Aetiological factors of hoarseness of voice in patients attending in a district level hospital

Background: Information about causes or related factors involving voice change was studied mainly in central tertiary level hospitals previously, not in hospital in peripheral districts in Bangladesh. Objective: To find out and evaluate the aetiological factors of hoarseness of voice irrespective of age and sex. Setting: Pabna medical college, a 250 bedded hospital in Bangladesh. Methods: This was a cross sectional, nonrandomized and longitudinal study conducted from 1 august 2011 to July 2017. All the patients with history of hoarseness underwent clinical examination, routine as well as special investigation to find the diagnosis. The final results were analyzed by simple manual analysis with frequency and percentage using SPSS program in 2017. Results: There were total 200 patients included in the study. Among them the age groups of 21 – 30 years and 31 – 40 years were mainly suffer from hoarseness. Similarly, among 200 patients 144 (72%) were males whereas 56 (28%) were females with male to female ratio of 2.5:1. The most common cause as per the distribution was acute laryngitis with frequency of 34% followed by acid peptic laryngitis, 25.5%, neoplasms of larynx 12%, whereas tuberculosis of larynx, intubation granuloma, trauma was very few. Conclusion: There was etiological variation in hoarseness ranging from simple laryngitis to malignancies. So it is important not to ignore the hoarseness and precise history, examination and investigations should be done.


Introduction
Hoarseness is the term often used by common people to describe changes in their voice quality. Actually the human voice is an extraordinary attainment, which is capable of conveying not only complex thought but also subtle emotion 1 . At every child birth the most singularly and universally awaited sign of life is the infant's cry. The cry signals a fulfilled physiological capability required for the infant's survival. Probably no other human organ system need work so immediately and effectively after birth 2 . "Although the voice is not visible to the eyes during speech production but its absence or malfunction is obvious". Hoarseness is the term used to describe a change in normal voice quality. It is non-specific term, similar to patient's complaint of dizziness when describing symptoms from lightheadedness to true vertigo. Hoarseness may imply breathiness, roughness, voice breaks or unnatural changes in pitch. Term dysphonia is used by laryngologists to describe abnormal voice quality. Complaints of hoarseness may represent serious disease, therefore, should not be ignored 3 . In the words of Chevalier Jackson "Hoarseness is a symptom of utmost significance and calls for a separate consideration as a subject because of the frequency of its occurrence as a distant signal of malignancy and other conditions" 4 .
The causes of hoarseness are determined after obtaining a detailed medical history of the circumstances preceding the onset of hoarseness and performing a thorough physical examination. The latter may include visualization of the vocal cords, possibly indirect laryngoscopy, flexible nasendoscopy or videolaryngoscopy. In the absence of an upper respiratory tract infection, any patient with hoarseness persisting for more than two weeks requires a complete evaluation. When the patient has a history of tobacco use, cancer of the head and neck must be considered and ruled out. Voice abuse is one of the most common causes of hoarseness and can lead to other vocal pathologies such as vocal nodules. Good vocal hygiene can prevent and treat some pathologies, and voice therapy is a cornerstone of management in some cases of hoarseness 5,6,7 .
If one has hoarseness for more than 3 weeks, it could be a sign of laryngeal cancer. This is one of the most common symptoms. But many other things can cause a hoarse voice. One of the most common causes is acute laryngitis. This usually happens due to a cold, a chest infection or over use of the voice, such as shouting or screaming.
Smoking can also cause hoarseness because it irritates the throat lining (mucous membranes). Other special causes that usually under rated for hoarseness includes acid reflux, post nasal drip, allergies, thyroid problems and laryngeal injury 8 .
Many people develop hoarseness as they get older. Acid reflux is acid leaking from your stomach up into your oesophagus. It can cause hoarseness, as stomach acid comes back up the oesophagus and irritates the larynx. Post nasal drip means mucus dripping from the back of your nose down into your throat. This can happen in cold, allergy or smoking. It produces cough and a hoarse voice 9 .
Psychological factors may be a predisposing, precipitating or perpetuating agent in cases of voice disorder. Sudden loss of voice may be caused by conversion reaction. Muscle tension dysphonia is a common cause of hoarseness . It may also co-exist with other voice disorder. This condition results from an imbalance of the synergist and antagonist muscles affecting vocal fold position . Puberophonia is a condition in male where normal change of the pitch of voice at puberty is hampered or delayed . Patient may have double voice . Presbylaryngis is age related change in the voice where the vocal becomes stiffened , bowed and atrophiclooking 7,9,10 . But these physiological and psychological voice changing factors were not included in this series.
The well-known risk factors for voice disorders are female, age (40-59yrs), vocal abuse, high vocal demand, extraoesophageal reflux, chemical exposures, smoking, frequent cold / sinus infection. Women are more prone to develop functional voice disorders because of vulnerabilities such as stress, anxiety, depression and coping with negative emotions. Professional voice users like singers, teachers, actors, politicians, announcers, call centres/ telephone workers are more at risk of developing occupational voice disorders 13 Methods This is a cross sectional, non-randomized and longitudinal study conducted from August 2011 to July 2017 in department of otorhinolaryngology of Pabna Medical College Hospital, Bangladesh. All the patients who presented with history of hoarseness were included in the study. The detailed history, clinical examination, routine as well as special investigation (flexible nasopharyngolaryngoscopy and direct laryngoscopy) was performed to find the diagnosis. In this hospital there was no facility of video laryngoscopy or flexible nasopharyngoscopy. So the patients were sent to Dhaka or Rajshahi for this endoscopic procedure.
Physiological, psychological, surgical conditions (i.e. thyroidectomy) or conditions outside the neck (i.e. RLN palsy due to lung or thoracic oesophageal malignancy) was excluded from study.
The final results were analyzed by SPSS 11.5 software.

Results
There were total 200 patients included in the study. Among them the age groups of 21 -30 years and 31 -40 years were mainly suffer from hoarseness as shown in table 1.    The frequency of chronic simple laryngitis was 14% in this study which is similar to other studies [13][14][15][16] . The frequency of vocal nodule, Reinke's edema and vocal polyp was 5%, 1.5% and 3% respectively. Our findings were different from other studies which showed somehow higher or lower frequencies of these diseases 9,17 .
In the present series, the frequency of laryngeal tuberculosis was only 1% which was much lower than the study performed by Woodson and Ramazan et al 10,11 and Iqbal K et al 16 . The reason could be because of more prevalence but early diagnosis and treatment of pulmonary tuberculosis in south east Asia 17 .
The neoplastic and neurological cause reported to be 12% and 2.5% here. The frequencies were lower than other different studies 9,12,18 .
In our study, the frequency of intubation granuloma was 0.5%, only 1 case was found.
The results were comparable to study performed by SmiT CE et al 9 but very lower than the other studies [18][19][20][21][22] . The lower frequency in our study could be timely elective tracheostomy of needy patients.
The hypothyroidism was 0.5% in our study like that of Mohsin A 21 and Ramazan HH 11 but differ from Ahmed and Hussain et al 22 which showed 83.3%. It could be in our place the prevalence of hypothyroidism is not so high.

Conclusion
There was variation in etiologies in hoarseness ranging from simple laryngitis to malignancies. So it is important not to ignore the hoarseness and precise history, examination and investigations should be done.