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VOICE ALTERATIONS DUE TO TRAUMA AND LARYNGEAL LESIONS A SYSTEMATIC

REVIEW

Cáceres, Ingrid1, Mora, Paula2, Soto, Merlys3.

1
Santander/ Bucaramanga 1, Manuela Beltrán University, Bucaramanga, Colombia.
2
Cundinamarca, / Bogotá 2, Manuela Beltrán University, Bogotá, Colombia
3
Santander/ Bucaramanga 3, Manuela Beltrán University, Bucaramanga, Colombia.

Keywords: Wounds and Injuries, trauma, coronavirus infections, larynx, voice.

vocal fatigue. On the other hand, at acoustic level the

INTRODUCTION
In the following article, a short systematic review will
be made for academic purposes from the physiology and
pathology of the voice. This study was aimed at knowing
the side effects on the voice due to trauma and laryngeal
lesions through evaluation instruments in which the
affectations of the anatomical structures involved in voice
production are evidenced. Understanding that the voice is
the tool most used by humans for their verbal
communication and participation of the subject in different
social contexts.
Currently, the health system has been modified due to
the health emergency that the world is facing because of the
SARS pandemic - COVID- 19. This has led to the
reinvention of different strategies by voice professionals to
be able to perform evaluation, diagnosis and treatment of
different voice pathologies. This has led to the analysis of
which is the most favorable instrument for the management
of patients with trauma and laryngeal injuries.
Among the relevant data found, it was known that
laryngeal trauma constitutes a group of infrequent injuries,
but of great clinical importance given its high
morbimortality. It requires a high level of suspicion, since
many of these injuries may go unnoticed in the initial
evaluation. All patients should be suspected of presenting
with cervical trauma and symptoms ranging from
dysphonia and anterior cervical pain to dyspnea and even
severe respiratory involvement due to airway obstruction.
The approach to these patients should begin with the
evaluation of the airway and ensure its stability, and then
focus on the specific diagnosis and management of the
injuries. (Ortiz, L. Barahona, L. Araya, P., 2019) Some of
the most relevant perceptual symptoms of the traumas and
laryngeal injuries found in the systematic search that were
observed in the hospital area are: dysphonia, hoarseness,
murmur, apnea, roughness,
following symptoms can be evidenced: low fundamental
frequency, shimmer and diminished jitter. However, after
carrying out the systematic search, it was possible to
evidence that there are still few articles related to traumas
and laryngeal lesions in times of COVID - 19.
METHODS
As a first step in this systematic review, a keyword
search was conducted on Decs (descriptors in health
science), in which 5 descriptors were found that helped to
strengthen the search for articles, these descriptors are
accompanied by their definitions.
Later, to guarantee the advanced search in databases, the
following equation was proposed: (injuries) or (trauma)
and (voice disorders). The databases used were, Elseiver,
Science direct, SciELO Analytics, Directory of open access
journals, Virtual book of training in ENT, Ebooks. Finding
a total of 588 articles. To structure and organize the
information, a flow chart was made to help create a meta-
analysis which allowed the classification of the articles
according to the inclusion and exclusion criteria, taking into
account parameters such as: main topic, year of publication
(2015 to 2020), language, focus of the article, type of
research that was carried out, characteristics of the voice
and its evaluation instruments. (Figure 1).
Table 1. Selected articles according to database
Databases Number of items found
Elseiver 1
Science direct 3
eBooks 7 - 24 2

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 disruption of structural continuity. Trauma: Clinical
distress among descendants of survivors of mass trauma, as
SciELo Analytics 4
if they had suffered through the same extreme historic
circumstances. Symptoms may persist through generations.
Coronavirus infections: Virus diseases caused by the
Figure 1. Flow chart coronavirus genus. Some specifics include transmissible
enteritis of turkeys (enteritis, transmissible, of turkeys);
Search equation feline infectious peritonitis; and transmissible
gastroenteritis of swine (gastroenteritis, transmissible, of
(injuries) or (trauma) and
swine). Larynx: A tubular organ of voice production. It is
(voice disorders)
located in the anterior neck, superior to the trachea and
inferior to the tongue and hyiod bone. Voice:The sounds
produced by humans by the passage of air through the
Elsevier, Science Articles found larynx and over the vocal cords, and then modified by the
direct, eBooks 7 -24, outside the resonance organs, the nasopharynx, and the mouth.
SciELO Analytics databases:
On the other hand, within the search it was found that
(n=0) the objective evaluations (direct and indirect laryngoscopy,
laryngoscopy, fibrolaringoscopy) of the voice play a more
important role than the subjective ones (GRBAS scale,
Total database search Cape - V, Wilson vocal profile) due to the delicate medical
results conditions in which the patient arrives, since these
(n= 588) circumstances, in most cases, compromise the airway
putting his life at risk.
A continuación, se definirán las características más
relevantes sobre las patologías de traumas y lesiones
Excluded records laríngeas. Una de ellas es el laryngeal granuloma It is an
after criteria filtering elevated lesion generally covered by a very thin or ulcerated
(n=577) superficial appearance affecting one or both vocal cords and
which sits on the vocal processes of the arytenoids.
Symptoms: The symptoms are a dysphonia characterized by
a fundamental frequency. Low that is accompanied by vocal
fatigue and the need to clear the voice by coughing or
articles selected frequent clearing Often accompanied by pain and bodily
according to the sensation body strange pharynx. Uno de los más
inclusion criteria mencionados en este artículo es laryngeal trauma: it is a
trauma that affects cartilage, mucosa, soft tissue nerves and
adjacent structures. two types: closed laryngeal trauma and
penetrating laryngeal trauma. Symptoms: Hoarseness,
The results of this bibliographic search allowed us to laryngeal pain, dyspnoea, dysphagia, aphonia, apnea.
know the key aspects involved in each pathology related to (Ortiz, L, et al, 2019).
laryngeal trauma and injuries and the possible voice
affectations in each of them. The most relevant pathologies Finalmente, Contact ulcers of the larynx: They are
were: laryngeal granuloma, contact ulcers in the larynx, usually caused by abuse of the voice in the form of sudden
closed laryngeal trauma, penetrating, laryngeal trauma after and repeated glottal attacks (sudden increase in volume at
inhalation injury and external laryngeal trauma and thyroid the beginning of phonation), which singers often
cartilage fracture. experience. They can also occur after endotracheal
intubation if an oversized tube erodes the mucosa lining the
Finally, a case report was consulted which was carried cartilage vocal processes. Symptoms: In varying degrees of
out in April 2020 at the Carlos Manuel de Cespedes hoarseness and mild pain on phonation and swallowing.
University Provincial Hospital in Cuba. Knowing that this (Barahoma, et al, 2019).
study was carried out in times of COVID - 19
Como se mencionaba anteriormente existen diversos
DISCUSSION tipos de evaluaciones objetivas las cuales ayudan a un
En la metodología se mencionan las palabras claves y sus diagnóstico acertado de las complicaciones que se producen
respectivas definiciones siendo estas: Wounds and en la voz a causa de un trauma, dentro de las evaluaciones
injuries: Damage inflicted on the body as the direct or más conocidas tenemos: Pharyngo-laryngeal fibroscopy:
indirect result of an external force, with or without procedure used for the diagnosis and treatment of diseases

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of the pharynx and larynx. This instrument allows you to Flexible Direct Laryngoscopy and the Exploratory
see the intervention area and illuminate it. Often this Cervicotomy constitute an effective method for the
diagnostic method is used to take biopsies in the territory diagnosis being this last one fundamental for the treatment.
that is scan, for the removal of small lesions in the scanned
area or to inject certain substances. It is performed under
local anesthesia that can be accompanied by sedation and Table2. Classification of laryngeal lesions.
analgesia according to the cases. Indirect laryngoscopy: it
can be done in the office using a small hand mirror that is
held directly to the palate. It will point the light toward the Symptoms and signs
roof of the mouth, helping the doctor to examine the larynx, Groups
vocal cords, and hypopharynx (lowest part of the
pharynx).laryngoscopy is generally not performed in Minor laryngeal hematomas or
children as it tends to cause gagging and may be difficult Group 1
lacerations with no detectable
for them to tolerate. Laryngostroboscopy: Is a diagnostic fracture.
imaging test that allows the speech therapist to visualize the
vocal.
On the other hand, we have an article that consists of a
case report of open laryngeal trauma where we are given Minor laryngeal hematomas or
the following case presentation is a 37-year-old black male lacerations with no detectable
patient, urban origin, with no history of disease. He is taken Group 2 fracture. Edema, hematoma,
to the emergency department of Otolaryngology because he minor mucosal tear without
received a bullet in the posterior region of the neck behind exposure of the cartilage, with
the sternocleidomastoid that crosses the larynx and has as
variable affectation of the
exit the anterior region of the contralateral neck in front of
the sternocleidomastoid. It presents aphonia, difficulty to airway. No displaced fractures.
breathe, decay and painful neck movements. He is promptly
taken to the operating room as shown in (Figure 3).

Figure 3. Image Massive edema, extensive

mucosal tearing, exposed
Group 3 cartilage, displaced fractures,
immobility of the vocal cord.

Same as group 3, but more

severe tearing of the anterior
Group 4 area of the larynx, unstable
fractures, two or more fracture
lines, severe mucosal injuries.

A direct laryngoscopy intervention with flexible Group 5 Complete laryngotracheal

gastroscope was proposed, in which it is observed and separation
edema of epiglottis, decreased mobility of the left
hemilarynx, loss of continuity (hole corresponding to the
exit of the projectile) in ventricular band and left ventricle
of Morgani, edema and congestion in the whole area that
does not allow visualizing the vocal cord, reduced glottic GROUP 3: Massive edema, extensive mucosal tearing,
space. exposed cartilage, displaced fractures, immobility of the
Finally, it was possible to conclude from this article that vocal cord.
the promptness of the diagnosis will guide us towards
timely treatment and thus save the patient's life. The

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 GROUP 4: Same as group 3, but more severe tearing of
the anterior area of the larynx, unstable fractures, two or
more fracture lines, severe mucosal injuries.
GROUP 5: Complete laryngotracheal separation
CONCLUSION
This systematic review as an academic activity allowed
the consolidation and analysis of basic concepts from
anatomophysiology to the evaluation and diagnosis of
traumas and laryngeal injuries that can greatly affect the
voice in people who have suffered these same injuries. A
series of specific characteristics of each case became
evident.
With the health problems of the COVID - 19 pandemic,
new strategies have been implemented for the evaluation,
diagnosis and intervention of the voice, it is the purpose and
responsibility of the voice professional to know each one of
them and how it should be applied in the best way to obtain
accurate data and results that will support the treatment of
this one. That is why when talking about trauma or
laryngeal lesions goes beyond the implemented by tele-
practice or teleconsultation, ie, talking about a medical
place where this person attends. And it is the duty of the
speech therapist to have his personal protection elements to
carry out his work and provide a quality service where his
protection and that of the user are being ensured.
Likewise, it can be deduced that for this type of injury
or trauma, objective tests are more relevant for the
diagnosis, because many times the user arrives at an
emergency service endangering his life because a vital
function for the human being, such as breathing, is
compromised and at the same time he is supporting the
production of the voice. In some cases, it is impossible to
obtain a subjective evaluation that covers this perceptual
evaluation of the voice in a timely manner. Finally, to give
relevance to the role of the phonoaudiologist in the
treatment and rehabilitation of the voice, generating
improvement in the quality of life, communication and
participation in all environments.
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