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ORIGINAL ARTICLE
Year : 2022 | Volume
: 29
| Issue : 4 | Page : 341-346
Hoarseness in a nigerian tertiary health facility: Prevalence, aetiology and predisposing factors
Foluso Mercy Adeyeye, Kufre Robert Iseh, Mohammed Abdullahi
Department of Ear, Nose and Throat Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
Correspondence Address:
Foluso Mercy Adeyeye
Department of Ear, Nose and Throat Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/npmj.npmj_184_22
Objectives: To determine the prevalence, aetiology and predisposing factors in patients presenting with hoarseness to Usmanu Danfodiyo University Teaching Hospital, Sokoto. Methods: The study was a prospective, hospital-based study involving patients with hoarseness ≥7 years. Demographic characteristics and information on voice abuse, smoking, alcohol ingestion and gastroesophageal reflux disease (GERD) were taken. Participants had laryngeal endoscopy using a flexible nasopharyngolaryngoscopy to determine the cause of hoarseness. Results: A prevalence of 2.97% was obtained in the study, and the age range of participants was 7 to 78 years, with a male:female ratio of 1.3:1. The most common cause of hoarseness was laryngeal inflammation 38 (40.0%), followed by benign neoplasm 24 (25.3%) , malignancy 20 (21.1%) and trauma 10 (10.5%). Voice abuse, GERD and smoking were significant predisposing factors for benign neoplasm (χ2 = 8.73; P = 0.0031), inflammation (χ2 = 19.79; P < 0.0001) and malignancy of the larynx (χ2 = 10.66; P = 0.0011), respectively. Conclusion: The study showed that acute and chronic laryngeal infection and neoplasms (benign and malignant) of the larynx were the most common causes of hoarseness. Voice abuse, smoking and GERD were the commonest predisposing factors.
Keywords: Hoarseness, laryngeal cancer, laryngeal infection, laryngoscopy, smoking, voice abuse
Voice may be a growl, babble, cry, song or any form of sound produced by the vibration of the vocal cords in the larynx when air is exhaled from the lungs against adducted vocal folds.[1],[2] It is an important tool for communication and expression of personalities and defines an individual intellectually and culturally.[3] A normal voice is a product of the vibrating vocal folds, combined with resonation of the sound throughout the vocal tract plus the input of the articulators. It should be audible, attractive, stable and appropriate for age and sex.[4] This is dependent on the intensity, pattern, rhythm and fundamental frequency of the voice, as well as a balance between oral and nasal resonance.[5] There is no clear definition of voice quality.[6] However, it depends on vocal folds adduction during phonation and the consistency of the mucosal waveforms.[4]
Hoarseness (voice change) is a pathological disorder of voice referring to a perceived rough, harsh or breathy quality of the voice.[7] It occurs as a result of functional and/or structural changes in the vocal cord, which can be due to laryngeal inflammation, trauma, neoplasm or vocal cord mobility disorder.[8],[9] For example, incomplete vocal cord adduction results in leakage of air, giving a breathy voice; conversely, a strongly adducted vocal cord will result in a strained voice, while asymmetric waveforms will give rise to irregular sound.[4] Patients with hoarseness present with a variety of associated symptoms such as throat clearing, sore throat and voice fatigue.[8] In addition, there may be a history of smoking, stress, intense voice use and upper respiratory tract infection.[10] This study, was therefore designed to determine prevalence, aetiology and predisposing factors of hoarseness in Sokoto, Nigeria. Data obtained from this study will provide information that can be used as a baseline for further studies of hoarseness in Nigeria.
MethodsStudy area
The study was carried out at the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Sokoto State. Sokoto state is located in the semi-arid zone within the northwestern region of Nigeria and lies between 5°E and 6°E and between 13°N and 14°N. The state has an annual rainfall between 500 and 1300 mm, with the highest peak in August. The cold harmattan marks the beginning of the dry season, usually from October to March, while the hot season extends from April to the end of May.[11] The temperature ranges from about 14°C to 41°C with an annual average of 28.3°C.
Study participants
The study population included adults and children above 7 years with hoarseness presenting to ENT Department, accident and emergency unit and general outpatient clinic of UDUTH Sokoto and consented to the study.
Study design
It was a cross-sectional, prospective, hospital-based study from December 2019 to February 2021. All patients (above 7 years) who presented with hoarseness and gave informed consent to participate were included in the study. However, children below 7 years and patients with nasal mass or oral mass were excluded. Demographic characteristics such as age, occupation and gender were obtained. In addition, information on the history of voice abuse, smoking, alcohol ingestion and gastroesophageal reflux disease (GERD) was obtained. Participants also had laryngeal endoscopy using a flexible nasopharyngolaryngoscope to establish the aetiology of hoarseness.
Sample size
This was determined using Cochran's formula as below:[12]
Where:
n = minimum required sample size in the population >10,000
Z = 1.96
p = proportion of success or prevalence from a previous study
q = proportion of failure (1.0 − p)
d = precision, the tolerable margin of error, expected difference
Using a prevalence of 5.7% obtained from pilot study in UDUTH, Sokoto as described by Srivastava;[13]
p = 5.7%
q = 1 − 0.057 i.e. 0.943
d = 5%
n = Z2pq/d2
n = 82.6
n is approximately 83.
Allowing for 10% attrition, a minimum of 92 was to be sampled. However, 95 patients were used for the study.
Ethical consideration
Ethical clearance was obtained from the Ethics and Research Committee of the UDUTH, Sokoto (UDUTH/HREC/2019/NO. 807). Informed consent/assent was obtained before patients were included in the study.
Data analysis
Data collected were entered into International Business Machine (IBM)-Statistical Product and Service Solutions (SPSS) version 20.0 Armonk, New York, USA. This was analysed using descriptive statistics such as frequency distribution. In addition, Chi-square (with Yate's correction) test was used to assess the association between aetiology and predisposing factors. Data obtained are presented in tables.
ResultsA total of 3,433 patients with otorhinolaryngological complaints presented to UDUTH within the study period. Of this, 102 participants presented with hoarseness, giving a prevalence rate of 2.97%. Thirty-one (30.4%) participants had acute hoarseness, while 71 (69.6%) had chronic hoarseness. However, 95 of the total participants with hoarseness met the inclusion criteria, consented and were recruited. Seven participants who were children below 7 years of age were excluded from the study.
The socio-demographic data of participants are presented in [Table 1]. The participants' age ranged from 7 to 78 years, with a mean of 39.82 ± 20.97 years. The majority 15 (15.8%) of the participants sampled were age group 7–15 years, while the least age group was 43–51 years 7 (7.4%). Male participants predominated in this study 54 (56.8%) with a male:female ratio of 1.3:1, while pupils/students were the major occupation 22 (23.2%). This was followed by teachers 16 (16.8%), traders 15 (15.8%) and homemakers 12 (12.6%). The least occupation were singers, welders and drivers with 2 (2.1%) each.
Table 1: Demographic data of participants recruited for the study (n=95)The aetiology and predisposing factors of hoarseness in participants presenting with hoarseness to UDUTH are shown in [Table 2]. The most common aetiology of hoarseness was inflammation 38 (40.0%), comprising chronic non-specific laryngitis 26 (27.3%) and acute laryngitis 12 (12.6%). Benign neoplasm was the second most common aetiology and included vocal cord nodules 10 (10.5%), vocal cord polyps 6 (6.3%), recurrent respiratory papillomatosis 6 (6.3%) and papilloma 2 (2.1%). The third most common aetiology of hoarseness in this study was malignancy 20 (21.1%), and this involved the larynx 13 (13.7%), thyroid 6 (6.3%) and hypopharynx 1 (1.1%). Trauma of the larynx 10 (10.5%) was the fourth most common cause of hoarseness among participants in this study. This comprised Cloth-line injury from hijab-strangulation 5 (5.2%), penetrating injury 3 (3.2%), post-thyroidectomy 1 (1.1%) and traumatic intubation 1 (1.1%). Foreign body 3 (3.2%) was the least cause of hoarseness in this study.
Table 2: Aetiology and predisposing factors of hoarseness in participants presenting to Usmanu Danfodiyo University teaching hospital (n=95)GERD was a significant (P < 0.001) predisposing factor in participants with inflammation, while voice abuse was significant (P < 0.001) in participants who had benign neoplasm. Smoking was a statistically significant (P < 0.001) predisposing factor in participants with malignancy. Alcohol was not a significant (P > 0.001) predisposing factor among all the participants in the study.
DiscussionHoarseness is a voice-related disorder that adversely affects participants' physical, social and work-related activities.[14] This study noted a prevalence rate of 2.97% for hoarseness, which is similar to the findings of Adegbiji et al.,[15] who reported an incidence rate of 2.4% in Ado Ekiti, Nigeria. However, it is higher than the reports of Cohen et al. in the US as well as Khurshid et al. and Banjara et al. in India, who reported rates of 0.98 %, 0.48 % and 0.45 %, respectively.[14],[16],[17] The reason for this is unknown despite sampling a similar age group as the present study but may be associated with differences in the study location. Studies on the prevalence of hoarseness are few, as most reports are from hospital-based studies, which only evaluated the pattern of hoarseness without establishing the prevalence in the facilities.[9],[18],[19] There were more participants with chronic hoarseness than acute, probably because hoarseness is perceived as a non-life-threatening voice disorder.[20] Most patients with hoarseness present late because they often manage it conservatively and only report to the hospital when it persists.
The majority of the participants with hoarseness in this study were aged 7–15 years. This is different from earlier reports in Nigeria,[15],[19] India and the US.[14],[21],[22],[23] The age group 34–42 years was the second most common age group in this present study. This was the most common age group reported by Alabi et al.[19] Their study was on school teachers in a Local government area in Lagos. Thus, it was among adults only and children were not included. The mean age of participants with hoarseness was 39.69 years, similar to previous reports,[19],[23] but lower than the reports of Okhakhu and Emma-Nzekwue,[24] Nwaorgu et al.[25] and Cohen et al.[14] The differences may be associated with variations in the study population and design. Most of these previous studies involved participants 20 years and above.
Hoarseness is an occupation-related disorder common among teachers, singers, social workers, lawyers and clergymen.[26] However, pupils and students were the major groups with hoarseness in the present study, contrary to earlier studies where homemakers[15],[20],[21] and labourers,[27],[28] were observed as the majority. Pupils and students are young people who place a premium on social interactions, hence requiring their voice for effective communication with tutors and peers. This may have been the drive for them to seek medical attention for any voice-related problem. Unlike in previous studies, the socio-cultural environment of the study location may limit the number of women presenting to health facilities. Most homemakers may wait to get permission from their husbands before visiting the hospital. Teachers were the second most common group presenting with hoarseness in this study. This is not unexpected since voice change is a known occupational hazard among professional teachers.[19] They develop hoarseness by using their voice with high intensity in noisy classes for a long time without suitable breaks.[29] In addition, teachers are prone to upper respiratory tract infections capable of causing hoarseness, especially in crowded classrooms.[30]
There were more males than females with hoarseness in the present study. This is consistent with previous reports in Benin, Ibadan and Maiduguri, all in Nigeria,[9],[24],[25],[31] and in India.[16],[17],[21],[27] However, this is in contrast with the report of Alabi et al. in Lagos, Nigeria,[19] and Gupta and Jamwal in India,[22] who reported a female preponderance. In developing societies, over one-third of the labour force relies on their voice as their primary work tool.[32] Hoarseness greatly impacts a person's communication skills, causing physical, social and emotional disabilities that will impair their productivity.[14],[23] Hence, more males tend to seek medical attention for voice-related conditions. Alabi and colleagues reported more females than males due to the nature of their study population, which had a higher number of females from the onset of the study.[19] Similarly, the majority of the participants with hoarseness in the study of Gupta and Jamwal,[22] were homemakers, and this could explain the female preponderance.
All causes of hoarseness in this study were of organic origin. Laryngeal inflammations comprising chronic non-specific and acute laryngitis were the most common cause of hoarseness. This agrees with previous reports in Benin,[18] Ado-Ekiti,[15] and Ibadan,[25] all in Nigeria as well in US,[14] but disagrees with the report of studies in India.[16],[17],[33] Acute laryngitis is usually of viral origin[34] and often results from upper respiratory tract infections. They are typically self-limiting, but bacterial superimposition may occur, leading to chronic laryngitis, which is a more severe form. In addition, GERD was a significant predisposing factor in patients with inflammatory lesions. GERD is a chronic disease that occurs when gastric acid comes in contact with the laryngeal and pharyngeal epithelium causing chronic inflammation and leading to hoarseness.[35]
Benign neoplasm of the larynx was the second most common cause of hoarseness in the present study. This comprised vocal cord nodules, vocal cord polyps, recurrent respiratory papillomatosis and papilloma. This is similar to the reports of Adegbiji et al.[15] in Ado Ekiti, Nigeria and that of Mahmood and Varshney in India.[36] However, it differs from the reports of Banjara et al.[17] and Pal et al.[27] in India. Among the benign neoplasms, vocal cord nodules and polyps were the most common, and these lesions usually occur following voice abuse.[15] Prolonged voice abuse leads to vascular congestion, oedema and possibly hyalinisation of the vocal cord epithelium, thereby forming nodule.[37] Malignancies of the larynx, thyroid glands and hypopharynx were the third most common cause of hoarseness, similar to the reports of Nwaorgu and Okhakhu and Emma-Nzekwue.[24],[38] Smoking was a significant predisposing factor for hoarseness in this study. This is in agreement with the reports of Banjara et al.[17] and Mahmood and Varshney in India.[36] Smoking and alcohol have been implicated in the occurrence of laryngeal carcinoma,[33] and cigarette smoking is a common practice in Sokoto.[39]
ConclusionThe study showed a point prevalence rate of 2.97% in patients presenting with hoarseness to UDUTH, Sokoto. The aetiology of hoarseness in presenting patients were acute and chronic laryngeal infection as well as neoplasms (benign and malignant) of the larynx. Voice abuse was a significant predisposing factor in patients with benign neoplasms of the larynx. GERD and smoking were the significant predisposing factors in patients with laryngitis and malignancy, respectively.
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Nil.
Conflicts of interest
There are no conflicts of interest.
References
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