JCPSLP Vol 22 No 2 2020

The clinical analysis, MBSImp analysis and PAS analysis of Jack’s VFSS procedure found he presented with a moderate oropharyngeal dysphagia of which the relevant MBSImp component, clinical physiological dysfunction and the resulting functional impact is reported in Table 2. Jack received recommendations to continue a puree diet and mildly thick fluids. Strategies recommended to support him to safely and efficiently swallow following his VFSS included a fluid flush with meals and extra clearance swallows to aid pharyngeal clearance. Further assessment of Jack’s dysphagia and dysphonia was scheduled following the VFSS procedure, including a fibreoptic endoscopic evaluation of swallowing (FEES). Unfortunately, Jack passed away unexpectedly from a cardiac event not long after his VFSS procedure. Discussion The case of a gentleman presenting with a rare fungal infection of the larynx has been presented. Through collaboration between ENT, infectious diseases and speech-language pathology, he was diagnosed with cryptococcal laryngitis characterised by moderate oropharyngeal dysphagia and aphonia. Visualisation of the larynx revealed impaired mobility of both right and left vocal cords and limited glottic opening as a result of an irregular mass. VFSS results supported the glottic dysfunction with high risk of aspiration secondary to impaired airway protection and an ineffective spontaneous cough reflex. VFSS was a useful tool to assist with characterising the severity of his dysphagia, risk of aspiration and establishing safest diet and fluid recommendations. Further supporting the finding of impaired true vocal cord mobility on nasendoscopy, perceptual voice analysis revealed aphonia, with limited useful data to describe and quantify Jack’s vocal quality change over the course of his disease. Therefore, a clear picture of his changing voice characteristics as the disease progressed could not be ascertained. Persistent vocal hoarseness is a common patient presentation within the practice of speech-language pathology; however, rarely is it attributed to a fungal infection. Commonly patients with a clinical presentation including dysphagia, odynophagia, persistent vocal hoarseness, weight loss and a history of smoking and alcohol intake, are suspected of having head and/or neck cancer. There is now emerging literature to support the clinical mimicry of chronic laryngeal infections, aiming to ignite a discussion regarding differential diagnosis of alternative causes, evaluation and treatment options for persistent vocal hoarseness other than carcinoma (Klein et al., 2005). The profession of speech-language pathology should remain vigilant about potential alternative and rare aetiologies for persistent vocal hoarseness and consider the negative sequelae including dysphagia and dysphonia. This case study emphasises the importance of committing to the learning and reflection principles of regular professional development for speech-language pathologists, especially in regards to rare cases that challenge clinical decision-making. In advocating for this patient population, speech-language pathologists can facilitate faster access to swallowing and voice evaluation and treatment options, and assist in team decision-making and differential diagnosis (Gordon et al., 2010). Clinical guidelines or consensus documents for the assessment and management of rare voice conditions may warrant

development at a national professional standards level. The most common treatment for isolated cryptococcal laryngitis is a trial of oral fluconazole, an anti-fungal medication. The literature highlights previous cases of cryptococcal laryngitis have responded to this form of treatment within 4–40 weeks (Gordon et al., 2010). In this case, following 4 months of oral fluconazole, the patient’s symptoms had not improved and not long after his VFSS, the patient passed away unexpectedly as a result of a cardiac event. It is unclear why his dysphagia and dysphonia were so severe in comparison to other reported cases in the literature and why his condition was seemingly unresponsive to traditional anti-fungal therapy. It is possible that his age and comorbidities (frail and elderly) could have had an impact on the severity of his presenting dysphagia and dysphonia and his response to treatment. Interestingly, examination of his cranial nerves demonstrated some deficits that could indicate potential neurological involvement and raises the question of other comorbid medical conditions or CNS cryptococcal spread. Headaches, fevers, cranial nerve impairments and memory loss have all been identified as signs of the cryptococcal infection in the CNS (Maziarz & Perfect, 2016). It is not known if Jack presented with other identified signs of potential CNS involvement. The literature has identified multiple other fungal infections of the larynx including candidiasis, blastomycosis, coccidioidomycosis, paracoccidioidomycosis, aspergillosis and sporotrichosis, differing in terms of their endemic region and treatment regime (Klein et al., 2005). Accurate diagnosis is paramount as, although all patients in these reports present with similar symptoms initially, prompt diagnosis and treatment may reduce risk of long-term complications (Subramanya et al., 2018). Despite the consistency of dysphonia as a presenting sign in previous reports, there have been no studies published highlighting the role of the speech-language pathologist. Where the presenting voice condition limits a patient’s participation in activities of daily living, particularly in the case of unknown aetiology, it is vital the speech pathologist advocates for further investigation. Our role can contribute specialised clinical information to assist in the differential diagnosis and subsequent management plan. This is the first case review to acknowledge there are no established guidelines for speech-language pathologists to refer to regarding the assessment, treatment, management and prognosis of the presenting dysphonia and/or dysphagia accompanying fungal infections of the larynx. Clinical recommendations and reflections In line with the clinical practice guidelines for hoarseness (Schwartz et al., 2009, pp. 16–18), it is recommended speech-language pathologists remain up to date with the following principles: • Medical practitioners should not routinely prescribe antibiotics to treat hoarseness. • Medical practitioners should visualise the larynx before prescribing voice therapy and document/communicate the results to a speech-language pathologist. • Speech-language pathologists should advocate voice therapy for patients diagnosed with hoarseness that reduces voice related quality of life. • A speech-language pathology clinical guideline or consensus document for the assessment and

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JCPSLP Volume 22, Number 2 2020

Journal of Clinical Practice in Speech-Language Pathology