Diseases Of The Nose Throat And Ear

CHAPTER 31
INVESTIGATION OF LARYNGEAL DISEASE

HISTORY. As the patient gives his history it is possible to form some opinion as
to the cause of the voice problem. If he is aphonic the vocal cords are not
meeting, and if he is dysphonic the vocal cords are meeting but the mucosal
surfaces are damaged in some way. The volume and the quality of the voice
can also give some help in cases of voice strain, neuromuscular problems and
hysteria.

Inquiry must be made about the onset of the problem and its progress since
the onset. The onset of a vocal cord paralysis is sudden and the voice gradually
improves as the mobile cord compensates. On the other hand, the onset of a
carcinoma or vocal cord polyp or nodule is gradual, and the hoarseness
increases as time passes. Most inflammatory conditions start fairly quickly
and then gradually improve. One must inquire about precipitating and
alleviating factors.

Not many laryngeal conditions, apart from cancer, arthritis and peri-
chondritis, give rise to pain but many laryngeal conditions may cause an
irritating cough. Laryngeal pain is usually referred to the ear.

If the arytenoids are swollen they will partially obstruct and overhang the
mouth of the oesophagus causing dysphagia. Another form of difficulty in
swallowing may be caused if the vocal cords fail to meet. In this event
swallowing is incoordinate because the patient cannot create a positive
subglottic pressure when the glottis is open with the result that food tends to
enter the trachea through the gap to give rise to bouts of coughing.

The patient's social habits must be investigated, especially with respect to
smoking, exposure to occupational air pollution and vocal abuse. With
regard to vocal abuse one must not forget that shouting at a deaf relative in
the home is every bit as traumatic as vocal abuse at work.

Lastly, inquiry must be made regarding the general health and past medical
history of the patient.

GENERAL EXAMINATION. While examination of the larynx is of paramount
importance a general examination must be performed. The neck is examined
for lymph node enlargement or added masses on the larynx. The size, shape
and mobility of the laryngeal framework are studied. The ears and naso-
pharynx are examined because tumours in these areas may paralyse the
laryngeal nerves. Myxoedema often affects the larynx and therefore the
configuration of the thyroid gland and the skin, hair and nails of the patient
must be examined.

INDIRECT LARYNGOSCOPY. It is impossible to teach indirect laryngoscopy by
the written word. Nothing can take the place of practice in order to learn the
skill. It is necessary to use a headlight, whether powered by a battery or by
mains electrical supply through a transformer, or to use light reflected on to a

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