EVALUATION hoarseness

EVALUATION hoarseness

By:

Tutut SRIWILUDJENG T.

Dr. Wahidin Sudiro Husodo Mojokerto

INTRODUCTION

Husky voice is a term often used by patients to describe changes in the quality of her voice. Causes of hoarseness variety - variety, ranging from the lightest of upper respiratory tract infections to the most severe malignancy that is the vocal cords.

Subjective evaluation, physical examination and routine examination of the larynx patients is valuable in assessing the quality of sound. At present, in accordance with kamajuan technology, a more objective examination would be very helpful in making the diagnosis, because with the right diagnosis, the therapy will be provided with more accurate as well.

This paper will describe the steps - the steps needed to perform the evaluation in patients with hoarse voice.

EVALUATION hoarseness

1. Anamnesis

Evaluation should be based on the raucous surau step - a comprehensive and sequential steps of history, comprehensive examination that includes examination of head neck and larynx, serata special diagnosttik test.

Anamnesis should be initiated with a chief complaint of patients, a description of how it happened, when the first time, how long (to find out acute or chronic) and how often they are incurred. In addition it should also be asked whether there when voice returned to normal, whether the voice fluctuates in throughout the day.?

Anamnesis of the existence of trigger factors and previous history of disease is needed, such as whether the hoarse brook preceded by infection of or raspy breath after screaming - screaming (for example during sports)? Is there a history intubation, previous neck trauma? Does the patient have thyroid surgery, or cardiothoracic esophagus? Does the patient have reflux disease or hypothyroidism?

History of symptoms related for example disfagi, ill talk time (odinofonia), stridor, chronic cough, himoptisis, obstructive airway disease / restrictive, burning sensation in the chest (heartburn), symptoms of allergies, sinusitis symptoms (postnasal drip).

Social history that need to be asked is whether the patient smokers alcohol drinkers?Whether patients are professional voice users such as teachers, singers, vendors that sometimes - sometimes using excessive voice (vocal abuse) because of his work?

Anamnesis of the patient environment, including noise levels irritating smoke, pollen (pollen), dust or toxins, or any history of hearing lack of upper respiratory mucosa jantug drug or hormone that causes coughing.

After anamnesis mentioned above, should be evaluated patients by using VoiceHandicap sound self assessement. Question - This question is divided into three parts, namely the functional aspects, physical and emotional. Functional aspects include a statement describing the effect of voice disorders on daily activities. Fisk describes aspects of the complaint laringnya patient perceptions and characteristics of the resulting sound, while describing the emotional aspects of patient affective response to her voice disorders.

2. The Comprehensive Physical Examination

A comprehensive physical examination is an important step to be able to make a diagnosis. A comprehensive examination consists of checking the head - neck and pemeriksaanlaring.

2.1 Checking the head - neck

Examination of the head area - the neck is very important in examining patients with hoarse voice. Hoarseness may be caused by compression / nerve interference somewhere in the head and neck, thyroid disorders or from other causes. Carcinoma of the larynx may also be life-threatening kalainan sauar which must be ensured in the examination. This examination includes:

2.1.1 Inspection

At the inspection visits of color and the integrity of skin and lumps on the neck area around the larynx, such as: enlargement of the larynx (because of infilrasi tumors in cartilage larynx), tumor colli, the movement of Adam's apple when swallowing, enlarged thyroid gland, retraction suprasternal on time etc. inspiration.

2.1.2 Palpation

Palpation conducted by the framework of the larynx and surrounding structures during respiration and swallowing with due regard to the thyroid cartilage, cartilage krikoid, thyroid gland and the motion of the larynx and thyroid gland simultans time swallowing.Checked also by the tenderness and enlargement of lymph nodes. Normal larynx easily moved to the right and left.

2.2 Examination larynx

Laryngeal examination consisted of examination with a mirror, rigid laryngoscopy, telescopic laryngoscopy, flexible laryngoscopy, and mikrolaringoskopi videostroboskopi.

2.2.1 Examination by mirror

Examination of the larynx that is not directly using the mirror is the first procedure to see the larynx. This examination is quick, inexpensive and requires only a mirror and an external light sources. Obvious abnormalities (gross) may be likely to be detected but minor abnormalities that would be difficult to see.

The drawback of this examination is the larynx can not be seen in the physiological position because the tongue fonasi excluded patients (extended) and the larynx in a state of elevation. Moreover, it can happen vomiting reflex hyperactivity in 50-10% of patients, difficulty in doing a biopsy and can not be created photo documentation.

Figure 1: Means laryngeal examination with a mirror

2.2.2 rigid laryngoscopy

This examination will define the specific use of laryngoscope. Patients should be fasted at least 6 hours in advance to avoid aspiration if vomiting. Also required the provision premedicated 1 hour before the examination with a sedative and sulfas atropine to reduce secretions and prevent vagal reflex. Local anesthesia is given to make use of spray lidocain. To enlarge the larynx is seen and make it easier to see the anterior commissures telescope can be used without the hook 30 with the epiglottis. Taking a photo documentation is often difficult because patients can rarely cooperative for a period of time required. Contra indications of this examination is the presence of abnormal cervical vertebra and trismus necessary because the hyperextension position of the head and mouth are enough to open for entry until the laringofaring tool. In addition, the degree of crowded patients also affect the difficulty of the examination.This examination is especially silakukan to get big enough so it is quite representative.

Figure 2: rigid laryngoscope

2.2.3 telescopic laryngoscopy

On examination with a rigid telescope will produce images that most clearly larynx and large.

Local anesthesia is given to the pharyngeal spray denfan lidocain. Telescope 70 or 90 is inserted through the patient's mouth above the tongue at the midline until the base of the tongue and on the surface of the epiglottis but still on the oropharynx to the larynx seemed, with the tongue the patient held by the examiner, because the evaluation of laryngeal function of time talking or singing can not performed. Patients asked to pronounce the letter / i / at three different pitches (high, normal, low) and the loud sound (loudness) is normal. Images obtained can be recorded on video. Hardly any contra indication for the appliance still be inserted into the patient's mouth. The disadvantage, unable to do a biopsy and there are factors that can anatomisseta vomiting reflex is limited.

Figure 3: telescopic laryngoscopy

According to the study of Shao et al (2002), when compared with the telescope 90, the telescope 70 can be more close to the vocal cords resulting in better visualization of the laryngeal surface of epiglottis, and anterior commissures subglotis area.

2.2.4 flexible laryngoscopy

In this examination of flexible laryngoscope is inserted through the nose into the larynx laringofaring to appear. Patients do not need to fast and do not need premedication.Local anesthesia is given to the pouch rice (lidocain-ephedrine 2%) and pharynx (spray lidocain). This examination can be easily done even in patients with excessive vomiting reflex and the child - the child. This tool is the one - the only tool that can examine the nasopharynx, pharynx and larynx in a position that is almost physiological, the state of the larynx of time talking, singing, coughing etc.. Although the image produced is not as clear larynx produced by a rigid laryngoscope. Images can be recorded on video. A biopsy can be done but with the result of a smaller biopsy than with rigid laryngoscopy.

Figure 3: flexible laryngoscope

2.2.5 Videostroboskopi

Videostroboskopi combining flexible or rigid laryngoscopy with a strobe light (light pulse synchronized) to get a slow motion picture of the vibrations of the vocal cords will provide important information about the effects of vocal cord abnormalities in the production of sound can be recorded. Documentation vibrations of the vocal cords are essential in the investigation of voice disorders efekstivitas also in the evaluation of therapy.

Patients do not need to fast and do not need premedication. Local anesthesia is given to the pouch rice (lidocain-ephedrine 2%) and pharynx (spray lidocain) if the inspection with endeskop flexible and only on the pharynx only if the inspection using endeskop stiff.

Endeskop flexible, easier to put more comfortable for patients and are ideal for observing the larynx in a state of talking, singing, etc., and be able to view the glottis malalui supragolik a narrow aperture. The downside is the light through to the end of the bundle fiberoptik endeskop have low intensity, so the resulting picture is not as clear as rigid.

Rigid endoscopes produce images large and clear, but need koopertif patient because the patient must be extended tongue and held by the examiner during the examination.This will cause distortion fonasi natural posture of the pharynx and larynx. Besides, patients must have a Suitable anatomy and physical tolerance for examination to see the entire glottis.

The difference between using stroboscopic examination and telaskop fleskibel laryngoscopy, according to research by Yanagisawa (1993) are as follows:

a) technical Ease

Failure on the telescope examination was due to the vomiting reflex hyperactivity, whereas the flexible all patients can be examined.

b) The image quality

The quality of images produced by the telescope is better than with a flexible ie larger, clearer, colors and better image resolution.

c) Distortion

Optical distortion caused by more factors obtained in the examination with a flexible, sebaga effects of a wide angle (wide-angel) of the lens fiberskop. When the flexible tip is inserted too close to the glottis, larynx looks bigger picture in the middle and smaller at the periphery, causing distortion of the image stroboskopi larynx and mucosal wave.In addition, if the flexible tip is inserted through the narrow cavity rice due to septal deviation or hypertrophy Konka which will cause a tendency to remain at a relatively lateral position in the hypopharynx. This will cause the image stroboskopi chordae supraglotis vocalist and structures that are not symmetry.

Telescope system provides minimal distortion over the telescope is on the line mesdian or shifted on the horizontal axis, there will be distortion of the cord so that the vocalist is not the same. Pilka glosoepiglotis can be used as a guideline for positions in the median line for inspection with a telescope.

Figure 5: Videostroboskopi

2.2.6 Mikrolaringoskopi

In the circumstances - circumstances required laryngeal examination with a microscope.The way this examination, in addition to diagnosis (with view or biopsy) while also being able to do therapy in the form of extirpation for example in vocal nodules, or polyps kiste.And the biopsy results can also be more numerous and more accurate. But the loss of this examination requires general anesthesia so that the necessary preparation and greater costs than in other laryngeal examination. Similarly, photo documentation can not be taken on the position and fonasi respiration. Contra indications mikrolangoskopi almost the same as contra indications on examination with rigid laryngoscopy is the existence kalainan cervical vertebra and trismus. But because in this way required a general anestesis the presence of disease - another disease that can be aggravating conditions such as failure patients jatung, kidney, liver, etc., should be considered and chosen another way of checking the best for the patient.

Figure 6: Mikrolaringoskopik

3. Specific diagnostic tests

Specific diagnostic tests are needed on the circumstances - circumstances tertenut a more targeted primarily at the cause of the multifactorial. Tests tests include:

3.1 laryngeal Electromyography (LEMG)

LEMG is a special test that measures the electrical activity generated by the muscular larynx. These checks provide specific information about the status of neural input to the laryngeal muscles. During the LEMG electrical activity recorded, magnified and ditmapilkan on the screen and / or associated with loudspeakers that can be analyzed visually and sound. This examination uses a small needle (LEMG recording needles / electrodes) such that dtusukkan acupuncture needles in the muscles of the larynx krikotiroid muskuli right and left and right and left muskuli tiroartenoid. Then patients were asked voiced / i /. The results will provide information on whether the function of nerves to the larynx muscles intack (normal), intack partial (paresis) or absent (paralysis). This result can also be an indication that needed some other medical tests before the diagnosis is established and therapy is planned.

Voice 3.2 Functional Testing Lab

A comprehensive sound parameter in the channel. Parameters of different sounds and speech will be evaluated through the analysis done by ahlipatologi acoustic sound (speech-language pathological) or other trained professional. With advances in technology, acoustic analysis can be done using computers to obtain quantitative measurements of voice disorders. This test can find small abnormalities that were missed in the ear without any assistance.

3.3 Reflux Test

Test to ensure there is reflux of gastric juices into laringofaring is to use double-proble pH monitoring that will be known amount of acid throughout the day in the hypopharynx and the esophagus. Besides it can also determine how many times a day that abnormal levels of acid occurs.

3.4 Radiological

Making images that can help make the diagnosis include X-photo soft tissue lateral neck laringografi, CT scan and MRI. The result of these photos can be used for the detection of tumors, and abnormal calcification or the presence of airway problems.

4. COMPLICATIONS

Complications can occur in any manipulation of the airway, especially the larynx such as doing a biopsy or extirpation. But the complication rates reported in the literature only a small range of about 1-3%. Complications can occur mainly in laryngeal examination using a rigid laryngoscope and mikrolangoskopi for using tools from the metal tube that is inserted into the hypopharynx, whereas in pemeriksaandengan telescope, a tool is inserted only until the oropharynx and with flexible, small-diameter tool and not rigid.Complications that can occur is the emergence of mucosal lesions cavum oris, oropharynx and lips, tooth decay, especially the maxillary right and stridor / laringospasme.

Literature

1. Rosen CA, Anderson D, Murry T. Evaluating hoarsenes: keeping your patient's voice helaty. American Family Phisician. June 1998. Available at: http://www.aafp.org/afp/980600ap/rosen.html. Accessed 2/8/2005.

2. Buckmire Stroboscopy RA. 2003. Available at: http://www.emedicine.com/ent/topic606. Htm. Accessed 2/8/2005.

3. Goldstein DP. Hoarsenes. 2004. Available at; http://icarus.med.utoronto.ca/carr/manual/hoarse.html. Accessed 2/8/2005.

4. Jones NG Assessement of voice. Baylor college of medicine. The Bobby R. Alford Department of Otolaryngology and Communicative Sciences, 2000.

5. HJ LeBoeuf. Evalution of the hoarse patient. Grand Rounds Presentations, UTMB, Dept.. of Otolaryngology, 2000. Available at; http://www.utmb.edu/otoref/Grnds/hoarse-eval-0005.html. Accessed 02/08/2005

6. Katzenmeyer K. Laryngeal dysfunction, hoarsenes, and videostrosboscopy. Grand Rounds Presentation, UTMB, Dept.. of Otolaryngology, 2001. Available at; http://www.utmb.edu/otoref/Grnds/hoarse-2001-10/hoarse-2001-10.html. Accessed 2/8/2005.

7. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the voice handicap index-10. Laryngoscope 2004; 114: Sept, 204, 1549-56.

8. Bastian RW. Delsupehe KG. Indirect larynx and phrynx surgery: a replacement for direct laryngoscopy. Laryngoscope 1996; 106: 1280-6.

9. M. Armstrong Jr., Mark LJ, Synder DS, Parker SD. Safety of direct laryngoscopy as an outpatient procedure. Laryngoscope 1997; 107:1060-5.

10. Yanagisawa E, Yanagisawa K. Stroboscopic videolaryngoscopy: a comparison of fiberscopic and telescopic documentation. Ann Otol Rhinol Laryngol 1993; 102:255 - 65.

11. Shao, Stern J, Wang Z, Hanson D, Jiang J. Clinical evaluation of 70 and 90 laryngeal telescope Arch Otolaryngol Head Neck Surg 2002; 128: 941-4.

12. Johns MM. Update on the etiology, diagnosi, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck Surgery 2003; 11: 456-61.

13. Shohet JA et al. Value of videostrosboscopic parameters in differentiating true vocal cord cysts from polyps. Laryngoscope 1996; 106: 19-26.

14. Kofman JA, Amin MR, Postman, GN. Controvercies in Laryngology. In: Bailey BJ, Calhoun KH, Healy GB, Johnson JT, Jackler RK, Pillsbury III HC, Tardy Jr. ME, eds. In: Head and Neck Surgery Otolaryngology.3 Ed. Philadelpia: Lippicott Williams & Wilkins.2001, Vol.1 641-7.

15. Rebeiz EE, Shapshay BC. Benign lesions of the larynx. In: Bailey BJ, Calhoun KH Healy GB, Johnson JT, Jackler RK, Pillsbury III HC, Tardy Jr. ME, eds. In Heand and Neck Surgery - Otolaryngology 3rd Ed. Philadelpia: Lippncott Williams & Wilkins. 2001, Vol.1: 617-26.

16. Phelps PD. Radiology of the phrynx and larynx. In: Scott-Brown's Otolaryngology: Laryngology.5 Ed. Butterworth. 1987; 730.

17. Hill RS, Koltai PJ, Parnes SM. Airway complications from laryngoscopy and panendoscopy. Ann Otol Rhinol Laryngol 1987; 96:691 - 4.

18. Klussmann JP, Knoedgen R, Wittekindt C. Complications of suspension laryngoscopy. Ann Otol Rhinol Laryngol 2002; 111: 972-6.