Voice Case of the Week: Hoarseness after Voice Use

About Dr. Reena Gupta

Dr. Reena Gupta is the Director of the Division of Voice and Laryngology at OHNI. Dr. Gupta has devoted her practice to the care of patients with voice problems. She is board certified in otolaryngology and laryngology and fellowship trained in laryngology, specializing in the care of the professional voice.

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The patient is a 31-year-old talent agent who noted severe hoarseness after a networking event. He saw a local ENT who said he had the beginnings of nodules. He was prescribed steroids. The patient did not improve and on subsequent follow up was told that he had developed nodules. He presented for a second opinion. His presenting videostroboscopic exam was as follows:

Based on a diagnosis of vocal fold hemorrhage, voice rest was recommended. However, his prognosis was guarded because there appeared to be a post-hemorrhagic mass forming within the vocal fold.

After voice rest, he did not improve. Intracordal injection of steroids similarly did not alleviate symptoms of pain, voice fatigue, and hoarseness. Therefore, the decision was made to proceed with an operative intervention. In the operating room, the following intracordal fibrotic mass was seen and excised.

Figure 1: An incision was made in the vocal fold lateral to the apparent mass.
Figure 1: An incision was made in the vocal fold lateral to the apparent mass.
Figure 2: Dissection was performed around the mass until it was freed from the normal tissue.
Figure 2: Dissection was performed around the mass until it was freed from the normal tissue.
Figure 3: After removal, the contour of the vocal fold margin was now straight. The vocal fold erythema (redness) was expected due to the prolonged period of time with blood in the fold.
Figure 3: After removal, the contour of the vocal fold margin was now straight. The vocal fold erythema (redness) was expected due to the prolonged period of time with blood in the fold.

After excision of the mass and appropriate time for healing, the following stroboscopic appearance was achieved. His throat pain was resolved and while he is still slightly hoarse, he is able to use his voice normally.

Discussion

This case highlights the importance of accurate vocal diagnosis. The correct diagnosis can often be easily missed because of inappropriate examination with older technology, particularly the flexible fiberoptic scope (the scope passed through the nose). In this scenario, the examiner must rely on their memory due to the limitations inherent to fiberoptic technology, such as low resolution imaging, insufficient color discrimination, and lack of video recording capability.

Stroboscopy allows for higher resolution and better color discrimination but most importantly, assists the identification of intracordal pathology by showing vibration. Video recording also allows for analysis of disease progression and a more accurate diagnosis. Prognosis and treatment hinges on accurate diagnosis; misdiagnosis was the reason for this patient’s prolonged course and morbidity. Had his hemorrhage been diagnosed accurately at its onset and treated appropriately with voice rest, he would not have formed an intracordal mass. He may therefore have avoided surgery.