History and Physical Exam


• Character of Dysphonia: onset and duration, time course (acute versus chronic), periodicity (morning hoarseness associated with GERD, evening hoarseness associated with vocal abuse)

• Contributing Factors: recent upper respiratory infection, fever, sore throat, cough, congestion; history of voice, tobacco, or alcohol abuse; past medical history of peripheral nerve diseases and other neurological disorders, gastroesophageal reflux, hypothyroidism, psychological stressors; previous laryngeal trauma, surgery, or airway manipulation

• Associated Symptoms: odynophagia, dysphagia, aspiration, weight loss, hearing loss, heartburn

• Think "KITTENS" for differential diagnosis (see Table 3-1)

Physical Exam

• Assess Perceptual Quality of Voice: see below

• Indirect and Direct Laryngoscopy (Mirror, Flexible Nasopharyngoscopy, Videostroboscopy): assess vocal fold motion, examine laryngeal lesions and appearance of vocal folds (edematous, erythematous, atrophic, etc), assess glottic competence

• H&N Exam: neck masses, thyroid masses, complete neurological exam

Perceptual Voice Abnormalities

• Abnormally High Fundamental Frequency: may be due to tension producing vocal fold masses, muscle tension phenomenon, protracted pubescence

• Abnormally Low Fundamental Frequency: consider load producing vocal fold masses (Reinke's edema, growths) or hypothyroidism (laryngeal myxedema)

• Abnormally Loud Voice: may be secondary to sensorineural hearing loss, hyperfunction (muscle tension dysphonia), excessive respiratory efforts, or psychogenic

• Abnormally Soft Voice: may be secondary to conductive hearing loss, reduced respiratory efforts, glottic incompetence, vocal fold masses, vocal fold paralysis, vocal fold bowing defect, or psychogenic

TABLE 3-1. Differential Diagnosis of Dysphonia: KITTENS Method

Infectious & (K) Congenital Idiopathic

Congenital webs

Underdeveloped larynx

Laryngitis (viral, bacterial, and fungal)

Vocal fold paralysis

Adductor spasmodic dysphonia

Muscle-tension disorders

Toxins & Trauma

Laryngeal cysts, nodules, polyps, and ulcers

Voice abuse

Reinke's edema

Arytenoid dislocation

Vocal fold granulomas

Caustic inhalation injuries



Recurrent laryngeal papillomatosis

Laryngeal cancer

Benign laryngeal neoplasms (hemangiomas, cystic hygromas)

Endocrine Neurologic Systemic

Hyp o thy ro idism (laryngeal myxedema)

Adrenal, pituitary, and gonadic disorders


Cerebral palsy

Multiple sclerosis

Extrapyramidal lesions (Parkinsons)


Guillain Barré

Myasthenia gravis

Other neurological disorders


Connective tissue disorders (rheumatoid arthritis, SLE)


• Hoarseness: consider vocal fold mass, vocal fold paralysis, vocal fold bowing defect, muscle-tension abnormalities, vocal fold swelling, or psychogenic

• Diplophonia: two simultaneous pitches, may be due to recruitment of false vocal folds during phonation or the presence of an asymmetric mass (eg, unilateral vocal fold polyp or cyst)

• Harshness: strained or strangled; may be from upper motor neuron dysarthria (spastic), adductor spasmodic dysphonia, psychogenic, muscle-tension abnormalities, or a compensatory result from an underlying vocal fold mass

• Tremorous: suggests organic vocal tremor (extrapyramidal system), spasmodic dysphonia, or psychogenic

• Breathy: excessive airflow from a longer "open phase" or incomplete ADduction; may be from a glottal chink (mass effect), bowed deformity secondary to vocal fold paralysis, presbylaryngis, glottic lesions, muscle-tension dysfunction, abductor spasmodic dysphonia, or a psychogenic disorder

• Arrest of Phonation: sudden stops; consider spasmodic dysphonia, load bearing vocal fold mass, muscle-tension disorders, psychogenic

• Aphonia: complete absence of phonated sound; often a functional disorder (psychogenic), bilateral ADductor vocal fold paralysis, mass that results in an open glottis

• Stridorous: may be due to bilateral vocal fold paralysis, obstructing vocal fold mass, paroxysmal laryngospasms, or psychogenic

• Hypernasality: suggests velopharyngeal incompetence (flaccid or spastic dysarthria, anatomic defects)

• Hyponasality: may be secondary to hypertrophied tonsils or adenoids, sinonasal disease, nasal obstruction (septal deformities, nasal masses), or a nasopharyngeal mass

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