Hoarseness

To the doctor hoarseness means dysphonia or an abnormal quality of the voice but to the patient it may also mean increased vocal effort or vocal tiredness. Common causes are:

• Upper respiratory tract infection, especially sinus infections and often with a postnasal drip.
• Tumours, malignant or benign. These include polyps, nodules, granulomas, cysts on vocal cord, laryngeal papilloma and laryngeal squamous cell carcinoma.
• Neurological disease can produce vocal cord paralysis, usually unilateral. There may be spasmodic dysphonia, movement disorders, essential tremor, and stroke.
• Inflammatory causes include viral, bacterial, tuberculosis and fungal infections, allergic laryngitis and gastro-oesophageal reflux.
• Miscellaneous causes include abuse of the voice, atrophy or scarring of vocal cords, hypothyroidism, muscle tension dysphonia, Reinke's oedema and drugs.
• These may be aggravated by smoking and excessive alcohol consumption.
• Vocal abuse is more common in pop singers than those who are classically trained as the latter tend to be taught how to use the voice properly. Vocal abuse used to be called clergyman's voice but a better term would be costermonger's voice as abuse of tobacco and alcohol are often involved and nowadays most churches have sound enhancement systems.
• Vocal disturbances in children are surprisingly common but pathology tends to differ from adults. Disturbances in vibration of the vocal folds cause dysphonia. The most common causes for dysphonia are infectious, anatomical, congenital, inflammatory, neoplastic, neurological, or iatrogenic. A child who presents with hoarseness requires a rapid and thorough assessment. Although some conditions are similar in the adult larynx, treatment of children often differs.¹

We are often told, "Listen to the patient. He is telling you the diagnosis." Here we must listen not just to what the patients says but how he says it.

• A breathy voice suggests vocal cord paralysis, spasmodic or functional dysphonia
• Hoarseness suggests a vocal cord lesion, reflux laryngitis or muscle tension dysphonia
• Low pitched voice occurs with Reinke's oedema that is subepithelial, usually bilateral, oedema of the vocal cords, with vocal abuse, vocal cord paralysis, muscle tension dysphonia, reflux laryngitis and hypothyroidism
• A strained voice suggests spasmodic or muscle tension dysphonia or reflux laryngitis
• Vocal tiredness accompanies muscle tension dysphonia, vocal paralysis or abuse and reflux laryngitis.

Specific questions to ask include:

• How long has the patient had the condition?
• Is it constant or does it come on with use of the voice?
• When is it worst?
• Ask about nasal congestion, hayfever and postnasal drip
• Especially in women, ask about symptoms that may suggest hypothyroidism
• Note any trauma to the neck
• Is there any heartburn?
• What is the patient's occupation? Ask about hobbies and pastimes too. He may be a football supporter, a rowing cox or a singer
• Note consumption of alcohol and tobacco
• Note any drugs, especially those that may have an anticholinergic effect
• Note also if there is use of inhaled steroids for asthma or COPD. Fluticasone may have advantages over beclomethasone and budesonide in terms of dose needed to improve asthma, but at similar doses it has a greater predisposition to cause hoarseness.² This tends to be dose related. Further investigation is required for CFC-free propellants.
• Poor general health and substance abuse have an adverse effect on the voice. There is a "drug abuser's voice"
• The voice tends to deteriorate with age and this may be aggravated by nerve deafness as feedback is required for good voice production.

• Does the patient look hypothyroid? Remember that the sensitivity and specificity of the clinical diagnosis of myxoedema are very low
• Check nose and throat looking for congestion and infection
• Neurological examination is unlikely to be rewarding unless there is something in the history to suggest a problem
• Palpate the neck for an enlarged thyroid gland and for lymph nodes. The latter may suggest infection or malignancy
• Few GPs have the necessary skills and equipment to perform an indirect laryngoscopy.

Remember the differential diagnosis of malignancy and if the patient does not get better by about 6 to 8 weeks then referral is required.

• X-ray of sinuses may be useful.
• Thyroid function tests should be performed, especially on women.
• The UK guidelines on lung cancer³ suggest that hoarseness is a symptom that merits investigation for that disease. However, the guidelines have been criticized as having a poor evidence base, and much is evidence level D, and in reality this is uncommon.⁴ Nevertheless, when there is paralysis of the recurrent laryngeal nerve, it is usually due to surgical trauma or malignancy.⁵
• A patient who has not had spontaneous resolution of hoarseness after 6 to 8 weeks should have indirect laryngoscopy by an ENT surgeon to assess the vocal cords
• Investigations such as CT and MRI may be required⁶ but this is usually done by specialists.

Hoarseness is a symptom rather than a disease and so the management depends upon the diagnosis.

Upper respiratory tract infections

URTI, including sinusitis may benefit from antibiotics if there is evidence of bacterial infection. Decongestants should be used with caution as they may aggravate hoarseness and make the mucus more viscous so that clearance is reduced and secondary infection is more likely. Steam inhalation is beneficial. The voice should be rested within reason.

Nodules

These are dreaded by singers. Sometimes nodules are asymptomatic but in most cases, nodules result in hoarseness, breathiness, loss of range, and vocal fatigue. Many nodules will regress within 6 to 12 weeks of voice training. A good singing teacher will offer sound advice but not all singing teachers are good and some encourage bad habits. If there is no progress the aid of a speech and language therapist should be enlisted. In many singers, bilateral symmetrical soft swellings at the junction of the anterior and middle thirds of the vocal folds develop after heavy use of the voice. There is no evidence that singers with physiological swellings are predisposed to the development of vocal nodules. The swelling usually subsides within 24 to 48 hours of rest after heavy voice use. Nodules carry a great stigma among singers, and the psychological impact of the diagnosis is immense. If a singer has nodules, the skills of breaking bad news are required as if telling a patient that he or she has a serious illness.

Polyps

They are a form of mass on the vocal folds. Even quite large polyps may subside with rest of the voice and low dose oral steroids such as prenisolone 5mg bd. Surgical removal is often required. Abuse of the voice may cause recurrence.

Reinke's oedema

This produces an "elephant ear" appearance of a floppy vocal fold. It is often noted during examination of amateur and professional voice users and is accompanied by a low, coarse, gruff voice. In Reinke's oedema, the superficial layer of lamina propria (Reinke's space) becomes oedematous. The lesion does not usually include hypertrophy, inflammation, or degeneration although other names for the condition include polypoid degeneration, chronic polypoid chorditis, and chronic oedematous hypertrophy. It is associated with smoking, voice abuse, acid reflux, and hypothyroidism. Underlying conditions should be treated but the condition often requires surgery. This should be reserved for high suspicion of serious pathology such as cancer, airways obstruction or if the patient is unhappy with personal vocal quality. For some voice professionals, abnormal Reinke's oedema is an important component of the vocal signature. Although the condition is usually bilateral, surgery should generally be performed on one side at a time.

Sulcus vocalis

This is a groove along the edge of the membranous vocal fold. Most are congenital, bilateral, and symmetrical, although post-traumatic lesions occur. It is often asymptomatic but if symptoms occur it can be treated surgically if voice therapy does not produce an adequate result.

Scars

They can form on the vocal fold after trauma. Fibrosis and obliteration of the layered structure of the vocal fold results. This may impede vibration and cause profound dysphonia. The result of surgical treatment is often unsatisfactory.

Haemorrhage

If it occurs into the vocal fold, it is a potential disaster for singers. Most haemorrhages resolve spontaneously and a normal voice is restored but sometimes the haematoma organises and fibroses, causing scarring. This affects the vibration of the vocal fold and can result in permanent hoarseness. In selected cases, surgical incision and drainage of the haematoma may prevent the complication. In all cases, vocal fold haemorrhage requires absolute rest of the voice until the haemorrhage has resolved, usually in about a week and relative voice rest until normal vascular and mucosal integrity have been restored. This often takes 6 weeks, sometimes longer. Recurrent vocal fold haemorrhages are usually due to weakness in a specific blood vessel, which may require cautery of the blood vessel.

Papillomas of the larynx

They are epithelial lesions caused by the human papilloma virus (HPV). Histology shows neoplastic epithelial cell proliferation in a papillary pattern and viral particles. They are usually managed surgically although newer techniques are being developed. Theses include injecting cidovir into recurrent lesions.⁷

Malignancy

The management of oropharyngeal tumours is discussed elsewhere. In Europe, laryngeal cancer accounts for only 2 to 5% of all cancers with a marked male preponderance. Smoking and alcohol represent the main avoidable risk factors. Several carcinogens, occupations and vitamin deficiencies have been associated with laryngeal cancer. There is a genetic susceptibility to environmental risk factors and carcinogens. Hoarseness is the main presenting feature. Surgery and radiotherapy are the main therapeutic options.

Vocal fold hypomobility

This may be caused by nerve damage or neurological disease, arytenoid cartilage dislocation, cricoarytenoid joint dysfunction, and laryngeal fracture. Differentiating these conditions is often more complicated than may be expected. Even with damage to the recurrent laryngeal nerve, there is often a gratifying result from speech and language therapy.

Gastro-oesophageal reflux

Acid reflux is said to occur in 4 to 10% of patients attending ENT clinics and 55% of those with hoarseness.⁸ How this compares with the general population is not stated. Nocturnal reflux seems to be a particular risk.⁹ Proton pump inhibitors are used as usual but there is a dearth of RCTs to justify this and other anti-reflux therapy.⁸ It is very common amongst singers but often asymptomatic. Endoscopy may be necessary for diagnosis. Risk factors include the production of high intra-abdominal pressure during singing and the disposition of some well known operatic maestros and divas to "feed the voice" with resultant obesity.

Muscle tension dysphonia

This appears to be a multifactorial condition in which a large study of 150 patients found GORD in 49%, high stress levels in 18%, excessive amounts of voice use in 63%, and excessive loudness demands on voice use in 23%. There were 60% female and 40% male with a mean age of 43. Speech pathology included poor breath support, inappropriately low pitch, visible cervical neck tension and inappropriate intensity. An interdisciplinary approach including speech and language therapy gave the best results.¹⁰

• Most cases of hoarseness resolve spontaneously, usually as an upper respiratory tract infection resolves.
• Thyroxine will reverse almost all the features of myxoedema but it is unlikely to reverse the changes of the vocal cords.
• The prognosis for squamous cell carcinoma is dependent upon the stage at diagnosis.
• Neurological disease is unlikely to improve but the attentions of a speech and language therapist may improve function.
• The prognosis for vocal abuse depends upon the degree of compliance but nodules on the vocal cord often recur.

The risk of hoarseness can be reduced by abstention from tobacco, moderation in the use of alcohol and correct use of the voice. Serious singers need competent vocal coaches. The boys and more recently girls too, who are choristers in our great cathedrals, use their voices a great deal during their childhood and they must be adequately supervised. This is particularly true of the older boys whose voices are approaching the age of breaking.