今日の臨床サポート

嗄声・発声障害

著者: 平野滋 京都大学医学部附属病院 耳鼻咽喉科・頭頸部外科

監修: 森山寛 東京慈恵会医科大学附属病院

著者校正/監修レビュー済:2020/07/03
参考ガイドライン:
  1. 日本音声言語医学会/日本喉頭科学会:音声障害診療ガイドライン2018年版. 金原出版,2018
患者向け説明資料

概要・推奨   

  1. 嗄声・発声障害に対しては喉頭内視鏡検査、ストロボスコピー検査による診断が必要である(推奨度1)。
  1. 呼吸困難の有無を必ず確認し、急性喉頭蓋炎などの救急疾患を見逃さないことが重要である(推奨度1)。
  1. 嗄声・発声障害の各病態に応じた治療法の選択が重要である(推奨度1)。
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
平野滋 : 講演料(メルクセローノ株式会社)[2021年]
監修:森山寛 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューのうえ、画像を追加した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 発声障害の原因は多岐にわたるが、主に隆起性病変、神経原性疾患、変性疾患、機能性疾患に分けられる。
  1. 隆起性病変:最もよく遭遇する。声帯ポリープ、結節、嚢胞、ラインケ浮腫など。
 
声帯ポリープの内視鏡所見(1)

左声帯中央にポリープを認める。声の乱用が原因とされ、典型的には粘膜内出血が血腫を来したものと解釈されている。

出典

img1:  著者提供
 
 
 
声帯ポリープ

右声帯前中1/3に赤色の出血性ポリープを認める。

出典

img1:  著者提供
 
 
 
声帯結節の内視鏡所見(1)

両側声帯前方に小隆起を認める。音声酷使が原因で、子どもにできる学童結節、大人では高音発声を行う女性、特に保母、幼稚園などでの音声酷使者に多い。

出典

img1:  著者提供
 
 
 
声帯嚢胞の内視鏡所見(1)

右声帯やや後方に嚢胞を認める。上皮下に形成される真性嚢胞で、外傷を機転として形成される。病変が小さくても音声障害は高度であることが多い[10]

出典

img1:  著者提供
 
 
 
ラインケ浮腫(ポリープ様声帯)の内視鏡所見

両側声帯のびまん性腫脹を認める。喫煙が最大の原因とされ、粘膜内の浮腫を来す。粗造性嗄声(がらがら声)が特徴[11]

出典

img1:  著者提供
 
 
 
  1. 神経原性疾患:反回神経麻痺が最も多いが、けいれん性発声障害も増加傾向にある。
 
反回神経麻痺の内視鏡所見(1)

右声帯(向かって左)は発声時(b)に内転閉鎖するが、左声帯は麻痺しており、発声時に内転しないため発声時の声門閉鎖不全を来す。息漏れが高度なので気息性でハスキーな声になる。発声持続時間は著しく短縮し、QOLが悪化する。高度の場合は誤嚥を来す。
a:吸気時
b:発声時

出典

img1:  著者提供
 
 
 
けいれん性発声障害の内視鏡所見

発声時に急激な声帯の過内転を来し声が中断する。とぎれとぎれの声になるのが特徴。発声時に声帯より上部の構造物が拘縮して、声帯の観察がしにくくなることが多い
a:吸気時
b:発声時

出典

img1:  著者提供
 
 
 
  1. 変性疾患:声帯瘢痕、溝症
 
声帯溝症の内視鏡所見

両側声帯に溝を呈する陥凹がみられる。この部位は硬く変性し粘膜振動が障害されるため、高度の嗄声を呈する。先天性、後天性、混合性が考案されている[12]

出典

img1:  著者提供
 
 
 
  1. 機能性疾患:声帯粘膜や運動性に異常を認めない疾患であり、見落としやすい。性同一性障害も増加傾向にある。
問診・診察のポイント  
 
  1. 発声障害の原因を正確に診断する必要がある。

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文献 

著者: Clark A Rosen, Annie S Lee, Jamie Osborne, Thomas Zullo, Thomas Murry
雑誌名: Laryngoscope. 2004 Sep;114(9):1549-56. doi: 10.1097/00005537-200409000-00009.
Abstract/Text OBJECTIVES/HYPOTHESIS: The objective was to develop an abbreviated voice handicap assessment instrument and compare it with the Voice Handicap Index (VHI).
STUDY DESIGN: Item analysis of the VHI in individuals without voice disorders and patients with voice disorders and creation and validation of the abbreviated VHI.
METHODS: Clinical consensus review of the VHI items was held to prioritize the clinical value of each of the VHI items (30 items in all). Item analysis of the VHI was performed using the VHI responses of 100 patients with voice problems and 159 control subjects. The 10 most robust VHI items were selected using the item analysis and clinical consensus results to form the Voice Handicap Index-10 (VHI-10). Statistical analysis comparing the validity of the VHI-10 with the VHI was performed with 819 patients representing a wide spectrum of voice disorders.
RESULTS: Statistical analysis of the VHI and VHI-10 scores from the study group showed no statistically significant differences between the VHI and the VHI-10. Irrespective of diagnosis, the correlation between the VHI and the VHI-10 was greater than .90 (P = .01). The ratios of the VHI-10 to VHI scores for a variety of voice disorder categories were analyzed and found to be consistently greater than the expected value (33%). This suggests that the VHI-10 may be a more robust instrument than the VHI.
CONCLUSION: The VHI-10 is a powerful representation of the VHI that takes less time for the patient to complete without loss of validity. Thus, the VHI-10 can replace the VHI as an instrument to quantify patients' perception of their voice handicap.

PMID 15475780  Laryngoscope. 2004 Sep;114(9):1549-56. doi: 10.1097/000・・・
著者: Lucian Sulica, Alison Behrman
雑誌名: Ann Otol Rhinol Laryngol. 2003 Oct;112(10):827-33.
Abstract/Text Empirical data are often not available to guide clinical practices in the treatment of benign mucosal lesions of the vocal folds. The purpose of this report is to describe opinions and practices in order to identify areas of consensus and discrepancy and thus guide future inquiry. A 16-item survey mailed to all active US members of the American Academy of Otolaryngology-Head and Neck Surgery (n = 7,321) included questions on the use of voice therapy; diagnostic testing; perioperative use of steroids, antibiotics, and antireflux medications; and use of lasers. Responses used a Likert 5-point scale with end anchors of 1 equaling "never" and 5 equaling "always" and were stratified according to lesion (nodules, polyps, cysts). A 16.5% response rate (n = 1,208) was obtained. A lack of consensus was most evident in the use of voice therapy for lesions other than nodules; antireflux medication; and intravenous steroids. Disagreement was also noted regarding the use of lasers, oral steroids, and antibiotics. Other than voice therapy as initial intervention for nodules, no statistically significant differences by lesion type exist regarding use of voice therapy, laser, or any medication. Prospective clinical trials addressing voice therapy, antireflux medications, steroids, and antibiotics are needed to inform clinical practice. Furthermore, treatment practices appear to be largely independent of lesion type. Therefore, traditional diagnostic categories do not seem to be useful guides to treatment, and may need to be reevaluated in light of improvements in diagnostic technology and surgical technique.

PMID 14587971  Ann Otol Rhinol Laryngol. 2003 Oct;112(10):827-33.
著者: N Roy, C N Ford, D M Bless
雑誌名: Ann Otol Rhinol Laryngol. 1996 Nov;105(11):851-6.
Abstract/Text Excessive activity of the extralaryngeal muscles affects laryngeal function and contributes to a spectrum of interrelated symptoms and syndromes including muscle tension dysphonia and spasmodic dysphonia. Recognition of the role of extralaryngeal tension is helpful in ensuring proper diagnosis and selection of appropriate treatment. This report demonstrates the application of manual laryngeal musculoskeletal tension reduction techniques in the diagnosis and management of laryngeal hyperfunction syndromes. The manual technique consists of focal palpation to determine 1) extent of laryngeal elevation, 2) focal tenderness, 3) voice effect of applying downward pressure over the superior border of the thyroid lamina, and 4) extent of sustained voice improvement following circum-laryngeal massage. The clinical utility of this innovative approach is discussed.

PMID 8916858  Ann Otol Rhinol Laryngol. 1996 Nov;105(11):851-6.
著者: B J Poburka
雑誌名: J Voice. 1999 Sep;13(3):403-13.
Abstract/Text A newly developed stroboscopy rating form is presented. The evolution of the new form is discussed by focusing on how problems with another commonly used form led to its development. Interjudge agreement and intrajudge reliability data for the new rating form reveal that the parameters of phase closure, phase symmetry, and phase regularity remain difficult to rate even with the revised rating form.

PMID 10498056  J Voice. 1999 Sep;13(3):403-13.
著者: Albert L Merati, Stacey L Halum, Timothy L Smith
雑誌名: Laryngoscope. 2006 Sep;116(9):1539-52. doi: 10.1097/01.mlg.0000234937.46306.c2.
Abstract/Text OBJECTIVES/HYPOTHESIS: Vocal fold paralysis continues to be a dominant topic in laryngology. Although the majority of cases can be attributed to a known etiology, a significant number of patients present without a clear precipitating event. Over 1,500 studies regarding vocal fold paralysis exist in the medical literature, although only a small percentage report on the use of serum or radiographic testing for the evaluation of idiopathic paralysis. Despite this, patients are routinely subjected to diagnostic evaluation to investigate the underlying cause. To characterize contemporary practice, a national survey of the American Broncho-Esophagological Association (ABEA) membership was undertaken. It is hypothesized that the current practice of diagnostic testing for idiopathic vocal fold paralysis is not well supported by an evidence-based medicine (EBM) review of the available medical literature.
STUDY DESIGN: The authors conducted a national survey, systematic EBM review of existing literature.
METHODS: Surveys were mailed to all active ABEA members; responses regarding practice specialization as well as serum/radiographic diagnostic preferences for idiopathic vocal fold paralysis were tabulated and subjected to statistical analysis. To compare contemporary practice with evidence in the available literature, an EBM review was first performed. Articles for evaluation were selected from a Medline search of English-language abstracts related to adult vocal fold paralysis. The publications were individually reviewed and an EBM level and grade were assigned and compared with the survey results.
RESULTS: Eighty-four of 249 active members responded with 76 (31%) replies submitted for analysis. Specific serum tests were advocated by 41 of 76 (54%) respondents, although the majority (52 of 65 [80%]) felt that they were only "occasionally" or "never" necessary. The most common tests were rheumatoid factor (38%), Lyme titer (36%), erythrocyte sedimentation rate (34%), and antinuclear antibody (33%). Fifty-one of 71(72%) felt that computed tomography (CT) was "always" or "often" necessary and 50 of 72 (69%) replied that chest radiography (CXR) was "always" or "often" necessary. There was no significant difference between CT and CXR ordering (P < .51). In contrast, magnetic resonance imaging (MRI) was described as "always" or "often" necessary in 28 of 71 (39%) of the surveys, significantly less than CT (P < .0001). There was no statistical impact of practice specialization on ordering of serum tests (P = .25) or imaging (P = .50 for CT; P = .46 for CXR; P = .45 for MRI). Following analysis of 1,510 vocal fold paralysis abstracts, 19 publications were found to be appropriate for an EBM review of serum testing with 15 available for review of radiographic imaging. Only one study presented level III evidence; the remainder were levels IV and V comprised of retrospective series and case reports. The evidence supporting serum or radiographic testing toward the evaluation of idiopathic vocal fold paralysis is given an overall grade of "C."
CONCLUSIONS: Serum and radiographic testing for the evaluation of vocal fold paralysis is supported by grade "C" evidence only. There are no existing prospective studies estimating the clinical impact of testing on diagnosis or patient outcome. Current practice, as estimated by a survey of the ABEA membership, is not well founded for serum testing and only by retrospective case series with regard to imaging. Further study into the nature of idiopathic vocal fold paralysis and outcomes assessment of diagnostic paradigms may improve clinical practice.

PMID 16954976  Laryngoscope. 2006 Sep;116(9):1539-52. doi: 10.1097/01.・・・
著者: A E Aronson, L O Ramig, W S Winholtz, S R Silber
雑誌名: Ann Otol Rhinol Laryngol. 1992 Jun;101(6):511-8.
Abstract/Text In an attempt to clarify the origin and frequency characteristics of a rapid voice tremor, or "flutter," in patients with amyotrophic lateral sclerosis (ALS), eight patients (four men and four women; ages 42 to 70 years) who had ALS and rapid voice tremor and an age- and sex-matched control group of eight subjects were asked to sustain the vowel /a/ and their voices were recorded for later analysis. Each segment of phonation was demodulated into amplitude and frequency components. From each subject's 8-second amplitude and frequency signals, a fast Fourier transform analysis was done on a 1-second segment previously identified perceptually as having the most apparent tremor or flutter. The results showed that patients with ALS had multiple combinations of levels and frequencies for amplitude and frequency modulations in comparison with control subjects, who had consistently low levels of modulations. In an attempt to quantify the tremor or flutter in ALS, amplitude and frequency modulations were not clearly or predominantly represented at one point along the spectrum. Nevertheless, these frequency and amplitude modulations are more prominent in patients with ALS than in normal subjects. The origins of these aberrant frequency and amplitude modulations in ALS patients remain obscure, although speculation is that they are of peripheral rather than central nervous system origin.

PMID 1610069  Ann Otol Rhinol Laryngol. 1992 Jun;101(6):511-8.
著者: Raphael J. Leo, Ramesh Konakanchi
雑誌名: Prim Care Companion J Clin Psychiatry. 1999 Apr;1(2):39-46.
Abstract/Text BACKGROUND: Pulmonary disease such as asthma is a psychosomatic disorder vulnerable to exacerbations precipitated by psychological factors. A case is described in which a patient thought to have treatment-refractory asthma was discovered to have a conversion reaction, specifically paradoxical vocal cord dysfunction (PVCD), characterized by abnormal vocal cord adduction during inspiration. DATA SOURCES: Reports of PVCD were located using a MEDLINE search and review of bibliographies. MEDLINE (English language only) was searched from 1966 through December 1998 using the terms functional asthma, functional upper airway obstruction, laryngeal diseases, Munchausen's stridor, paradoxical vocal cord dysfunction, psychogenic stridor, respiratory stridor, vocal cord dysfunction, and vocal cord paralysis. A total of 170 cases of PVCD were reviewed. STUDY FINDINGS: PVCD appears to be significantly more common among females. PVCD spans all age groups, including pediatric, adolescent, and adult patients. PVCD was most often misdiagnosed as asthma or upper airway disease. Because patients present with atypical and/or refractory symptoms, several diagnostic tests are employed to evaluate patients with PVCD; laryngoscopy is the most common. Direct visualization of abnormal vocal cord movement is the most definitive means of establishing the diagnosis of PVCD. A number of psychiatric disturbances are related to PVCD, including conversion and anxiety disorders. PVCD is associated with severe psychosocial stress and difficulties with modulation of intense emotional states. CONCLUSIONS: Psychogenic respiratory distress produced by PVCD can be easily misdiagnosed as severe or refractory asthma or other pulmonary disease states. Recognition of PVCD is important to avoid unnecessary medications and invasive treatments. Primary care physicians can detect cases of PVCD by attending to clinical symptoms, implementing appropriate laboratory investigations, and examining the psychological covariates of the disorder. Psychotherapy and speech therapy are effective in treating most cases of PVCD.

PMID 15014694  Prim Care Companion J Clin Psychiatry. 1999 Apr;1(2):39・・・
著者: J Shvero, R Koren, T Hadar, E Yaniv, J Sandbank, R Feinmesser, R Gal
雑誌名: Pathol Res Pract. 2000;196(2):95-8. doi: 10.1016/S0344-0338(00)80039-4.
Abstract/Text Cysts of the true vocal cords are less common than other laryngeal cysts. They are usually easily recognized and managed. Patients present with complaints of hoarseness and/or dyspnea. We report our experience with 41 cases of cysts located in the true vocal cords. Clinical and histological aspects are reviewed and discussed. A new histological classification is proposed: A: cysts lined by columnar epithelium with mucous content; B: lined by columnar epithelium with cilia; C: lined b squamous epithelium without keratinization; D: lined by squamous epithelium with keratinization.

PMID 10707365  Pathol Res Pract. 2000;196(2):95-8. doi: 10.1016/S0344-・・・
著者: S M Zeitels, R E Hillman, G W Bunting, T Vaughn
雑誌名: Ann Otol Rhinol Laryngol. 1997 Jul;106(7 Pt 1):533-43.
Abstract/Text Reinke's edema (RE) has been associated typically with smoking and sometimes with vocal abuse, but aspects of the pathophysiology of RE remain unclear. To gain new insights into phonatory mechanisms associated with RE pathophysiology, we used an integrated battery of objective vocal function tests to analyze 20 patients (19 women) who underwent phonomicrosurgical resection. Preoperative stroboscopic examinations demonstrated that the superficial lamina propria is distended primarily on the superior vocal fold surface. Acoustically, these individuals have an abnormally low average speaking fundamental frequency (123 Hz), and they generate abnormally high average subglottal pressures (9.7 cm H2O). The presence of elevated aerodynamic driving pressures reflects difficulties in producing vocal fold vibration that are most likely the result of mass loading associated with RE, and possibly vocal hyperfunction. Furthermore, it is hypothesized that in the environment of chronic glottal mucositis secondary to smoking and reflux, the cephalad force on the vocal folds by the subglottal driving pressure contributes to the superior distention of the superficial lamina propria. Surgical reduction of the volume of the superficial lamina propria resulted in a significant elevation in fundamental frequency (154 Hz) and improvement in perturbation measures. In almost all instances, both the clinician and the patient perceived the voice as improved. However, these patients continued to generate elevated subglottal pressure (probably a sign of persistent hyperfunction) that was accompanied by visually observed supraglottal strain despite the normal-sized vocal folds. This finding suggests that persistent hyperfunctional vocal behaviors may contribute to postsurgical RE recurrence if therapeutic strategies are not instituted to modify such behavior.

PMID 9228851  Ann Otol Rhinol Laryngol. 1997 Jul;106(7 Pt 1):533-43.
著者: C N Ford, K Inagi, A Khidr, D M Bless, K W Gilchrist
雑誌名: Ann Otol Rhinol Laryngol. 1996 Mar;105(3):189-200.
Abstract/Text The term sulcus vocalis has been applied to a spectrum of disorders ranging from minor vocal fold indentations to destructive lesions causing severe dysphonia. To clarify the pathophysiology and to develop a more rational approach to treatment, we report a series of sulcus patients including 20 surgical cases. Clinical and histopathologic analysis produced a clinically useful classification: type 1 is a physiologic variant accentuated by atrophy but with intact lamina propria; types 2 (sulcus vergeture) and 3 (sulcus vocalis) are characterized by severe dysphonia, loss of vibratory activity, and destruction of the functional superficial lamina propria. These latter cases respond favorably to microsurgery designed to remove destroyed tissue, release scar contracture, and promote mucosal redraping by regional undermining. Further study of the extracellular matrix of the superficial lamina propria (Reinke's space) might indicate a common pathway in the pathogenesis of sulcus deformities and other related benign vocal fold lesions.

PMID 8615582  Ann Otol Rhinol Laryngol. 1996 Mar;105(3):189-200.

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