JCPSLP Vol 22 No 2 2020

language pathologist for treatment of dysphonia but there was no further information provided regarding the voice and swallowing sequelae, assessment or intervention provided (Kerschner, Ridley, & Greene, 1995). Treatment commonly included provision of anti-fungal medication with all cases that had a documented outcome reporting symptomatic improvement within 3 weeks to 9 months (Worrall et al., 2019). Of the 30 reported cases, no data has been reported on the voice and swallowing sequelae, assessments or intervention provided, despite all patients presenting with dysphonia. Here, we present a case of severe cryptococcal laryngitis in which the patient appeared non-responsive to traditional anti-fungal therapy and presented with worsening dysphonia and dysphagia. This is the first reported case in the literature of detailed swallowing and voice outcomes in An 82-year-old gentleman, Jack (name changed for privacy purposes), presented to his general practitioner (GP) in December 2014, reporting a two-month history of sore throat and hoarse voice. His past medical history included chronic obstructive pulmonary disease, ischemic heart disease, hypertension and osteoarthritis. Jack had no history of immunocompromise. Jack was retired and living at home with his supportive wife. He was an ex-smoker (quitting 40 years ago) and occasionally consumed alcohol. He was initially diagnosed with laryngitis and was prescribed two courses of antibiotics. His symptoms did not improve and he was referred to an ear, nose and throat (ENT)/otolaryngology specialist. The ENT specialist involved an infectious diseases specialist physician as part of the differential diagnosis process. Jack was diagnosed with cryptococcal laryngitis and prescribed oral fluconazole, a common anti-fungal medication. Two weeks later, his symptoms had not improved but had progressed, with worsening dysphagia and dysphonia. On 27 April 2015, 4 months following his diagnosis and limited response to medical management, Jack presented with shortness of breath to a metropolitan acute secondary teaching hospital in a large Australian city. During his admission Jack was referred to speech-language pathology for assessment of his swallowing and voice dysfunction. During his admission the speech-language pathologist obtained informed verbal consent from Jack regarding publication of de-identified case information; this was documented in his patient notes at the time. Diagnostic assessment and outcomes The patient underwent the following assessments. ENT assessment ENT conducted a microlaryngoscopy on the 8 January 2015, where an irregular mass was identified and biopsied. The microlaryngoscopy reported impaired mobility of both right and left vocal cords, irregular appearance of false cords and limited glottic opening as a result of an irregular mass. The biopsy revealed cryptococcal laryngitis. Speech pathology assessment Jack was referred to speech-language pathology for ongoing dysphonia, odynophagia, and dysphagia. During his initial examination, Jack reported he had been experiencing odynophagia and dysphonia for 6 months. He a case of cryptococcal laryngitis. Patient information

Figure 1: Microlaryngoscopy image conducted by ENT on 8 January 2015

had also developed a chronic cough, dysphagia for solids and liquids, and 23kg weight loss over this period. He was self-modifying his meals to a pureed consistency and was reporting intermittent coughing with thin fluids. Dysphonia Jack was interviewed by the speech-language pathologist to determine the history of his dysphonia. He reported a slow onset of progressive loss of voice, with changes in voice quality he reported descriptively as “hoarseness” and “losing my voice”. Jack reported the dysphonia impacted his ability to communicate with family and friends. He reported he felt he could only generate a whisper and had begun writing on a notepad when communicating with his wife. Jack reported that in the lead up to his admission he had experienced some variation in dysphonia over the past few months, with intermittent partial recovery of vocal quality enabling him to occasionally verbally communicate with his wife, in addition to utilising written forms of communication. On admission to hospital in April 2015, the severity of his dysphonia had progressed to the point of total loss of voice with Jack only able to achieve a whisper. Perceptual vocal screening was conducted by the treating clinician by recording the Rainbow Passage on the 6 May 2015. The Rainbow Passage was recorded using the Voice Memos application on an Apple iPhone 5/6 in a sound- proof clinical examination room. Minimum vocal parameters of grade, hoarseness, roughness, breathiness, asthenia and strain were measured using the GRBAS (grade, roughness, breathiness, asthenia, strain) scale (Isshiki, Olamura, Tanabe, & Morimoto, 1969). Perceptual voice analysis revealed Jack presented as aphonic, with severe dysfunction (rating of 3) across all components of the GRBAS scale. Attempts at vocalising during the assessment were difficult for Jack and further vocal assessments to quantify pitch, loudness, flexibility and range (including s/z ratio, sustained and incremental vowels and maximum phonation time) were unable to be conducted. In respect to the International Classification of Functioning, Disability and Health (World Health Organization, 2001),

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JCPSLP Volume 22, Number 2 2020

Journal of Clinical Practice in Speech-Language Pathology