PREDISPOSING FACTORS AND AETIOLOGY OF HOARSENESS OF VOICE Shambhu Baitha', R. M. Raizada*, A. K. Kennedy Singh’, M. P. Puttewar‘, V. N. Chaturvedi" af hoarseness of voice seen in 43 6% of cases ABSTRACE . A study comprising 110 patients wuh hoarseness of voice was carried out between Jan 1998 and September 1999 10 find out the preduposing factors and aetology of the condition Sepite foct in nose and throat and vocal abuse were the common predisposing factors observed in 41 8% and 40 9% cases respectively Chrome non specific laryngitis was the commonest aetiology Key words: Hoarseness, Predisposing factors, Actilogy. INTRODUCTION The human voice 15 an extraordinary attainment which 1s capable of conveying not only complex thought but also subtle emotion Production of voice 1s a complex mechanism It 1s produced from larynx, also known as VOICE BOX as it houses the vocal folds which constitute the vibrator that generates the voice during speaking (Colton et al, 1990) The vocal folds produce tone that ‘becomes modified by pharynx, palate, tongue and hps to generate the individual sounds of speech Larynx must ‘operate in close synchrony with other parts of speech production apparatus if intelligible speech 1s o be produced Hoarseness or change in voice 1s a common presentation of patients having laryngeal pathology to an otolaryngologist, but not much work has been carmied out 1n this field and the role of predisposing factors for hoarseness 15 yet to be established “Although the vorce 1s not visible to eyes during speech production but its absence or malfunction 1s obvious” (Colton et al, 1990) Detection of the causes for its malfunction and role of ‘common predisposing factors in various conditions leading to hoarseness 1s the purpose of this presentation MATERIAL AND METHODS The present study, compnsing of 110 cases of hoarseness of voice, was cared out in department of Otolaryngology —HNS, MGIMS, Sewagram, Wardha between Jan 1998 to Sept 1999 All the cases presenting to Otolaryngology department with history of hoarseness were included in this study except for the cases with change in voice due to (1) congemital disease (1) nasal «and nasopharyngeal pathology (mt) oral and oropharyngeal pathology and (1v ) speech det lesions, is produced due 10 CNS Detailed history with special emphasis on predisposing factors (if any) was recorded in a proforma All patients were clinically examined and relevant investigations were done to find out the aetiology of hoarseness of ¥ OBSERVATIONS AND DISCUS A) PREDISPOSING FACTORS — 1) Predisposing factors for hoarseness Septic focus (dental caries, pharyngitis, rhinitis, symptomatic DNS ) and vocal abuse were the common predisposing factors accounting for 418% and 40 9% cases of hoarseness respectively Others, in descending order of frequency, were smoking in 28 cases ( 25 45%), chewing of tobacco and gutka (tobacco preparation ) in 19 patients (17 27%), aleohol consumption mn 14 (12 72%) cases and betel nut in 9 (8 18%) cases SION In 29 (26 3%) 1€ slightly more than one fourth patients no predisposing factor for hoarseness of voice could be found whereas in more than half of patients there was single predisposing factor — most important being vocal abuse (1m 26 1e 23 63% cases ) followed by (13 63%), tobacco chewing (8 18%), septic focus alone (5.4%) and betel mut chewing (454%) In 14.5% cases, two predisposing factors were incriminated — most common combination being of vocal abuse and alcohol consumption followed by vocal abuse and smoking. In rest of 10 patients (9%) three or more factors 1m combination were recorded to be present along with ther symptom of hoarseness of voice Thus in 23.5% cases smoking Clinical Resident “Additional Professor ‘Lecturer ‘Professor and Head Department of Otolaryngology Medical Sciences Sevagram 442102 India HNS MG Irstiute ofPredispoung Factors and Actology of Hoarseness of Votce 187 Table I: Aetiology versus predisposing factors in patients with hoarseness (n = 110) Sr. | Etiology Vocal | Smoking [Alcohol [Tobacco [ Betel nut | No Total No. of No. abuse chewing predisposing | cases (%) Factors Yes [No] Yes [No] Yes [No Yes [No | Yes[No 1 | Ac. Laryngitis 10 fiefs |22]s f23 fs far [2 [2a [a3 26(23.63) 2 | Chronic simple laryngitis]2 |8 | 2 |8 j2 |s fs |7 fa Jo [3 10(9.09) 3 | Chronic hyper plastic 1o* ]4 | 2 i2]2 2 fa fur fa fs f2 1412.72) laryngitis 4 | Vocal nodule romeo fa fas]. fia fa fas fa fas] 1412.72) 5 | Vocal polyp 3 f2]3 |2f2 B pb f2 J- Is ]- 5 (4.50) 6 | Dysphonia plica 2 fr f- [afr fe fh f2 y- fa f- 3.2.72) ventricularis 7 | Acid peptic taryngitis J. }2 Ji fa f- fo |e fo fa fa fa 208) 8 | Tuberculartaryngitis ]1 |s }- Jo |- Jo |r fs |- jo |4 6 (5.45) 9 | Carcinoma larynx 2 fia}ao*ta ja fi2 fo fia [3 [3 fa 16 (14.5) 10 | Vocal cord paralysis. 1. J9 3/7 fr fo 2 [8 10 |s 10 (9.09) 11 | Senile larynx ried fee pie fe fe pf 2.81) * erp < 005 #8: p< 0001 Table II : Aetiology of hoarseness of voice : comparative studies St. | Aetiology Mehta (1985) Parikh (1991) | Present study (1999) No. 20 (%e) n=100(%) n=110 (%) 1. _| Inflammatory 1. Acute laryngitis 13 (10.83) 9 (9.00) 26 (23.63) 2. Chronic laryngitis 78 (65) Tab 54 (49.09) A. Chr. N. Sp. Laryngitis 51 (42.50) 48 (48) 48 (43.55) Chr. Simple laryngitis 19 (15.83)* 7a 10 (9.09) Chr. hyperplastic laryngitis, - 14 (12.72) Vocal nodule 15 (12.50) 24 (24) 14 (12.72) Vocal polyp 14 (11.66) 15.15) 5 (4.54) Dysp. plica ventricularis | - - 3 (2.72) Acid peptic laryngitis - ; 2.81) Chr, laryngitis of childhood | 3 (2.50) - : = Non classified : 22) - B. Chr. Sp. laryngitis (TB) 27 (22.50) 23(23) 6 (5.45) 11. | Neoplastic -Carcinoma larynx 9 (7.50) 12 (12) 16 (14.54) Benign tumors 4.3.33) 33) : TIL. | Vocal cord paralysis 11 9.16) 3) 10 (9.09) IV. | Trauma - - 20.81) V.__ | Foreign body 2 (1.66) : Vi. | Senile larynx : - 20.8) Vil. | Functional dysphonia 3 (2.50) 202) - Total 120 (100) 100(100) 110 (100) “Chronic simple laryngitis and chronic hyperplastic laryngitis included in single group. Indian Journal of Otolaryngology and Head and Neck Surgery, Vol 36, No.3, July ~ September, 2004188, two, three or more predisposing factors were noted Septic focus im combination with other predisposing factors was noted in 40 cases (36 3%) Septic focus observed to be present in 41.7% of our cases Our metdence of septic foct in patients with hoarseness 1s mn agreement with Mehta (1985) and Pankh (1991) who reported septic foct in 43% of their patients with hoarseness Kaluskar (1971) has reported a higher rerden« of vowe In the oral cavity, oropharynx or nose was of septic foci (59%) 1m patients with hoarseness Vocal abuse Rosen et al (1988) mentioned vocal abuse as one of the most common cause of hoarseness and it can lead to other vocal pathologies In our study, vocal abuse was noted in 40.9% cases as the major contributory factor for hoarseness Kaluskar (1971), Mehta (1985) and Pankh (1991) have given a vanable higher incidence than ours 1¢ 62.5%, 49% and 56% respectively Cigarette / Bidi smoking Brock (1997) has mentioned inhaled srritant espectally cigarette smoke as most important predisposing factor for hoarseness Smoking ‘was noted mn 25 45% patients in our study, whereas Parikh (1991) has found st m 20% patients only Kaluskar (1971) has noted hoarseness up to extent of 49% 1m smokers, whereas other workers like Mehta (1985) and Prout et al (1997) have cited lower figures of 28% and 11% respectively Putney and O*keefe (1953) and Noms & Peal (1963) reported very high incidence of smokers (89 8% and 94% respectively) in patients with chronic laryngitis ‘This shows the strong assocration of cigarette smoking and chrome laryngitis, However, we have found vocal abuse to be more important than smoking i chrome laryngutis Muluple factors Henry Shaw (1979) concluded that chrome mucosal irritation by heavy smoking, excessive intake of alcohol (spints) and the chewing of tobacco and aromatic nuts in Asian countries play significant role in aetiology of hoarseness Pankh (1991) observed that in India and other developing countnes, the prevailing lower economic status, poorer nutrition, poorer general health Indian Journal of Otolaryngology and Head and Neck Surgery Vol 56 Predisposing Factors and Aetology of Hoarseness of Voce of the population, different food habits, vocal habits, smoking and drinkmg habits, unhealthy environment and different social customs mfluence the incidence of hoarseness In our study muluple predisposing factors (two ot more) were seen in 23 54% cases 2) Predisposing factors for individual conditions leading to hoarseness a) Acute laryngitis A total of 26 patients of acute laryngitis presented to ENT OPD Out of them 13 (50%) were having septic foci n the form of dental carmees, pharyngitis, laryngitis and symptomatic DNS smgly or in combination Similarly vocal abuse was noted alone or in combination with above as a predisposing factor in 10 patients. Smoking and tobacco chewing were also found as predisposing factors (Table 1) In 13 patients no predisposing factor for acute laryngitis could be detected (may be due to viral infection) Brock (1997) observed that acute laryngitis 15 often associated with and 1s secondary to an acute infection of nose, throat or PNS, viral or bacterial Isolated pyogenic infections of larynx are unknown Most cases of acute laryngitis are caused by colds so any thing predisposing to cold, predisposes to acute laryngitis A large number of viruses assoctated with infection of the upper respiratory tract_may be accompanied by inflammation of larynx Influenza and common colds are the leading infectious causes of acute laryngitis Bacterial superinfection may develop as a late sequel of viral infection involving upper respiratory tract Acute bacterial infection of the larynx also occurs by direct invasion or by seedling from the nasopharynx or oropharynx Salmon (1979) noted that acute inflammatory changes 1n the larynx may result from infection by a vanety of pathogenic organisms, trauma of different kinds, chemical ritation, excessive heat, 1onzing, radiation and antigen antibody reaction Often more than one of these factors are volved In our series vocal abuse, smoking and chewing were the other predisposing factors encountered alone or in combination tobacco b)Chrome Laryngitis Predisposing factors for hoarseness of vorce in chromic laryngitis which were seen in this study include vocal abuse {27 cases-statistically just significant (p = 005)}, smoking (9 case: 2 (8 cases), septic foct in nose and throat (6 cases) and alcohol ntake (3 cases) Some patients had multple predisposing , tobacco chew: No 3 July September 2004Predisposing Factors and Aetology of Hoarseness of Vowe factors whereas ten patients were without any predisposing factor. Chronic laryngitis is more frequently found in patients suffering from chronic infections of the upper and lower respiratory tract. In a study of $8 patients with chronic laryngitis, 53 % patients had history of infection (Stell and Mc Loughlin, 1976). Parikh (1991) found 43% patients of hoarseness having infection of upper respiratory tract. In our series we observed septic foci in nose and throat in form of rhinitis, symptomatic DNS and pharyngitis in 6 patients (11.11%) only. This figure is quite Jow as compared to above studies out of which the former (Stell and Mc Loughlin, 1976) is quite high probably because it is based on a history of infections. * Predisposing factors for subgroups of chronic laryngitis *Chronic simple laryngitis: Out of 10 cases, no predisposing factor was present in three whereas in remaining cases vocal abuse, tobacco chewing, smoking etc. were noted in combination or as sole factor (Table 1). Repeated infection of upper and lower respiratory tract, alcohol and tobacco use along with vocal abuse have been incriminated in the aetiology of chronic simple laryngitis by Salmon(1979). We have noted these agents in 70% of our cases and consider them to be strong predispositions. *Chronic hyperplastic laryngitis : Vocal abuse was the single most significant (p<0.05) predisposing factor for chronic hyperplastic laryngitis in this study (Table 1. Tobacco chewing, smoking and alcohol have also been noted by us, Broek (1997) has mentioned some additional factors like mouth breathing, irritants and chronic infection of the sinuses and the lower airways also, *Vocal nodule and polyp : In the study done by Parikh 2991) history of vocal abuse was present in 56%, septic foci in upper respiratory tract in 43% and 20% patients were chronic smokers. We have found vocal abuse as the single most significant (p<.001) predisposing factor for vocal nodule in 85.71% patients whereas smoking could be noted in one patient only in our study. In case of vocal polyp. vocal abuse and smoking were important factors in our study (Table 1) ©) Carcinoma of larynx and laryngopharynx Carcinoma larynx and laryngopharynx was found to be present in 16 patients. Cigarette/bidi smoking was noted Indian Journal of Otolaryngology and Head and Neck Surgery, Vol 56, No 3, July 189 in 12 patients (75%) and this was found to be highly significant(p<0.001) whereas 4 patients had two or more than two predisposing factor. One patient didn’t have any predisposing factor (Table 1). Laryngeal cancer is extremely rare in non smokers and its incidence increases with increase in no. of cigarettes smoked per day. Smoking increases the risk of cancer by 4 to 40 times than non smokers (Cowles, 1983). In our study 12 out of 16 patients (75%) were cigarette/bidi smokers and out of remaining 4 patients, 2 patients had habit of chewing tobacco while one patient was betel nut chewer. If taken together this constitutes 87.5%, and our data roughly corresponds with the study conducted by ‘Thomson et al (1999) who has reported it to be 83.6% Our value (87.5%) is slightly higher than the value (76.3%) of Lilly- Tariah et al.(1999) because they have studied it in less number of patients (total 38 patients with hoarseness). Four patients (25%) in our series had history of alcohol intake also along with smoking, Thompson et al (1999) reported 47.1% patients taking alcohol with or without tobacco. Alcohol consumption among the laryngeal cancer patients is much lower than among patients with carcinoma of oral cavity and pharynx (Broek, 1997), Epidemiological data has demonstrated a strong correlation between tobacco usage and laryngeal cancer (Bruch et al, 1984, Hammond 1966, Wynder & Stellman 1977), Heavy alcohol intake increases the risk by three times of non- drinkers (Cowles, 1983). Consumption of alcohol along with cigarette smoking increases the relative risk by 50% above that predicted by simple additive effects. In our cases statistical analysis showed a very significant association of laryngeal cancer with cigarette/bidi smoking. B) _ AETIOLOGY OF HOARSENESS OF VOICI Hoarseness is a symptom and has various causes, The various aetiological conditions for hoarseness of voice which were found in our study and as noted by other workers have been shown in Table I. Chronic non specific laryngitis (43.63%) was the most common actiology of hoarseness in our series. Acute laryngitis was seen in 23.63%, carcinoma of larynx in 14.54%, vocal cord paralysis in 9.09%, tubercular laryngitis in 5.45%, laryngeal trauma in 1.81% and presbylaryngeus in 1.81%. Mehta (1985) in his series of 120 cases with hoarseness reported chronic non specific laryngitis and vocal cord paralysis in 42.50% and 9.16% of cases which is close to September, 2004190 our figures of 43 63% and 9 09% respectively In another series comprising of 100 cases Parikh (1991) reported chromic non specific laryngitis in 48%, acute laryngitis in 9%, tubercular laryngitis in 23%, carexnoma larynx in 12% and vocal cord paralysis in 3%( Table Il) Thus at 1s observed that chromic non specific laryngitis 18 the most common aetiology of hoarseness in all the above series of patients Mehta (1985) and Parikh (1991) reported very hugh meidence of tubercular laryngitis 1n their studies- 22.5% and 23% respectively We observed tubercular laryngitis m only 5.45% cases As far as conditions for vocal cord palsy are concerned, we could not find any cause in six out of ten cases encountered in our study In 3 cases it was due to malgnancy (bronchus- 2,oesophagus-1) whereas in one case it followed endotracheal intubation SUMMARY AND CONCLUSION Septic focus was the most common predisposing factor for hoarseness of voice (41.7%) followed by vocal abuse (40 9%), smoking, tobacco chewing and alcohol mtake. Chrome non specific laryngitis (43 63%) was the most common aetiology for hoarseness of voice followed by acute laryngitis (26.63%), neoplastic conditions of larynx. (14 54%) and neurological involvement of larynx (9 094%). ACKNOWLEDGEMENT Authors are thankful to Sh. Dhirubhar Mehta, Director, Dr (Mrs) P Narang, Dean & Dr AP Jain, Med Supdt MGIMS & Kasturba Hospital for their kind permussion to publish this article REFERENCES 1 Broek P(1997) Acute and chronte laryngitis In Scott Brown's, ‘Otolaryngology, 6th Ediuon, edited by John Hibbert, Oxford, Bunerworth Hememann ,5/5/ 1-20 2 Bruch JDetal (1984) Tobacco, aleohol, asbestos and nickel mn the etiology of eancer ofthe larynx. a case control study INCI, 67 1219 3 Colton RH, Casper JK, Hirano M (1990) Understanding voree problem edited by John P Butter, Baltimore, Willams and walkins 19 4° Cowles SR (1983) Cancer of Larynx Occupational and Environmental Associations Southern Medical journal , 76 (©) 894 898 Indiare Journal of Otolaryngology and Head and Neck Surgery Vol 56 No 3 July Predisposing Factors and Aetiology of Hoarseness of Votce 10 u Hammond EC (1966) Smoking in relation to the death rates fof one mullion men and women, NCI Monogr , 19 127 Kaluskae (1971) Study on hoarseness of voice A thesis submitted for Master of Surgery (Otorhinolaryngology), Gujarat University Lilly Tanah OB, Ukolt CO, Nwana EI(1999) Cancer of lary an lack Atticans in Jos Nigena Cent Af J Med 45 (2) 40 2 Mebta AS (1985) An Aeuological Study of hoarseness of voice ‘A tests subsutted for Master of Surgery (Otorhunoluryngology), Guyarat University Norns CM, Peale AR (1963) Keratoss ofthe larynx Journal of laryngology and otology ,77 635 647 Pankh NP(1991) Aenologieal study of 100 cases of hoarseness of voice Indian Journal of Otolaryngology & Head and Neck Surgery, 43 (2) 71-73 Prout MN, Sudan JN, Watrburg RA etal (1997), Head and Neck Cancer Screening among 4611 tabacco users older than forty years Otolaryngology Head Neck Surgery , 116(2) 201.208 Putney FI, O'Keefe 1 (1953) keratosis of the larynx as a premalignant lesion Annals of Owlogy .62 48 Rosen CA, Anderson D Murry T (1998) Evaluating hoarseness keeping your patient's voice healthy Am fam Physicran STN) 2775 - 2782 Salmon LFW (1979) Acutelaryngus In Scott Brown's Dseases of the Bar, Nose and Throat, 4th edition, Edited by John Ballantyne, John Groves, London Butterworth , 345379) Sataloff RT (1992) The ampact of pollution on the voice Otolaryngology Head Neck Surgery . 106 (6) 701 705 Shaw HJ (1965) Journal of Laryngology and Otology 79.1 Stell PM, Melaughlin MP (1976) Clinical Otolaryngology . 1 265 Thompson LD, Wenig BM, Heffner DK etal (1999) Exophytie and papillary squa clinicopathologic series of 104 cases. Otolaryngology Head Neck Surgery , 120 (5) 718» 724 Wynder EL, Stellman $D(1977) Comparauve epidemiology 37 4608 The clinical significance of jous cell carcmomas of the larynx A of tobacco related cancers Cancer Res Address for Reprints: Dr RM Rarzada Professor & Head Deptt of Otolaryngology -HNS MGIMS, Sevagram-442102 September 2004