A Cross-sectional Study on the Aetiology and Predisposing Factors of Hoarseness of Voice

Abstract

The primary objective of the study was to find out the aetiology of hoarseness and analyse people with hoarseness based on socio-demographic profile like age, gender, occupation and socio-economic status. Secondary objective was to find out the predisposing factors of hoarseness and to see their association between benign and malignant causes of hoarseness. The study was conducted for a period of one and half years in 178 patients who were above the age of 18 years of age and presented with hoarseness lasting for more than 2 weeks to the Department of Otorhinolaryngology. After obtaining a written informed consent, history was taken using a structured proforma and a proper clinical examination was done including indirect laryngoscopy. Nasopharyngolarygoscopy was done where indirect laryngoscopy was difficult. In a sample of 178 patients with hoarseness, 159 patients had structural lesions and 19 patients had movement disorders. Of the structural lesions, 86 patients were due to malignancy, 64 due to non-neoplastic causes, and 9 were due to premalignant causes. The most common malignant cause for hoarseness was Malignancy glottis, which had a male predilection. Smoking and alcoholism were found to be the main predisposing factors. The most common non neoplastic cause were vocal cord nodule and vocal cord polyp. The main predisposing factor was vocal abuse and was seen mostly in females. Vocal cord palsy was found to be the most common movement disorder. Hoarseness as a symptom if taken lightly can lead to serious consequences. Therefore it is important to avoid predisposing factors like smoking, alcoholism and also to educate the people regarding the proper use of voice.

Introduction

Hoarseness is a general, non-specific term used to describe a change in the voice quality [1]. It is a perceived rough, harsh or breathy quality to the voice most often associated with the abnormalities of the vibratory margins of the vocal cords [2]. The consequences of voice problems can handicap a person’s life by affecting him physically, functionally, psychosocially, professionally and financially. The aetiology of hoarseness is diverse and varies from trivial infections to life threatening malignancies. These causes can be determined after obtaining a detailed history, thorough physical examination and investigations. The causes of hoarseness are diverse and include acute and chronic laryngitis, functional dysphonia, physiological ageing, psychogenic factors, benign and malignant tumours of the larynx, and movement disorders like vocal cord paralysis. Malignancy hypopharynx, thyroid, oesophagus or even silent bronchogenic carcinoma can cause hoarseness. The predisposing factors of hoarseness include different vocal habits which may be linked with occupation, smoking and alcoholism, infections and inflammations. Voice abuse is one of the most common factors predisposing to hoarseness. Therefore, educating the patient regarding the proper use of voice through voice therapy, cessation of smoking, alcoholism and lifestyle modifications including changes in food habits play an important role in the prevention and management of hoarseness.

The predisposing factors of hoarseness include different vocal habits which may be linked with occupation, smoking and alcoholism, infections and inflammations. Voice abuse is one of the most common factors predisposing to hoarseness. Therefore, educating the patient regarding the proper use of voice through voice therapy, cessation of smoking, alcoholism and lifestyle modifications including changes in food habits play an important role in the prevention and management of hoarseness.

Materials and Methods

This study is a cross sectional study of 178 patients above 18 years of age presenting with hoarseness of voice of more than 2 weeks duration to the Department of Otorhinolaryngology, for a period of one and a half years. Patients with change in voice due to articulation disorders, central nervous system diseases, non-organic voice disorders, those who had undergone laryngeal surgery and those with hoarseness of less than 2 weeks duration were excluded from the study. The study was conducted after getting permission from the Department of Otorhinolaryngology, and approval from the Institutional Review Board.

After obtaining a written informed consent, a thorough history was taken and details evaluated using a structured proforma. A proper clinical examination was done including Indirect Laryngoscopy. Nasopharyngolaryngoscopy was done in cases where indirect laryngoscopy, was difficult. In case a direct laryngoscopy and biopsy or a microlaryngealsurgery and excision was done as in cases of malignancy, benign vocal cord lesions like vocal nodule, vocal polyp, vocal cord cyst then their findings were noted and histopathological reports followed up.

Statistical Analysis

Data was coded and entered in Microsoft Excel and analysed using IBM SPSS software.

Results

In this cross-sectional study, 178 patients with hoarseness who fulfilled the inclusion criteria and attended the Department of Otorhinolaryngology were included during a period of one and a half years. Out of the 178 patients 132 were males and 46 females.

Table 1 and Fig. 1 indicates the distribution of the 178 patients based on their diagnosis. Malignancy Glottis was the most common cause of hoarseness of voice and was seen in 34.8% of patients. All of them were males except for 1. Vocal cord nodule and Vocal polyp were seen to have a similar distribution in these patients with nodules most commonly seen in females and polyps in males.

Table 1.

Distribution of study subjects based on diagnosis

Diagnosis	Number	Percentage
LPRD	8	4.5
Vocal cord palsy	19	10.7
Malignancy Glottis	62	34.8
Reinke’s oedema	6	3.4
Vocal cord nodule	22	12.4
Growth supraglottis	19	10.7
Vocal cord polyp	22	12.4
Transglottic Malignancy	1	0.6
Contact Granuloma	2	1.1
Vocal cord cyst	1	0.6
Keratosis vocal cord	6	3.4
Vocal cord leukoplakia	1	0.6
Sulcus vocalis	2	1.1
Vocal cord web	1	0.6
Vocal cord papilloma	2	1.1
Malignancy Subglottis	2	1.1
Malignancy Hypopharynx	2	1.1
Total	178	100.0

Fig. 1.

Distribution of study subjects based on diagnosis

Majority of the patients with hoarseness who had malignant diseases were in the age group 61–70 years (37 cases), on the other hand non-neoplastic causes were more common in the 41–50 age group (25 cases). A chi square analysis was done to analyse the association between age group and malignant and benign causes of hoarseness. A significance of p < 0.01 was obtained. Hence proving that there is an association between age group and benign and malignant causes of hoarseness.

A greater number of male patients were seen in the 61–70 years age group and a greater number of female patients were seen in the 41–50 age group. A chi square analysis was done and p value of less than 0.01 was obtained, proving that there is an association between gender and malignant and benign causes of hoarseness. 64.4% of the males had malignant causes of hoarseness and 97.8% of females had benign causes of hoarseness. An odds ratio of 81.4 was obtained indicating that male gender is more likely to be associated with malignancy.

In regards to occupation, manual labourers were the largest group of patients (26.4%), followed by farmers. Non neoplastic causes were most common in housewives (11.2%), while malignant lesions were more common in manual labourers (23.6%) followed by farmers (13.4%). This is indicated in Table 2.

Table 2.

Vocal Professionals according to the classification by Koufman and Issacson

Levels	Percentage
Level I (the elite vocal performers)	0.56%
Level II(the professional voice users)	6.7%
Level III(non-vocal professionals)	23.6%
Level IV (nonvocal nonprofessionals)	69%

An association was found between a history of Upper respiratory tract infection and benign and malignant causes of hoarseness indicated by a p value < 0.01. 76.3% of the population with upper respiratory tract infection had benign causes of hoarseness. An odds ratio of 0.254 was obtained indicating that upper respiratory tract infection is less likely to occur in those with malignant causes of hoarseness.

As part of the aggravating factors voice abuse was found to have an association with benign and malignant causes of hoarseness. 62.1% of the population with voice abuse was found to have benign causes of hoarseness. Chi square analysis showed a p value of 0.02.

Vocal abuse was present in 104 patients and it was specially seen in patients with vocal cord nodule and polyp. This is indicated in Table 3.

Table 3.

Distribution of the study subjects based on history of voice abuse

History of voice abuse	Number	Percentage
Present	104	58.4%
Absent	74	41.6%
Total	178	100.0%

119 patients were smokers and 76 patients consumed alcohol. 45 of the 62 patients with Malignancy Glottis consumed alcohol and were smokers, indicating a possible correlation. The percentage of patients who smoked and consumed alcohol is seen in Fig. 2 and 3.

Fig. 2.

Percentage of study subjects based on those smoke

Fig. 3.

Percentage of study subjects based on those who consume alcohol

An association was found between those who consumed both alcohol and smoked and malignant causes of hoarseness indicated by a p value of less than 0.01.

In our study, out of 19 cases with vocal cord palsy, 17 cases were U/L vocal cord palsy and 2 cases were B/L vocal cord palsy. Vocal cord palsy was seen in 10 males (52.6%) and 9 females (47.4%). Hence the male to female ratio is 1.11:1. The most common aetiology of vocal cord paralysis was Idiopathic (6 cases-31.6%) followed by Post Thyroidectomy (4 cases-21%). The causes of vocal cord palsy are represented in Fig. 4.

Fig. 4.

Causes of vocal cord palsy

178 patients with hoarseness were studied and out of this 159 patients had structural lesions and 19 had movement disorders. Of the structural lesions, 86 were malignant, 64 were non neoplastic causes and 9 were premalignant lesions. The commonest non-neoplastic lesions were vocal cord nodule and vocal cord polyp. The commonest premalignant lesion was keratosis vocal cord and the commonest malignant lesion was malignancy glottis. The commonest movement disorder in our study was unilateral vocal cord palsy and the commonest cause of vocal cord palsy was idiopathic. Non neoplastic lesions like vocal nodule and reinke’s oedema were more common in females than in males. Vocal cord cyst was not associated with any of the predisposing factors. This is shown in Table 4.

Table 4.

Distribution of structural lesions and movement disorders causing hoarseness

Structural lesions	Benign	64	36%
	Malignant lesions	86	48.3%
	Premalignant lesions	9	5.1%
Movement disorder (Vocal cord palsy)		19	10.7%

Discussion

Patients who were above 18 years old were considered in this study. Majority of the patients with hoarseness who had malignant diseases were in the age group 61–70 years (37 cases), on the other hand non-neoplastic causes were more common in the 41–50 age group (25 cases). In our study, majority with hoarseness were in the age group 61–70. A greater number of male patients were seen in the 61–70 years age group and a greater number of female patients were seen in the 41–50 age group. In a study done by Amarnath et al. [3] on 150 patients, majority of the cases with hoarseness were in the age group 51–60, with the number of both males and females greater in this group. In a study by Hansa Banjara et al. [4] on 251 cases, majority of patients with hoarseness were in the 4th and 6th decade of life, with male patients showing a higher number in the 51–60 years age group while female patients showing a higher percentage in 31–40 years age group. In comparison to these two studies majority of the patients in our study were in the 7th decade and male and female patients showed maximum number in the age groups 61–70 and 41–50 respectively.

Male preponderance for hoarseness was noted in most of the major studies in the literature. According to Hansa Banjara et al. the male to female ratio was 1.89:1 and according to Bhaitha [5] it was 2:1. In our study the overall male to female ratio was 3:1. For non-neoplastic causes the male to female ratio was 1:1.3, with more number of females and for malignant diseases, most of the patients were males with the exception of a single case of malignancy glottis seen in a female patient.

According to the classification by Koufman and Issacson [6], majority of the patients with hoarseness who presented to us were in the Level IV (non-vocal non-professionals)-69% followed by the Level III (non-vocal professionals)-23.6%. In a retrospective study by Hansa Banjara on 251 cases, 85.3% patients were non-vocal non-professionals and 9.56% patients were non vocal professionals.

In our study there were 104 patients (58.4%) who gave a history of vocal abuse. Of these, 79 were males and 25 were females. According to Amarnath et al. on 150 patients, there were a total of 30 patients with vocal abuse of which 25 were females and 5 were males. This does not correlate with our study. In the study by Kumar et al. [7] out 100 patients, vocal abuse was seen 53% of cases which is similar to our finding. and in a study by Upadhya et al(138) on 45 patients with non-neoplastic lesions, vocal abuse was seen in 74% of cases. The percentage of patients with voice abuse according to Kumar et al. is very close to that of ours.

There was a very close association between smoking and alcoholism and so it was difficult to make a distinction between the two. The total number of smokers in our study population was 119 (66.8%) and total number of alcoholics were 76 in number (42.7%). In a study by Kumar et al. on 100 patients, 32% were smokers and 21% people consumed alcohol. Out of 86 patients who had malignant lesions, 67 patients were addicted to both smoking and alcohol (78%). In a study by Hansa Banjara et al. [4]on 251 cases, out of a total of 24 patients who had malignancy, addiction to both smoking and alcohol were seen in 19 patients(79%). This correlates well with our study.

In a study conducted by Chinthapeta et al. [8] in 50 patients with benign lesions, vocal nodule (24%) was found to be the most common aetiology of hoarseness. However in a study by Pal et al. on 100 patients, vocal polyp was found to be the main causative factor for hoarseness. In our study vocal nodule and vocal polyp had an equal distribution 12.4% each and they were found to be the main causes of hoarseness amongst the non-neoplastic lesions.

In our study, out of 19 cases with vocal cord palsy, 17 cases were U/L vocal cord palsy and 2 cases were B/L vocal cord palsy. Vocal cord palsy was seen in 10 males (52.6%) and 9 females(47.4%). Hence the male to female ratio is 1.11:1. According to Amaranth et al. out of a total of 22 cases of vocal cord palsy, 14(63.6%) were males and 8 (36.4%) females, having a male to female ration of 1.7:1. Hence the male preponderance seen here correlates with our study also. The 2 cases with B/L vocal cord palsy were females and both of them gave a history of thyroidectomy. The most common aetiology of vocal cord paralysis was Idiopathic (6 cases-31.6%) followed by Post Thyroidectomy (4 cases-21%). According to a dissertation done by Minu Madeswaran [9], out of 15 patients, the cause was idiopathic in 8 patients(53.4%) and Post thyroidectomy in 3 cases (20%).

Key Message

1. Avoiding risk factors like smoking, alcohol and voice abuse and creating public awareness regarding the ill effects of smoking and alcohol.

2. Detailed and early evaluation of hoarseness especially if it lasts for more than 2 weeks is important to rule out the possibility of malignancy, which has very high rates. Hence screening among people is required for early detection.

3. Educating the people especially vocal performers regarding vocal hygiene and also about the proper use of voice by avoiding activities as yelling, screaming and habitual throat clearing.

To summarise, hoarseness as a symptom should not be taken lightly as failure to give prompt medical attention may lead to serious consequences.

Funding

No funding has been used for this research. This research was ethically approved by the Institutional Review Board.

Declarations

Conflicts of Interest

There are no potential conflicts of interest (financial or non-financial).

Informed Consent

I…………………….have been informed about the study titled ‘Aetiology and predisposing factors of hoarseness of voice ’ being conducted by Dr. Liza Mathew Luke of the department of Otorhinolaryngology. I have been explained about the nature of the study and my questions have been answered satisfactorily. I have been informed about the risk (if any) associated with the procedures during the study. I voluntarily agree to be included in the study. I understand that blood tests or other tests may be needed for the study. I will inform the investigator about any untoward incident during the study.

I am aware that I have the freedom to opt out of the study, at any time, without being asked for any reason, thereof.

I have been informed that my treatment will not be affected, even if I do not join the study or leave the study at any time. I have been informed that no additional expenses are to be borne by me for the purpose of the study.

I understand that the results of the study will be published or released without any further intimation to me, but respecting the confidentiality and without my identity being revealed.