Voice Case of the Week: Side Effects of Medications

About Dr. Reena Gupta

Dr. Reena Gupta is the Director of the Division of Voice and Laryngology at OHNI. Dr. Gupta has devoted her practice to the care of patients with voice problems. She is board certified in otolaryngology and laryngology and fellowship trained in laryngology, specializing in the care of the professional voice.

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The patient is an 82 year old male who presented with complaints of loss of voice. He had noted initial symptoms 7 months ago and had noted a gradual decline since that time. He had a self-reported normal voice prior to this. He went to an ENT who noted that he was simply elderly and that this was the cause of his voice symptoms. Unsatisfied with this, he sought a second opinion. The second ENT noted that he had some inflammation after performing flexible fiberoptic laryngoscopy. This doctor suggested a steroid injection into the vocal fold. The patient agreed and had this done as an office-based procedure. He noted significant discomfort from the procedure and no improvement. He presented here for a third opinion.

He noted onset of symptoms while he was travelling abroad and did admit to mild dehydration during that time. He states that he loves to talk and that he has found this extremely frustrating because as a public speaker, he had never had voice symptoms previously.

A general physical exam revealed him to be in good ENT health. Videostroboscopy was performed and demonstrated the following:


Based on the above findings and the patient’s recent history of antibiotic use, a diagnosis of fungal laryngitis was made. Close follow up was arranged to ensure that oral medication would be sufficient to manage this patient’s illness, which had progressed unabated for 7 months due to prior misdiagnosis.

This case highlights several important points:

  • Misdiagnosis is frequent, even with flexible fiberoptic laryngoscopy due to poor visualization and inexperience.
  • Procedures may be suggested, even in the absence of a clear diagnosis. The proposition of a procedure does not imply practitioner competence.
  • Aging does not happen suddenly and worsen over 7 months. History is critical. There is no way for age-related changes to cause these symptoms. However, if this patient had not been his own advocate, he may have trusted this first opinion, allowing the infection to progress.
  • Even with good visualization, considerable expertise is required to make this diagnosis and treat this patient. A laryngologist should be sought for the care of voice problems.

Below is an example of an operatic tenor and choir director who had the same problem, from steroid inhaler use for his asthma. Luckily, he had a prior relationship with me, which allowed me to catch the change of an early fungal plaque forming on his vocal fold. Treatment was instituted and he resolved within 3-4 weeks.

Figure: Patient 2 before treatment.
Figure: Patient 2 before treatment.
Figure: Patient 2 after treatment.
Figure: Patient 2 after treatment.

To learn more about Dr. Reena Gupta or voice evaluation and treatment, please visit www.voicedoctorla.com.