response for patients with vocal nodules. Surgery was the mainstay of treatment in those with benign and malignant lesions and consisted of excision of vocal nodules, excision of laryngeal polyp and microlaryngoscopic clearance of recurrent respiratory papilloma. The patients with squamous cell carcinoma of the larynx presented in advanced stage disease. The main surgical interventions undertaken for those with histologically confirmed squamous cell carcinoma was tracheostomy for relieve of upper airway obstruction and 6 patients had total laryngectomy and postoperative radiotherapy. One of the post laryngectomy patient succumbed to the disease while 5 are still being followed up in our outpatient department. Some of them declined surgery and opted for radiotherapy. Better outcome was observed in those who had surgery primarily followed by post-operative radiotherapy.
| Discussion|| |
Hoarseness is a common presentation for which patients are referred to the Otorhinolaryngologist. Our study of the pattern of hoarseness revealed a male preponderance among the study population. This is at variance with studies which reported hoarseness to be commoner in women, ,, but similar to findings by Nwaorgu et al.  and in other studies of malignant laryngeal conditions where male preponderance to the degree of M:F ratio of 12:1 was reported. ,, Hoarseness cuts across all age-groups and this is reflected in this study as the age range was 7-78 years. Our study revealed that hoarseness was as a result varying pathologies and this is similar to findings by other researchers. ,,, The cause of hoarseness is often multifactorial ranging from infective, inflammatory, or benign lesions to malignant lesions. This was similarly observed in our study. It is noteworthy that a majority of the patients presented after 24 months following the onset of symptoms. This is similar to findings by Nwaorgu et al.  and Amusa in Ile-ife.  This late presentation impacts negatively on prognosis especially in patients with malignant conditions.  Misdiagnosis of the cause of hoarseness by primary care providers was high in our study with 86.7% of the patients being diagnosed as having asthma and placed on various anti-asthmatic medication. This high rate of misdiagnosis may be due to failure to visualize the larynx. There is need to be guided by the dysphonia management guidelines to forestall situations like these. The major cause of community acquired hoarseness is viral and typically symptoms last from 1-3 weeks.  Hoarseness persisting beyond this period requires that the larynx should be visualized. This is necessary because a more sinister differential like laryngeal carcinoma may be responsible for the dysphonia. Moreover, delays in the diagnosis of laryngeal cancer leads to higher stages of diseases at diagnosis and consequently poorer survival. 
Tobacco use among the studied population was 18.7% while alcohol use was higher at 44% with most claiming to be occasional or social alcohol drinkers. Alcohol and tobacco are recognized risk factors for carcinoma of the larynx. However, our study revealed that of those with malignant lesions, 9 were both cigarette smokers and alcohol drinkers. This finding further reinforces the role of irritants in laryngeal cancer.  This is at variance with findings by other workers. ,, Laryngopharyngeal reflux disease is a common cause of hoarseness yet it is often unrecognized. , Although the means for objective reflux assessment is not available in our center, diagnosis of laryngopharyngeal reflux is based on history and physical examination findings of edema, erythema, hyperaemia, granulation tissue, granuloma formation, or thick mucus. , There is need to consider laryngopharyngeal reflux disease in the work up of patients presenting with hoarseness. ,,
The time from onset of symptoms to presentation to otolaryngologic care was greater than 24 months in a large proportion of the patients and this is at variance with findings by Cohen et al. who reported <1 month to >3 months.  of note is that 18.7 % of the patients presented within 3 months of onset of symptoms. Similar delays in presentation was noted in studies from other parts of Nigeria. ,, What is bothersome is the fact that many of these patients had been treated for prolonged periods by their primary care physicians without prior visualization of the larynx. The high 65 (86.7%) rate of misdiagnosis at the peripheral centers encountered in this study is worrisome. This is because valuable time is lost and this is particularly disturbing in malignant conditions of the larynx. This is similar to findings in a study where all the patients were initially diagnosed as asthmatics with a final diagnosis of carcinoma of the larynx.  This may be ameliorated if medical students are exposed to longer periods of posting in ear, nose and nose and general practitioners have continuing medical education about the need for laryngoscopy and early referrals for hoarseness persisting for more than 3 weeks. Vocal cord paralysis following thyroidectomy was the iatrogenic source of hoarseness in our study. This is a recognized complication  and may be more likely to occur if surgery is for malignancy of the thyroid and repeat thyroidectomy for recurrent disease.  The patients who developed vocal cord palsy in our study were 4 and the indications for thyroidectomy were huge multinodular goitre in 3 and thyroid malignancy in 1. There was failure to carry out preoperative laryngoscopy in one of the patients with a huge multinodular goiter who had her surgery at a private facility. There is need to evaluate the state of the vocal cords preoperatively in all patients undergoing thyroidectomy. Intra-operative recurrent laryngeal nerve monitoring may lead to a reduction in the incidence of postoperative laryngeal nerve injury. 
Tuberculosis of the larynx can cause a diagnostic dilemma. It tends to present like a neoplastic lesion rather than an infectious lesion.  The patients in our study did not have features suggestive of tuberculosis and the diagnosis was established following histopathologic examination of the laryngeal specimen which showed chronic inflammation with caseating granulomas. These patients did not present with cough hence were not requested to have sputum examined for acid fast bacilli. They were commenced on anti-tuberculosis chemotherapy. The lesions the patients with tuberculosis had were similar in macroscopic appearance to those of malignant condition. This is similar to other reports of tuberculosis of the larynx masquerading as carcinoma of the larynx. ,, The human immunodeficiency virus infection has a myriad of otolaryngologic manifestations and hoarseness is the major presentation with laryngeal involvement. Neoplasms of the larynx appear with increased frequency in human immunodeficiency virus (HIV)-positive patients.  In patients with HIV, the possibility of neoplasms in the laryngeal region must be borne in mind to forestall delays in diagnosis.
| Conclusion|| |
Hoarseness is a relatively common manifestation of laryngeal disease which is often subject to misdiagnosis in the absence of laryngoscopy. The causes of hoarseness range from inflammatory through benign to malignant lesions. Delayed presentation is a prominent feature which can adversely affect outcome. All cases of hoarseness persisting beyond 3 weeks should be subjected to laryngoscopy.
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[Figure 1], [Figure 2]