Laryngology and Voice Disorders: Dysphonia, Airway, and Swallowing
Laryngology questions hinge on history and laryngoscopy. Any dysphonia lasting more than 3 weeks, especially in a smoker, requires visualization of the larynx. Distinguish organic causes (vocal fold nodules, polyps, cysts, papilloma, carcinoma, paralysis) from functional causes (muscle tension dysphonia, spasmodic dysphonia).
Know the benign mucosal lesions: nodules are bilateral, at the junction of the anterior and middle thirds (phonotrauma); polyps are typically unilateral and related to vocal abuse or smoking; Reinke edema is smoking-related and bilateral. Recurrent respiratory papillomatosis (HPV 6/11) causes hoarseness and airway obstruction; treatment is repeated surgical debridement, and HPV vaccination reduces incidence.
Understand vocal fold paralysis: left recurrent laryngeal nerve is longer and more vulnerable (thoracic disease); right is shorter. Bilateral paralysis can cause airway obstruction and stridor; unilateral paralysis causes a breathy voice. Also know spasmodic dysphonia (adductor type: strained, strangled voice; botulinum toxin treatment) and laryngopharyngeal reflux (globus, throat clearing, posterior laryngitis).
Traps: attributing hoarseness to reflux without visualizing the larynx; missing airway compromise in bilateral vocal fold immobility; and confusing muscle tension dysphonia with structural pathology.
Rule of thumb: "Hoarseness >3 weeks = look at the larynx."
Worked example: A 60-year-old smoker with 6 weeks of hoarseness and a neck node has a laryngeal mass on flexible laryngoscopy. Proceed to biopsy and staging imaging; do not treat empirically for reflux.