What is the management approach for a patient with post-tuberculosis (TB) hoarseness of voice?

Management of Post-Tuberculosis Hoarseness of Voice

Voice therapy should be the primary treatment for post-tuberculosis hoarseness of voice, as it can significantly improve voice-related quality of life and functional outcomes. 1

Diagnostic Evaluation

Before initiating treatment for post-TB hoarseness, a proper diagnostic evaluation is essential:

1. Laryngoscopy:

   • Should be performed promptly in patients with persistent hoarseness following TB treatment 1
   • Options include transoral rigid endoscopy, transnasal flexible fiberoptic, or distal-chip laryngoscopy 1
   • Enhanced visualization with stroboscopy may reveal functional abnormalities not visible with standard laryngoscopy 1

2. Assessment for specific post-TB laryngeal findings:

   • Vocal fold scarring
   • Fibrosis of laryngeal structures
   • Glottic insufficiency
   • Possible granulomatous lesions

Treatment Algorithm

First-Line Management:

1. Voice Therapy:

   • The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends voice therapy for patients with hoarseness that reduces voice-related quality of life 2, 1
   • Therapy should focus on:
     • Proper vocal techniques
     • Breathing exercises
     • Vocal hygiene
     • Resonance therapy
     • Reduction of vocal strain

2. Voice Rest and Hydration:

   • Avoid vocal abuse and misuse
   • Maintain adequate hydration to optimize vocal fold function 2
   • Specifically avoid whispering, which can increase laryngeal strain 1

Second-Line Options (if voice therapy alone is insufficient):

1. Surgical Intervention:
   • Consider for:
     • Symptomatic scarring not responding to conservative management
     • Significant glottic insufficiency affecting voice quality
     • Persistent granulomatous lesions 1
   • Surgical techniques may include:
     • Vocal fold medialization
     • Scar release procedures
     • Injection laryngoplasty

Important Considerations

Medications to Avoid:

1. Corticosteroids:

   • The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends against routinely prescribing oral corticosteroids for hoarseness 2
   • Potential adverse effects include lipodystrophy, hypertension, and cardiovascular disease 2

2. Antibiotics:

   • Should not be routinely prescribed for hoarseness 1

3. Anti-reflux Medications:

   • While reflux can contribute to laryngeal irritation, anti-reflux medications should not be prescribed empirically without evidence of gastroesophageal reflux disease 2, 1

Prevention Strategies:

• Avoid tobacco smoke and irritants 2
• Maintain proper vocal hygiene
• Adequate hydration
• Avoid vocal strain

Monitoring and Follow-up

• Regular follow-up with laryngoscopic examination to assess progress
• Adjust voice therapy techniques based on response
• Consider referral to a multidisciplinary team including pulmonologists if there are concerns about active TB recurrence 3

Pitfalls to Avoid

• Delaying evaluation in patients with persistent hoarseness 1
• Using empiric medications without proper diagnosis 1
• Incomplete examination of the vocal tract during laryngoscopy 1
• Failing to consider laryngeal TB in differential diagnosis of persistent hoarseness in endemic areas 3

Voice therapy remains the cornerstone of management for post-TB hoarseness, with surgical interventions reserved for cases that don't respond adequately to conservative measures. Regular monitoring and appropriate specialist referral are essential components of effective management.