What is the comprehensive approach to managing patients with voice hoarseness, stridor, and stertor, including anatomy, physiology, diagnosis, and emergency management?

Comprehensive Management of Voice Hoarseness, Stridor, and Stertor

Definitions and Pathophysiology

Voice hoarseness (dysphonia) should be diagnosed in patients with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life. 1

• Hoarseness/Dysphonia: Altered voice quality perceived as rough, breathy, strained, or with abnormal pitch
• Stridor: Harsh, high-pitched respiratory sound caused by turbulent airflow through a partially obstructed airway
  • Types: Inspiratory (supraglottic/glottic obstruction), Expiratory (tracheal/bronchial obstruction), Biphasic (subglottic/glottic obstruction)
• Stertor: Low-pitched snoring sound caused by partial obstruction of the nasopharynx or oropharynx

Anatomical Considerations

Triangles of the Neck

• Anterior Triangle: Bounded by midline, mandible, and sternocleidomastoid
  • Contains: Carotid arteries, jugular veins, cranial nerves (IX-XII), larynx, thyroid
• Posterior Triangle: Bounded by sternocleidomastoid, trapezius, and clavicle
  • Contains: Brachial plexus, subclavian vessels, spinal accessory nerve

Danger Triangle of the Face

• Area from corners of mouth to bridge of nose
• Red Flags: Infections in this area can spread to cavernous sinus via facial vein
• Clinical Red Flags: Fever, rapid progression, orbital cellulitis, altered mental status

Laryngeal Anatomy

• Framework: Thyroid, cricoid, arytenoid cartilages
• Vocal Folds: True and false vocal folds
• Glottis: Space between vocal folds
• Subglottis: Area below vocal folds to inferior border of cricoid cartilage
• Supraglottis: Area above vocal folds including epiglottis, aryepiglottic folds

Respiratory Muscles

• Normal Respiration: Diaphragm (primary), external intercostals
• Forced Respiration: Sternocleidomastoid, scalenes, pectoralis minor, serratus anterior (inspiration); internal intercostals, abdominal muscles (expiration)

Differential Diagnosis of Hoarse Voice

Acute Causes (< 4 weeks)

• Viral/bacterial laryngitis
• Vocal fold hemorrhage
• Acute vocal fold trauma
• Foreign body

Chronic Causes (> 4 weeks)

• Neoplastic: Laryngeal cancer, vocal fold lesions
• Inflammatory: Chronic laryngitis, reflux laryngitis
• Neurologic: Vocal fold paralysis, spasmodic dysphonia
• Systemic: Hypothyroidism, amyloidosis
• Functional: Muscle tension dysphonia

Cancer Red Flags 1

• Progressive hoarseness >4 weeks
• Dysphagia/odynophagia
• Hemoptysis
• Unilateral otalgia
• Neck mass
• Weight loss
• Tobacco/alcohol history
• Age >50 years

Assessment Algorithm

1. History and Physical Examination 1

   • Duration and progression of symptoms
   • Voice usage patterns and occupational demands
   • Smoking (pack-years = packs/day × years smoked)
   • Alcohol consumption (1 standard unit = 8g alcohol; whisky glass ≈ 1-2 units)
   • Associated symptoms: dysphagia, odynophagia, dyspnea, weight loss

2. Neck Examination

   • Palpate for masses, lymphadenopathy
   • Assess for tracheal tug (downward movement of trachea during inspiration - indicates airway obstruction)
   • Evaluate thyroid gland

3. Laryngoscopy 1

   • Timing: May be performed at any time for dysphonia
   • Must be performed when:
     • Dysphonia fails to resolve within 4 weeks
     • Serious underlying cause is suspected
     • Before prescribing voice therapy

4. Imaging 1

   • CT/MRI: Not recommended prior to laryngoscopy
   • Indications for imaging:
     • After laryngoscopy shows suspicious lesion
     • Evaluate extent of known pathology
     • Assess for invasion or metastasis

5. Nasendoscopy/Laryngoscopy

   • Definition: Examination of nasal cavity, pharynx, and larynx using flexible or rigid endoscope
   • Indications: Persistent hoarseness, stridor, suspected mass, preoperative assessment

Emergency Management of Airway Distress

Assessment of Severity

• Mild: Hoarseness with normal breathing
• Moderate: Stridor with increased work of breathing
• Severe: Stridor at rest, decreased air entry, accessory muscle use, altered consciousness

Emergency Management Algorithm

1. Immediate Actions for Severe Distress:

   • Position patient upright
   • Administer high-flow oxygen
   • Prepare for possible airway intervention

2. Medication Management:

   • Adrenaline (Epinephrine):

     • Indications: Acute laryngeal edema, anaphylaxis, croup
     • Route: Nebulized (5mL of 1:1000 solution) for upper airway edema; IM (0.01mg/kg, max 0.5mg) for anaphylaxis
     • Mechanism: Vasoconstriction, bronchodilation, reduced mucosal edema

   • Dexamethasone:

     • Indications: Airway edema, croup, post-extubation stridor
     • Dosage: 0.6mg/kg (max 16mg)
     • Mechanism: Reduces inflammation and edema of the glottis by inhibiting inflammatory mediators

3. Airway Interventions:

   • Tracheostomy:
     • Indication: Severe upper airway obstruction not manageable by other means
     • Procedure: Surgical creation of opening in anterior trachea between 2nd-3rd tracheal rings

Management of Specific Conditions

Stridor Management

• Inspiratory Stridor: Suggests supraglottic/glottic obstruction

  • Common causes: Epiglottitis, foreign body, angioedema, tumor
  • Management: Secure airway, identify and treat cause

• Expiratory Stridor: Suggests tracheal/bronchial obstruction

  • Common causes: Foreign body, tracheal stenosis, tracheomalacia
  • Management: Bronchoscopy may be needed for diagnosis and treatment

• Biphasic Stridor: Suggests fixed obstruction at subglottic/glottic level

  • Common causes: Subglottic stenosis, vocal fold paralysis, tumor
  • Management: May require surgical intervention

Stertor Management

• Causes: Adenotonsillar hypertrophy, macroglossia, nasal obstruction
• Management: Identify and address underlying cause

Voice Disorders Management

1. Conservative Measures:

   • Voice rest
   • Adequate hydration
   • Avoid irritants (smoking, alcohol)

2. Voice Therapy 1:

   • Indications: Most benign vocal fold lesions, muscle tension dysphonia
   • Approach: Should be prescribed after laryngoscopy
   • Techniques: Resonant voice therapy, vocal function exercises

3. Medical Management:

   • Antireflux Therapy: Not recommended for isolated dysphonia without laryngoscopy 1
   • Corticosteroids: Not routinely recommended prior to laryngoscopy 1
   • Antibiotics: Not routinely recommended for dysphonia 1

4. Surgical Management:

   • Indications: Suspected malignancy, symptomatic benign lesions not responding to conservative management, glottic insufficiency 1
   • Procedures: Microlaryngoscopy with excision, vocal fold injection, thyroplasty

Multidisciplinary Team Approach

• Core MDT Members: Otolaryngologist, speech-language pathologist, radiologist, pathologist
• Extended MDT: Oncologist, radiation oncologist, respiratory physician, gastroenterologist

Cancer Management

• Staging: TNM classification for laryngeal cancer
• Common Metastases: Regional lymph nodes, lung, liver, bone
• Histopathology: Squamous cell carcinoma (most common)
• Sentinel Node Biopsy: Identifies first draining lymph node to determine spread

Clinical Pitfalls and Caveats

1. Delayed Diagnosis: Patients often discount voice symptoms, delaying medical evaluation for >100 days 1

2. Misdiagnosis: Stridor in children often misdiagnosed as croup or asthma

3. Inadequate Assessment: Failure to perform laryngoscopy for persistent hoarseness >4 weeks

4. Inappropriate Treatment: Prescribing antireflux medications without laryngoscopy

5. Overlooking Red Flags: 52% of patients with vocal fold cancer initially thought their hoarseness was harmless 1

6. Professional Voice Users: Require more aggressive and earlier intervention to preserve voice quality

By following this comprehensive approach, clinicians can effectively diagnose and manage patients with voice disorders, stridor, and stertor while ensuring timely identification of potentially serious underlying conditions.