Hoarseness is a general term used to describe any voice changes. This may include changes in voice quality (breathy, raspy, or strained), volume (loudness), or pitch (high or low).
Probably the most feared cause of hoarseness is a cancer of the larynx. Smoking and alcohol are major risk factors for cancer. Any smoker who is hoarse should be seen by an otolaryngologist.
Most causes of hoarseness are not serious and tend to go away in a short period of time. An example is acute laryngitis which is usually associated with the common cold, upper respiratory tract infection, or vocal abuse (excessive voice use or screaming/yelling).
Other benign causes of hoarseness include postnasal drainage or gastroesophageal reflux disease. Vocal nodules, small callous-like growths on the vocal cords, result from prolonged vocal abuse. Neurological disorders can cause impairment of vocal cord movement and also result in swallowing difficulty. A vocal cord paralysis often results in a breathy voice or a voice that fatigues – stronger at the start of the day and breathy or gone by the end of the day. This can be caused by tumors of the skull base, neck and chest pressing on the nerve that controls vocal cord movement, viral infections, inadvertent injury during surgery, blunt neck or chest trauma, and occasionally from endotracheal intubation.
Some systemic diseases can cause hoarseness such as laryngeal myxedema from hypothyroidism. Medications causing chronic cough (such as angiotensin-converting enzyme inhibitors) can lead to voice changes.
The typical examination for hoarseness includes a full head and neck exam as well as visualization of the vocal cords. Sometimes a full view with a hand held mirror in the throat can be obtained but usually a view with a fiberoptic scope is needed.
Photodocumentation and the use of stroboscopy (slow motion assessment) is used to help evaluate the condition and motion of the vocal cords.
There are two main types of scopes that may be used. One is a flexible fiberoptic scope that is inserted into the nose and gently down into the upper part of the throat. This allows testing of sensation and visualization of the cords during phonation as well as eating. Sometimes you may be asked to ingest food or water colored with a food dye during fiberoptic visualization to assess for any signs of aspiration (food going down into the trachea instead of the esophagus). This exam is called a fiberoptic endoscopic examination of swallowing (FEES).
The other scope is a rigid fiberoptic scope that provides superior resolution and better detailed visualization of the vocal cords and surrounding throat. This scope is held inside the mouth.
Treatment of hoarseness depends on the cause. Often behavior modification such as diet and vocal behavior is all that is needed. Diet modification and medications can help with gastroesophageal reflux. Vocal abuse is often treated with voice rest and may be modified with the help of speech and language pathologists and professional voice trainers. Staying well hydrated and sometimes using medications to thin mucus can help. Avoiding smoking and exposure to second hand smoke will decrease the risk of laryngeal cancer.
Sometimes surgery on the vocal cords will expedite recovery and is often entertained after conservative measures above have failed. Removal of vocal cord nodules or masses will often fail if the initial reasons for vocal abuse are not addressed and removed.
If the reason for hoarseness is related to vocal cord paralysis, voice therapy can improve the voice or a procedure to augment the vocal cord can be done. Patients with this problem often also have difficulty protecting their airway during swallowing and can aspirate food. If the patient also has a weak cough and can’t clear the aspirated food, this can lead to pneumonia. A vocal cord injection with an absorbable material can offer a few months relief for patients with a likely temporary vocal cord paralysis (after an upper respiratory tract infection, recent neck or chest surgery where the nerve that moves the cord is identified and intact but “stunned” after surgery). For permanent paralysis or a paralysis that lasts over a year a permanent but reversible surgery to augment the vocal cord is offered.
Laryngeal cancer (link to throat cancer treatments) is a separate category and is not treated with conservative measures. A biopsy in the operating room is required for diagnosis but the treatment includes surgery, radiation therapy, chemotherapy or a combination of these treatments.
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