New-Onset Dysphonia: A Silent Manifestation of COVID-19

It’s been almost a year since the World Health Organization declared the novel Coronavirus outbreak as a global pandemic in March 2020. Amid the continuous effort to curb the disease, signs of slowing down are nowhere close and it appears that the outbreak has entered the fourth and strongest wave yet. Novel clinical manifestations are emerging rapidly on a daily basis. Dysphonia or perturbation of voice has recently been lauded as a manifestation of Coronavirus disease 2019 (COVID-19). ¹ Myriad etiologic factors have linked dysphonia and COVID-19 including postviral vagal neuropathy, inflammatory factor causing vocal cord edema or inflammation, vocal cord injury due to forceful coughing or vomiting, intubation injury which includes vocal cord granuloma, vocal cord palsy, crocoarythenoid joint dislocation, and dysphonia secondary to poor lung function or psychogenic cause.

A literature search was conducted to identify published articles on dysphonia in patients with COVID-19. The literature search was conducted on January 10, 2021, and articles published in PubMed were searched using the following search terms: dysphonia; hoarseness; COVID 19; SARS CoV 2.

A total of 4 articles were identified, including 2 cross-sectional studies and 2 case reports (Table 1). A total of 198 patients with female predominance was noted. All patients included had new-onset hoarseness or dysphonia as one of the manifestations of COVID-19.^1-4 Unilateral vocal cord palsy was identified in 1 article via a transcervical laryngeal ultrasound, whereas psychogenic cause was detected as the cause of dysphonia in one article. ³ None of the patients included had dysphonia as an isolated pathology of COVID-19. Resolution of symptoms was mentioned in 1 article. ³

Table 1.

Summary of Characteristics and Main Findings of COVID-19 Patients With Dysphonia.

Author	Type of study	Country	Total patients	Age	Gender	Dysphonia cause	COVID test	Investigations for Dysphonia	Treatment	Outcome
Lechien et al 1	RS	France	188	NR	44 Male 144 Female	NR	RT-PCR	NA	NR	NR
Buselli et al 2	CR	Italy	1	50	Female	Psychogenic	RT-PCR	Pneumology examination, chest CT scan, Brain scan, Echocardiography, Pulmonary ultrasound	Azithromycin + Hydrochloroquinine + Psychological support	NR
Eltelety et al 4	CR	Eqypt	1	27	Male	Unilateral vocal cord palsy (Right)	RT-PCR	Transcervical laryngeal ultrasound	Symptomatic	Improve
Elibol 3	RS	Turkey	8	NR	NR		RT-PCR	NR	NR	NR

Abbreviations: CR, case report; NA, Not available; NR, not reported; RS, retrospective study; RT-PCR, reverse transcription–polymerase chain reaction.

A recent study conducted by Asiaee et al to evaluate acoustic parameters of voice between healthy individuals and patients with COVID-19 revealed significant differences across various acoustic parameters to support that COVID-19 does affect the voice quality in affected individuals. In the same vein, alterations in acoustic parameters are hypothesized to be caused by insufficient airflow, increased aperiodicity, irregularity, signal perturbations, and level of noise resulting from laryngeal and pulmonary involvement. ⁵

It is interesting that postviral vagal neuropathy remains a possible etiologic factor ensuing the neurotrophic as well as neuroinvasive characteristics of severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2).

Postviral vagal neuropathy (PVVN) was a term coined by Amin and Koufman in 2001, pertaining to a group of upper aerodigestive manifestations ensuing vagal neuropathy resulting from an upper respiratory tract infection. ⁶ As both sensory and motor branches of the vagus nerve is affected, the manifestation of PVVN, which includes dysphonia, vocal fatigue, odynophagia, dysphagia, neuropathic pain, cough, globus, laryngospasm, excessive throat clearing, and signs of laryngopharyngeal reflux. ⁷ Vagus nerve contributes to both sensory and motor innervations of the pharynx and larynx. Laryngeal sensory disruption of the vagus nerve leads to cough, throat clearing, and globus, whereas motor disturbance leads to aphonia or dysphonia as well as vocal fatigue. Postviral vagal neuropathy has been traditionally diagnosed clinically with a prior history of recent upper respiratory tract while ruling out other discernable causes such as malignancy and trauma.

The inflammatory process involving laryngeal structures may lead to edema, erythema, and congestion. An ongoing study in the Anatomy Department of University of Mons reported that high expression of angiotensin-converting enzyme 2, a COVID-19 receptor, was found in vocal folds. ¹ Angiotensin-converting enzyme 2 is known as the entry point of SARS-CoV-2, and this would explain the root cause of dysphonia among patients with COVID-19.

Additionally, the pulmonary system has been reported to be severely inflicted by the SARS-CoV-2 could explain the new-onset dysphonia in patients with COVID-19 as optimal pulmonary air support is an essential prerequisite for efficient phonation.

Psychogenic dysphonia should not be overlooked as the ongoing pandemic causes emotional strain to most individuals. Psychogenic dysphonia or psychogenic disturbance of speech and voice quality can be suspected once the primary organic changes in the larynx have been ruled out. ⁸ Females aged 30 to 50 have been reported with psychogenic dysphonia, which can be treated with adequate counseling and voice therapy.

New-onset dysphonia requires thorough history taking along with physical examination. In addition to the laryngeal examination, reverse transcription–polymerase chain reaction should be carried out in all patients with new-onset complaints to rule out COVID-19 as dysphonia may be the silent manifestation of COVID-19.