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- Laryngitis -
10/14/04 re: Allergic cause of dysphonia I have a patient who has been referred to me with intermittent attacks of dysphonia. She has been assessed by ENT Specialists and a definite mild symmetrical edema of both ary-epiglotic folds has been documented. She is known to have allergies to strawberries though I could not confirm this on SPT which we did for several aero and food allergens. Do you think dysphonia can be explained on the basis of allergies? Do you suggest any more allergy tests for her? Do you think a trial of restricted diet is indicated? This lady is otherwise healthy and well and this problem has been there for the last 14 months.
I think that a food allergy is an unlikely cause of isolated dysphonia with the laryngeal findings you described. One can see posterior pharyngeal edema in the Oral Allergy Syndrome (OAS) as a contact response, most commonly as part of an allergy to certain fresh fruits. However, such episodes almost always also have edema of the anterior pharyngeal mucosa and/or lips. In some cases, there is erythema and itching in the peri-oral skin area. I assume from your lack of mentioning this that the OAS is highly unlikely here. Therefore, I think that extensive food skin testing and a food elimination diet would likely have very low yield and would not do that first.
A few diagnostic possibilities come to my mind. One always thinks of vocal abuse, particularly in certain occupations and in mothers shouting at children frequently. However, my understanding of this condition is that there is more of a diffuse involvement of the vocal cords. Certain chronic infections can involve the larynx, with certain patterns such as the involvement of the posterior aspect of the cords in Tbc. Most of such Tbc cases occur in the presence of pulmonary involvement. Vocal cord dysfunction can present with dysphonia and sometimes asthma-like symptoms. The diagnosis is confirmed by seeing paradoxic narrowing of space between the vocal cords during inspiration during laryngoscopy when the patient is symptomatic.
A real possibility as a cause of this picture is laryngealpharyngeal reflux (see enclosed abstracts). Patients diagnosed with this disorder frequently have intermittent dysphonia, throat clearing and an upper airway-type cough. Because of reflux of upper G-I contents into and around the larynx, diffuse edema in laryngeal components may be seen. One has to be fortunate to observe a period of reflux using video-laryngoscopy to make this diagnosis.
Am J Med. 2003 Aug 18;115 Suppl 3A:90S-96S.
Abnormal endoscopic pharyngeal and laryngeal findings attributable to reflux.
Belafsky PC.
Scripps Center for Voice and Swallowing, La Jolla, California 92037, USA.The symptom complex associated with acid-induced injury to the larynx is referred to as laryngopharyngeal reflux (LPR). Basing the diagnosis of LPR on patient symptoms or 24-hour dual-probe pH data may be inaccurate, as these diagnostic tests are restricted by limitations in both sensitivity and specificity. The clinician must have a thorough understanding of endoscopic findings associated with this disorder. The severity of laryngeal inflammation caused by acid and activated pepsin can be quantified. This article reviews the abnormal endoscopic pharyngeal and laryngeal findings that are attributable to reflux.
Acta Otorhinolaryngol Ital. 2004 Feb;24(1):13-9.
Dysphonia and laryngopharyngeal reflux.
Cesari U, Galli J, Ricciardiello F, Cavaliere M, Galli V.
Department of Otorhinolaryngology, University "Federico 11", Naples, Italy.The correlation between laryngo-pharyngeal reflux and dysphonia has been evaluated in patients without significant laryngoscopic findings and without vocal misuse. Studies were performed, using a validated questionnaire on typical reflux symptoms as well as instrumental means, e.g. video-laryngoscopy, multi-electrode 24-hr oesophageal pH monitoring, vocal acoustic analysis, gastro-oesophagoscopy, on 62 patients (51 male, 11 female) with dysphonia for > or = 3 months, selected from 350) consecutive patients presenting with voice disorders. Standard criteria were: absence of laryngeal neoformation (benign or malignant) and correct use of voice. Anti-reflux treatment was prescribed in all selected patients. A group of 62 selected patients without laryngo-pharyngeal disease were studied as controls. Mean values of the harmonic to noise ratio and maximum phonation time were pathological in all patients with dysphonia and significantly correlated (p = 0) with the entity of the larynx alteration. The 24-hour pH monitoring revealed gastro-oesophageal reflux in all cases with a clear prevalence of episodes in the upright, compared to supine, position. From a multiple regression analysis of pH-metric values, considered important in predicting maximum phonation time and harmonic to noise ratio alteration. The significant predictors (p < 0.01) were those parameters indicating the existence of a laryngo-pharyngeal reflux disease: in an upright position, the prevalence of the number of refluxes and of time of pH < 4. In conclusion, the association between electro-acoustic reliefs and laryngoscopic data, as well as an alteration in maximum phonation time and harmonic to noise ratio in patients with pH-metric indicative parameters of laryngo-pharyngeal reflux disease led to the hypothesis of a possible correlation between entity and duration of the reflux and dysfunction of the arytenoid muscles, upon which chronic vocal fatigue, with consequent laryngeal compensatory stress, depends.
