• Muscle tension dysphonia — excessive tension in perilaryngeal muscles without structural lesion. Often seen in high-demand voice users who develop maladaptive patterns.

• Conversion disorder — voice loss without organic pathology, typically in the context of psychological stressor. Characteristically, the patient can cough (which requires cord adduction) but claims they cannot speak.

Key history points: Smoking, Occupation/voice demand, Details of hoarseness, and Red flag symptoms for malignancy. ^[1]

Additional history to consider (from integration with supporting material):

• GERD / laryngopharyngeal reflux — a common contributor to chronic laryngitis and Reinke's oedema ^[6]
• Alcohol — synergistic risk with smoking for laryngeal SCC ^[4]
• Previous neck surgery (thyroidectomy, anterior cervical spine surgery) — iatrogenic RLN injury
• Previous intubation — can cause cord palsy or granuloma
• History of head & neck radiotherapy — can cause chronic laryngeal changes

Examination of a patient with hoarseness: (1) Cervical lymphadenopathy, (2) Inspection of the larynx. ^[1]

Cervical lymphadenopathy — palpate all levels systematically. Enlarged, hard, fixed nodes suggest metastatic disease.

Laryngeal inspection methods (from simple to complex):

Stroboscopy works by synchronizing light pulses to the patient's voice frequency, creating an apparent slow-motion view of the mucosal wave. This is critical for detecting subtle lesions like early cysts or sulci that alter the mucosal wave pattern. ^[1]

Classically affects singers, teachers. Caused by voice abuse. Bilateral and ALWAYS symmetrical at the junction of anterior and middle 1/3 of vocal folds. ^[1]

Pathophysiology from first principles:

• Repeated vocal trauma → localized oedema at the point of maximal collision between the vocal folds → fibrosis → nodules
• The junction of the anterior 1/3 and middle 1/3 is where the amplitude of vibration is greatest, hence this is where nodules form
• They are always bilateral and symmetrical because both cords collide at the same point

Clinical features:

• Husky voice and easy fatigue due to air leak — the nodules prevent complete glottic closure, so air leaks through, making the voice breathy and requiring more effort ^[1]

Management:

• Speech therapy and vocal hygiene — this is FIRST-LINE and usually curative ^[1]
• Surgery is rarely needed; nodules often regress with proper voice use
• Vocal hygiene = adequate hydration, voice rest, avoiding shouting/whispering, treating reflux

Unilateral vocal cord lesion. Caused by acute vocal trauma → bleeding from mucosal vessel → organized haematoma → polyp. ^[1]

Pathophysiology:

• A single episode of intense vocal trauma (e.g. screaming at a concert) ruptures a submucosal vessel → haematoma forms → organizes into a polyp
• Unlike nodules (chronic, repeated trauma), polyps arise from acute events
• Unilateral because the vascular rupture happens on one side only

Clinical features:

• Husky voice and easy fatigue due to air leak — same mechanism as nodules (incomplete glottic closure) ^[1]

Management:

• Microlaryngoscopy + Excision — unlike nodules, polyps don't respond well to speech therapy alone because they are organized haematomas ^[1]

Fluid collection in Reinke's space (superficial lamina propria). Causes: smoking, laryngeal reflux, hypothyroidism. ^[1]

Pathophysiology:

• Reinke's space is the superficial layer of the lamina propria — a potential space between the epithelium and the vocal ligament
• Chronic irritation (smoke, acid reflux) → increased vascular permeability → fluid accumulation in this space
• The fluid makes the vocal folds heavy, bulky, and floppy

Clinical features:

• Effortful, low-pitched, and rough voice — the heavy, oedematous folds vibrate at a lower frequency, hence low pitch ^[1]
• Classic patient: middle-aged female smoker with a deep, gravelly voice

Management:

• Correct underlying causes (quit smoking!!) — most important step ^[1]
• Microlaryngoscopy + Excision — suction/strip the oedema from Reinke's space ^[1]
• Treat reflux if contributing

Associated with HPV subtypes 6 and 11. Transmission: in-utero transfer, birth tract contact, oral sex. Affects both adults and children. ^[1]

Pathophysiology:

• HPV 6 and 11 are low-risk HPV types (same subtypes causing genital warts)
• The virus infects the basal layer of the laryngeal epithelium → papillomatous growth
• In children: acquired during passage through an infected birth canal
• In adults: acquired through oral sex or reactivation of latent infection

Presentation:

• Hoarseness
• Airway obstruction — can be life-threatening, especially in children where the airway is narrower
• Malignant transformation (→ SCC) — rare but possible, especially with HPV 11 ^[1]

Management:

• Microlaryngoscopy + Excision — the mainstay; typically requires multiple procedures because of recurrence ^[1]
• HPV vaccine reduces recurrence ^[1]
• Adjuvant medical therapy: Cidofovir, alpha interferon, Avastin (bevacizumab) ^[1]

Leukoplakia = whitish plaque. Erythroplakia = reddish plaque. Both can be premalignant (dysplasia) or malignant (SCC). MUST BIOPSY!!! ^[1]

Why biopsy is mandatory:

• You cannot distinguish dysplasia from carcinoma-in-situ from invasive SCC by appearance alone
• Erythroplakia has a higher risk of malignancy than leukoplakia — the redness reflects increased vascularity and inflammation associated with neoplasia
• Investigation: Microlaryngoscopy + biopsy ^[1]

Risk factor: smoking. Commonest pathology: squamous cell carcinoma. Clinical features: hoarseness, airway obstruction, cervical lymph node metastasis. ^[1]

Key anatomical regions of the larynx (from supporting material ^[4]):

Why glottic cancer has the best prognosis:

1. Early symptom (hoarseness) → detected early
2. Poor lymphatic drainage → low risk of nodal spread
3. Therefore often curable with radiotherapy or limited surgery

Risk factors (from lecture + supporting material ^[4]):

• Smoking (single most important)
• Alcohol (synergistic with smoking)
• Chronic laryngitis, GERD/laryngopharyngeal reflux
• Family history
• Previous irradiation

Risk of synchronous cancer: 8–10%, due to field change effect from carcinogen exposure. ^[1]

Field change (field cancerization) explained from first principles:

• The entire upper aerodigestive mucosa (mouth, pharynx, larynx, oesophagus, bronchi) is exposed to the same carcinogen (smoke + alcohol)
• Multiple foci of dysplasia/carcinoma can develop simultaneously
• Therefore, finding one cancer means you must look for others

Panendoscopy (bronchoscopy + esophagoscopy) is performed to detect synchronous lesions. ^[1]

Two methods to obtain biopsy in the larynx: (1) LA flexible laryngoscopy + biopsy, (2) GA microlaryngoscopy + biopsy. ^[1]

1. Flexible laryngoscopy to assess extent. 2. Biopsy for histological diagnosis. 3. Panendoscopy for synchronous lesion. 4. Ultrasound neck for nodal metastasis ± FNA. 5. Contrast CT neck to assess extent. ^[1]

Three main categories: (1) Neurogenic, (2) Cricoarytenoid joint, (3) Intrinsic muscle. ^[1]

Malignancy 25%, Iatrogenic 25%, Idiopathic 20%. ^[1]

Malignant causes (arise along the course of the vagus/RLN):

• Ca thyroid, oesophagus, lung, lymphoma, NPC, metastatic LNs ^[1]

Iatrogenic causes:

• Thyroid surgery, neck dissection, anterior spinal surgery, cardiothoracic surgery (more common on LEFT), intubation ^[1]

Injection laryngoplasty: material (e.g. fat, hyaluronic acid, calcium hydroxylapatite) injected into the paralysed cord to medialize it → improves glottic closure → better voice and less aspiration. ^[1]

Thyroplasty: a silastic implant is placed through a window in the thyroid cartilage to medialize the paralysed cord permanently. ^[1]

GERD can manifest with extra-esophageal symptoms including hoarseness, throat tightness, and chronic cough via laryngopharyngeal reflux ^[6]. This is a common contributor to Reinke's oedema and chronic laryngitis. In a patient with hoarseness + heartburn + throat clearing, always consider LPR. Management includes PPI, dietary modification, and lifestyle changes.

Post-thyroidectomy RLN injury is one of the most feared complications ^[5]:

• Unilateral RLN injury (< 1%) → vocal cord paralysis → hoarseness → treat with medialization (injection laryngoplasty)
• Bilateral RLN injury → both cords adducted → stridor upon extubation → require immediate re-intubation ± tracheostomy
• SLN injury → weak voice, cannot sing high pitch — important to warn professional singers pre-operatively

Left RLN palsy causing hoarseness can be a presenting feature of lung cancer (especially left hilar/mediastinal tumours compressing the nerve as it loops under the aortic arch) ^[5]. Also causes "bovine cough" (cough without explosive quality because cords can't adduct properly).

Advanced laryngeal cancer or bilateral cord palsy can cause upper airway obstruction requiring tracheostomy. This connects to GC 220 (Upper airway obstruction and tracheostomy).

Stem: "A 60-year-old gentleman who is a chronic smoker came to your clinic with a 5 cm right neck mass which has been there for 2 months... He also has progressive hoarseness. Select the MOST LIKELY primary site of the cancer."

Options: A. Carcinoma of the cervical oesophagus, B. Carcinoma of the glottis, C. Carcinoma of the hypopharynx, D. Carcinoma of the subglottis, E. Carcinoma of the supraglottis, F. Carcinoma of the tongue, G. Nasopharyngeal carcinoma, H. Parotid gland cancer

Answer: B. Carcinoma of the glottis

Rationale: Progressive hoarseness in a chronic smoker with a neck mass points to glottic carcinoma. The glottis is the most common site of laryngeal cancer, and hoarseness is its hallmark early symptom due to vocal cord involvement. While supraglottic cancer can also cause hoarseness, it typically presents late and with dysphagia rather than hoarseness as the primary symptom. A 5 cm neck mass indicates nodal metastasis (possible advanced glottic disease extending beyond the glottis, or consider supraglottic which has richer lymphatics — the answer depends on which symptom best matches the primary site. Hoarseness as the primary complaint = glottis).

Stem: "Progressive hoarseness of voice for 4 months with an increasing difficulty in breathing in a chronic smoker."

Options: A. Acoustic neuroma, B. Adenoid cystic carcinoma, C. Allergic fungal sinusitis, D. Allergic rhinitis, E. Chronic suppurative otitis media, F. Laryngeal carcinoma, G. Meniere disease, H. Nasopharyngeal carcinoma, I. Obstructive sleep apnoea, J. Pleomorphic adenoma

Answer: F. Laryngeal carcinoma

Rationale: Progressive hoarseness + increasing dyspnoea + chronic smoker = classic presentation of laryngeal carcinoma. The progressive dyspnoea suggests the tumour is growing to obstruct the airway — a late feature.

Stem: "A 67-year-old gentleman diagnosed with advanced nasopharyngeal carcinoma 8 years ago was treated with radical radiotherapy and chemotherapy. He presented to the Accident and Emergency Department with difficulty in breathing and stridor. Laryngoscopy showed bilateral vocal cord palsies. What type of surgery did he need?"

Options: A. Bronchial toileting, B. Emergency tracheostomy, C. Injection laryngoplasty, D. Thyroplasty

Answer: B. Emergency tracheostomy

Rationale: Bilateral vocal cord palsy (likely from radiation damage to both RLNs or direct tumour involvement) → both cords are fixed near midline → airway obstruction with stridor. This is an airway emergency requiring tracheostomy. Injection laryngoplasty and thyroplasty are for UNILATERAL palsy to improve voice — they would worsen airway obstruction in bilateral palsy by further narrowing the glottis. Bronchial toileting is for secretion clearance, not cord palsy.

Stem: "A 65-year-old man, who is a chronic smoker and chronic drinker, presents with hoarseness, a right neck mass and infrequent haemoptysis for 2 months."

Options: A. Adenocarcinoma, B. Adenoid cystic carcinoma, C. Ameloblastoma, D. Basal cell carcinoma, E. Dermatofibrosarcoma protuberans, F. Epulis, G. Multiple myeloma, H. Osteosarcoma, I. Pleomorphic adenoma, J. Squamous cell carcinoma

Answer: J. Squamous cell carcinoma

Rationale: Chronic smoker + chronic drinker + hoarseness + neck mass + haemoptysis = squamous cell carcinoma of the larynx (or hypopharynx). SCC is the commonest malignant tumour of the larynx, strongly associated with smoking and alcohol.

Stem: "A 65-year-old man who is a chronic smoker and attended the ENT clinic with a 2-month history of a painless mass in the left upper neck which has been progressively increasing in size. Which of the following would be the first-step investigation?"

Options: A. Examination of the head and neck region under general anaesthesia for possible primary site, B. Fine needle aspiration of the neck mass for cytology, C. Incisional biopsy of the neck mass for histology, D. Positron emission tomography with integrated-computer tomography for distant metastasis

Answer: B. Fine needle aspiration of the neck mass for cytology

Rationale: For an adult with a painless enlarging neck mass (especially a smoker), the first-step investigation is FNA of the mass — it's minimally invasive, provides cytology for initial diagnosis, and guides further workup. Incisional biopsy of neck masses is generally AVOIDED as first-line because it can seed tumour cells and compromise subsequent neck dissection planes. GA examination and PET come after initial tissue diagnosis.

Stem: (Sections 1–4) An 80-year-old lady with enlarging neck swelling and increasing difficulty in breathing over 6 months. Section 1: "List six important questions that should be asked during history taking." and "List six important physical signs that should be checked."

Correct approach includes asking about:

• Voice change/hoarseness (dysphonia → suggests RLN involvement/malignancy)
• Choking/aspiration
• Dysphagia
• Weight loss/appetite
• Smoking/drinking history
• Family history of malignancy
• Previous neck surgery or radiation

Physical signs include:

• Stridor
• Tracheal deviation
• Retrosternal extension (can't get below the mass)
• Vocal cord mobility (if laryngoscopy available)
• Cervical lymphadenopathy
• Eye signs (thyroid disease)

Relevance to this lecture: The case demonstrates how dysphonia/voice change is an important question to ask in neck mass workup, and how RLN palsy from thyroid pathology connects to vocal cord palsy management.