Hoarseness is a subjective term, and usually refers to a weak or altered voice. Dysphonia is similar, but may also mean difficulty making sounds. Some terms which may be used to describe a voice change are: breathy, harsh, tremulous, weak, reduced to a whisper, or vocal fatigue (voice deteriorates with use).
Note: any patient with unexplained hoarseness persisting >3 weeks requires investigation to exclude malignancy (see 'Investigation and referral' section below).
The first part of this article discusses hoarseness as a presenting symptom. The second part covers some common laryngeal conditions causing hoarseness.
Airway emergencies and hoarseness
Hoarseness may be a feature of laryngeal obstruction - so can be a warning of impending airway obstruction.
This may occur in:
- Infections - acute epiglottitis, diphtheria, croup, laryngeal abscess.
- Inflammation/oedema - airway burns, anaphylaxis, physical trauma, angio-oedema, hereditary angio-oedema.
- Vocal cord immobility - laryngeal nerve palsy (depending on the position of the cords) or cricoarytenoid joint disease.
Possible signs of laryngeal obstruction are:
- Dyspnoea, stridor, wheeze, exertional dyspnoea, anxiety or signs of hypoxia.
- Dysphagia or drooling.
- Facial or oral oedema.
- Do not examine the throat or attempt distressing procedures; allow the patient to find the most comfortable position.
- Get senior help/anaesthetist.
- Emergency procedures such as tracheostomy may be needed.
- Treat the specific cause where feasible.
In Western societies, about one third of the workforce need their voice for work. In the UK, about 50,000 patients per year with voice problems are referred to ear, nose and throat (ENT) departments.
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Risk factors for voice problems
- Smoking (also the main risk factor for laryngeal carcinoma).
- Excess alcohol consumption.
- Gastro-oesophageal reflux.
- Professional voice use, eg teachers, actors and singers.
- Environment: poor acoustics, atmospheric irritants and low humidity.
Anatomy and physiology
Sound is produced in the larynx by vibration of the vocal cords. Resonance occurs in the pharynx, nose and mouth; articulation uses the mouth and tongue. Coughing requires adduction of the vocal cords to be effective.
Innervation of the laryngeal muscles is from the vagus nerve via its branches, the superior laryngeal and recurrent laryngeal nerves. The recurrent laryngeal nerve controls abduction and adduction of the vocal cords. This nerve has a long course, from the base of the skull to the mediastinum: on the left side it loops under the aortic arch and on the right under the subclavian artery.
The vocal cords are subject to high forces and so are vulnerable to voice overuse or misuse.
Voice problems are often multifactorial and due to voice overuse. Serious pathology must be excluded (see 'Investigation and referral' section).
Causes of hoarseness
- Where no organic cause is found - a diagnosis of exclusion.
- A common cause of hoarseness. There are various forms (below).
- Acute laryngitis (common), often with upper respiratory infection. Usually viral (may have secondary infection with staphylococci or streptococci).
- Other infections - fungal or tuberculosis.
Benign laryngeal conditions (for details see last section 'Some specific voice disorders and their management'):
- Voice overuse - common.
- Benign lesions of the vocal cords, eg nodules (singer's nodes), polyps and papillomas.
- Carcinoma of the larynx - smoking is major risk factor.
- Other neck or chest tumours, eg lung cancer, lymphoma, thyroid cancer.
- Laryngeal nerve palsy (see 'Some specific voice disorders and their management' below): this has various causes including lung cancer, other tumours and thoracic aortic aneurysm.
- Stroke and other focal brain lesions.
- Parkinson's disease (voice change can be a presenting feature).
- Motor neurone disease.
- Essential tremor.
- Myasthenia gravis.
- Endocrine: hypothyroidism, acromegaly.
- Rheumatoid arthritis affecting the cricoarytenoid joints.
- Granulomatous disease, eg sarcoid, tuberculosis, syphilis, Wegener's granulomatosis.
- Autoimmune disorders can affect the larynx.
Causes in children:
- Congenital, eg laryngeal web, laryngomalacia, congenital cyst.
- Older children: vocal cord nodules, voice overuse, gastro-oesophageal reflux, papillomas (as for adults).
- Very rarely, malignancy.
- Various rare causes of hoarseness, from case reports, are described by Ulis.
- Drying of the laryngeal mucosa, eg from low humidity, nasal obstruction, smoking, air pollution or medication, eg antihistamines, inhaled steroids, and anticholinergics.
- Upper respiratory tract infection.
- Voice overuse (see 'Some specific voice disorders and their management' below).
- Gastro-oesophageal reflux (reflux laryngitis or laryngopharyngeal reflux).
- Scarring, eg after prolonged intubation.
- Age-related loss of pliability (normal ageing of the voice).
- Symptoms - duration, onset and pattern of symptoms; check the patient's meaning of 'hoarseness'.
- Precipitating factors - recent upper respiratory tract infection, change in voice use, eg shouting or singing..
- Occupation, normal pattern of voice use, impact of voice problem on the patient's life.
- Other ENT symptoms - dysphagia, aspiration, throat or ear pain, nasal blockage.
- Smoking, alcohol.
- Reflux symptoms, eg acid taste in the mouth in the morning, throat clearing, cough or 'choking' sensation, sensation of lump in the throat.
- Past medical history, particularly chest disease, thyroid surgery, neck trauma, neurological symptoms.
Examination in primary care:
- Signs of airway obstruction - see emergency under 'Management' section above.
- Laryngeal function - listen to the patient's voice, and assess cough and swallowing.
- Examine the neck - scars, lymph nodes, thyroid gland. Localised tenderness suggests infection or abscess.
- Any signs of underlying cause, eg fever, hypothyroidism, tremor, weight loss.
- Chest or neurological examination may be appropriate.
- Inspection of the larynx - by indirect laryngoscopy and/or fibreoptic nasendoscopy.
- Voice quality can be evaluated using the GRBAS (= Grade (severity), Roughness, Breathy voice, Asthenia (weakness) and Strain) assessment.
- The Reflux Symptom Index can be used to identify likely gastro-oesophageal reflux.
Investigation and referral
Initial investigationsHoarseness persisting for >3 weeks requires investigation to exclude malignancy:
- Carcinomas of larynx and lung must be considered, so chest X-ray and/or laryngoscopy are indicated.
- National Institute for Health and Clinical Excellence (NICE) guidance on suspected cancer states that for patients with hoarseness persisting for >3 weeks, particularly smokers aged ≥50 years and heavy drinkers:
- Arrange urgent chest X-ray.
- Patients with positive findings should be referred urgently to a team specialising in the management of lung cancer.
- Patients with a negative finding should be referred urgently to a team specialising in head and neck cancer.
These depend on the clinical picture:
- Consider investigations for systemic causes where appropriate, eg thyroid function.
- Fibreoptic laryngoscopy - does not require general anaesthetic, so enables examination of the larynx while using the voice.
- Stroboscopy (videolaryngostroboscopy) uses fibreoptic images in slow motion to provide pictures of the working larynx.
- Voice pathologists use various other techniques to measure aspects of voice production, such as amplitude, pitch, range and aerodynamic efficiency.
Management depends on the specific cause, but voice therapy and other nonsurgical management is the first-line treatment for most benign lesions of the larynx.
- Voice hygiene advice (see box below).
- Treat gastro-oesophageal reflux (if suspected):
- Voice therapy:
- Teaches techniques to maximise vocal effectiveness.
- Is effective for both organic pathology (eg nodules and polyps) and nonorganic causes (eg muscle tension dysphonia).
- Referral to a specialist voice clinic:
- Is appropriate if the larynx appears normal and there is no improvement with initial voice therapy. Provides detailed voice assessment and specialist investigations such as videostroboscopy.
- Other therapies:
Voice hygiene advice
- Adequate hydration.
- Avoid vocal strain (shouting, throat clearing, excessive voice use).
- Smoking cessation, alcohol reduction (both are irritants and alcohol is dehydrating).
- Reduce caffeine intake.
- Laryngeal papillomas require surgery first-line.
- Persistent nodules and polyps may require surgery.
- There are various surgical techniques used to treat vocal cord paralysis.
- Voice therapy is often used as a adjunct to surgery.
Some specific voice disorders and their management
Laryngeal nerve palsy or vocal cord paralysis
This may cause a 'breathy' voice, an inefficient cough or airway narrowing. The clinical features depend on whether one or both cords are affected, and the position of the cords - whether abducted or adducted. 'Semon's law' suggests that an incomplete paralysis of the recurrent laryngeal nerve affects the abductor muscles first, so that the vocal cord is in the midline. Complete paralysis affects the adductor muscles also, so the cord is fixed midway, in the paramedian position.
Surgical techniques such as Teflon® injection or implants, combined with voice therapy, can restore function.
Benign lesions of the vocal cords
Vocal cord nodules (nodes or singer's nodes) - these are epithelial thickenings of the vocal cord, similar to calluses; often due to voice overuse. Voice therapy is the main treatment; surgery is occasionally needed.
Polyps of the vocal folds - these are unilateral (unlike nodules which are normally bilateral). They may need excision to exclude malignancy.
Papillomas of the larynx - lesions caused by the human papillomavirus (HPV). If untreated and large, they may cause airway obstruction. Invasive carcinoma can occur rarely. They are usually treated surgically. Intralesional antiviral therapy (cidofovir) may be used for recurrent papillomas.
Reinke's oedema - oedema of the vocal folds, which tends to give a deep, hoarse voice. It is usually linked to smoking plus voice overuse. Smoking cessation and voice therapy may help; surgery has also been used.
Voice overuse or misuse
This is a common problem in some occupations such as acting and teaching; it may also follow unaccustomed voice use, such as shouting at a football match. Vocal strain may be exacerbated when attempting to compensate for an acute respiratory infection.
Benign lesions such as nodules ('singer's nodules'), cysts, haemorrhages and varices can occur with voice overuse.
- Excluding other pathology.
- An accurate diagnosis (see 'Investigations') - fibreoptic laryngoscopy and stroboscopic techniques are useful.
- A specific programme tailored to the observed pathology can then be devised. Prescribing rest alone may not be effective.
- Persistent nodules can be excised.
This is a diagnosis of exclusion, where there is neither a structural abnormality of the larynx, nor cord paralysis. There are various types of functional dysphonia. Symptoms include vocal fatigue (voice becoming worse with use) and laryngeal discomfort. There may be various interacting causes, such as heavy demands on the voice, poor vocal technique and stress.
Voice therapy is the main treatment. Other treatments used include relaxation techniques, biofeedback, and other methods such as mental imagery and laryngeal shaking or laryngeal massage.
Spasmodic dysphonia - this is a type of functional dysphonia. It is thought to be a focal dystonia of the laryngeal muscles. Symptoms are breaks in the voice or voice tremor. Some forms of spasmodic dysphonia can be treated with botulinum toxin injection or denervation.
Prevention measures include:
- 'Vocal hygiene' measures (see box above).
- Recognising early warning signs of voice problems, such as an unintentional change in pitch, voice fatigue (the voice gets weaker with increasing use) and sore throat not due to infection.
Further reading & references
- Meyer TK; The larynx for neurologists. Neurologist. 2009 Nov;15(6):313-8.
- Lions Voice Clinic of the University of Minnesota; About the voice, Accessed May 2008; Detailed information and illustrations about the anatomy and physiology of the larynx and voice acoustics; self-help measures and medical/surgical treatment for voice problems
- Sataloff RT; Common Medical Diagnoses and Treatments in Professional Voice Users, eMedicine, Jun 2009
- Rosen CA, Anderson D, Murry T; Evaluating hoarseness: keeping your patient's voice healthy. Am Fam Physician. 1998 Jun;57(11):2775-82.
- Bossingham DH, Simpson FG; Acute laryngeal obstruction in rheumatoid arthritis. BMJ. 1996 Feb 3;312(7026):295-6.
- Carding P, Wade A; Managing dysphonia caused by misuse and overuse. BMJ. 2000 Dec 23-30;321(7276):1544-5.
- Carding P; Voice pathology in the United Kingdom. BMJ. 2003 Sep 6;327(7414):514-5.
- Van Houtte E, Van Lierde K, D'Haeseleer E, et al; Van Houtte E, Van Lierde K, D'Haeseleer E, et al; The prevalence of laryngeal pathology in a treatment-seeking population with Laryngoscope. 2010 Feb;120(2):306-12.
- Ulis JM, Yanagisawa E; What's new in differential diagnosis and treatment of hoarseness? Curr Opin Otolaryngol Head Neck Surg. 2009 Jun;17(3):209-15.
- Syed I, Daniels E, Bleach NR; Hoarse voice in adults: an evidence-based approach to the 12 minute consultation. Clin Otolaryngol. 2009 Feb;34(1):54-8.
- Fass R, Achem SR, Harding S, et al; Review article: supra-oesophageal manifestations of gastro-oesophageal reflux disease and the role of night-time gastro-oesophageal reflux. Aliment Pharmacol Ther. 2004 Dec;20 Suppl 9:26-38.
- Referral for suspected cancer, NICE Clinical Guideline (2005)
- Voerman MS, Langeveld AP, van Rossum MA; Retrospective study of 116 patients with non-organic voice disorders: efficacy of J Laryngol Otol. 2009 May;123(5):528-34. Epub 2008 Sep 2.
- Voice problems; Loughran S, ENT Consultant - Manchester, Accessed May 2008
- Wilson JA, Deary IJ, Scott S, et al; Functional dysphonia. BMJ. 1995 Oct 21;311(7012):1039-40.
- Ruotsalainen JH, Sellman J, Lehto L, et al; Interventions for treating functional dysphonia in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD006373.
- Ludlow CL; Treatment for spasmodic dysphonia: limitations of current approaches. Curr Opin Otolaryngol Head Neck Surg. 2009 Jun;17(3):160-5.
|Original Author: Dr Naomi Hartree||Current Version: Dr Naomi Hartree|
|Last Checked: 18/03/2011||Document ID: 789 Version: 25||© EMIS|
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