Dysphonia

Background

• Dysphonia is an abnormality of phonation (hoarseness, voice change, or difficulty producing voice)
• The primary EM concern is whether dysphonia indicates potential airway compromise
• Acute onset dysphonia with dyspnea, stridor, or swallowing difficulty is an airway emergency
• Evaluate all patients with dysphonia for signs of upper airway obstruction before focusing on underlying diagnosis
• New-onset "hot potato voice" (muffled voice) suggests supraglottic process (peritonsillar abscess, epiglottitis, Ludwig's angina)

Clinical Features

History

• Onset: acute (hours) vs. subacute (days-weeks) vs. chronic (months)
• Associated symptoms: dyspnea, stridor, dysphagia, odynophagia, drooling, cough, fever
• Preceding events: intubation, surgery, trauma, illness, caustic exposure
• Voice use (singer, teacher — overuse)
• Smoking history (laryngeal cancer)
• Medication review (ACE inhibitors, inhaled corticosteroids)
• Neurologic symptoms (weakness, sensory changes, diplopia)

Physical Exam

• Assess airway first: listen for stridor, evaluate respiratory effort
• Oropharyngeal exam: peritonsillar swelling, floor of mouth elevation (Ludwig's angina), tongue swelling
• Neck: tracheal deviation, subcutaneous emphysema, mass, thyroid enlargement
• Cranial nerve exam (CN IX, X, XII)
• Voice quality: hoarse (vocal cord), muffled/"hot potato" (supraglottic), breathy (vocal cord paresis)

Red Flags

• Stridor or respiratory distress → imminent airway compromise
• Drooling, inability to swallow secretions → severe supraglottic process
• Acute onset after trauma → laryngeal injury
• Subcutaneous emphysema → tracheal or laryngeal disruption
• Rapidly progressive → angioedema, epiglottitis
• Associated neurologic deficits → stroke (lateral medullary), myasthenia gravis, botulism

Differential Diagnosis

Emergent/Urgent Causes

• Tracheal injury, laryngeal airway trauma, strangulation
• Posterior sternoclavicular dislocation (compressing recurrent laryngeal nerve)
• Iatrogenic recurrent laryngeal nerve injury: ENT, thyroid, or thoracic surgery; vagal nerve stimulator complication
• Foreign body aspiration
• Caustic ingestion, smoke inhalation injury
• Angioedema
• Epiglottitis, diphtheria
• Ludwig's angina, peritonsillar abscess, retropharyngeal abscess
• Aortic dissection (left recurrent laryngeal nerve compression)
• Stroke (lateral medullary infarction — Wallenberg syndrome)
• Botulism
• Myasthenia gravis
• Acute flaccid myelitis

Non-Emergent Causes

• Laryngitis (most common overall cause — viral)
• GERD / laryngopharyngeal reflux
• Post-intubation or post-laryngeal mask airway
• Voice overuse/misuse
• Vocal cord nodules or polyps
• Laryngeal cancer (chronic smoker with progressive hoarseness)
• Hypothyroidism / myxedema of vocal cords
• Inhaled corticosteroid use (candidal laryngitis)
• Note: voice may sound abnormal to you but be completely normal for that patient

Evaluation

Immediate

• Assess airway stability — if concerning, prepare for difficult airway management
• Do not agitate patient if concern for supraglottic pathology (especially in children)

Workup

• Testing depends on suspected underlying cause based on history and exam:
  • Soft tissue lateral neck X-ray: prevertebral widening (retropharyngeal abscess), epiglottic swelling (thumbprint sign)
  • CT neck with contrast: abscess, mass, trauma
  • CT angiography: if aortic dissection or vascular cause suspected
  • CT head/MRI brain: if stroke or intracranial pathology suspected
  • Nasopharyngoscopy / fiberoptic laryngoscopy: direct visualization of vocal cords (if available and patient is stable)

Laboratory

• Generally guided by suspected diagnosis
• CBC, blood cultures if infectious cause suspected
• Wound cultures if neck trauma with contamination
• Consider TSH for chronic hoarseness without clear cause

Management

Airway Management

• If airway compromise: secure airway using intubation with backup surgical airway plan
• Prepare for difficult airway — have smaller ETT sizes available
• Call ENT and anesthesia early for anticipated difficult airway
• See Difficult Airway Algorithm

Condition-Specific

• Angioedema: epinephrine, antihistamines; for ACE inhibitor-induced consider icatibant
• Epiglottitis: IV antibiotics, airway management in controlled setting
• Peritonsillar abscess: drainage, IV antibiotics
• Ludwig's angina: IV antibiotics, ENT consultation for possible surgical drainage
• Laryngeal trauma: ENT consultation, may require surgical repair
• Laryngitis: supportive care (voice rest, hydration, humidified air)
• Post-intubation: usually self-limited; ENT follow-up if persistent >2 weeks
• Stroke: activate stroke protocol

Disposition

Admit

• Any patient with airway compromise or risk of progressive obstruction
• Deep space neck infections requiring IV antibiotics and monitoring
• Laryngeal trauma
• Stroke with dysphonia
• Botulism or myasthenia gravis (risk of respiratory failure)

Discharge

• Laryngitis (viral): voice rest, hydration, follow-up if no improvement in 2-3 weeks
• Mild post-intubation dysphonia: ENT follow-up if persistent
• Return precautions: difficulty breathing, worsening voice changes, inability to swallow, drooling, fever
• Any hoarseness lasting >2-3 weeks should have ENT evaluation (rule out malignancy)

See Also

• Laryngitis
• Stridor
• Epiglottitis
• Angioedema
• Difficult Airway Algorithm