Abnormal changes in the voice are called hoarseness. When hoarse, the voice may sound breathy, raspy, strained, or show changes in volume or pitch (depending on how high or low the voice is).
Voice changes are related to disorders in the sound-producing parts (vocal folds) of the voice box (larynx). While breathing, the vocal folds remain apart. When speaking or singing, they come together and, as air leaves the lungs, they vibrate, producing sound. Swelling or lumps on the vocal folds hinder vibration, altering voice quality, volume, and pitch.
What are the causes of hoarseness?
Acute Laryngitis: The most common cause is acute laryngitis swelling of the vocal folds that occurs during a common cold, upper respiratory tract viral infection, or from voice strain. Serious injury to the vocal folds can result from strenuous voice use during an episode of acute laryngitis.
- Speaking in noisy situations
- Excessive use
- Telephone use with the handset cradled to the shoulder
- Using inappropriate pitch (too high or too low) when speaking
- Not using amplification when public speaking
Benign Vocal Cord Lesions: Prolonged hoarseness can occur when you use your voice too much, or too loudly for extended periods of time. These habits can lead to nodules, polyps, and cysts. Vocal nodules (singers’ nodes) are callus-like growths of the vocal folds. Vocal fold polyps and cysts also occur in those who misuse their voice, but can also occur in those who do not.
Vocal Hemorrhage: If you experience a sudden loss of voice following a yell or other strenuous vocal use, you may have developed a vocal fold hemorrhage. Vocal fold hemorrhage occurs when one of the blood vessels on the surface of the vocal folds ruptures and the soft tissues fill with blood. It is considered a vocal emergency and should be treated with absolute voice rest and examination by an otolaryngologist (ear, nose, and throat doctor).
Gastroesophageal Reflux (GERD): A possible cause of hoarseness is gastro-esophageal reflux, when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal folds. Other typical symptoms of GERD include heartburn and regurgitation. Usually, the voice is worse in the morning and improves during the day. These people may have a sensation of a lump or mucus in their throat and have an excessive desire to clear it.
Laryngopharyngeal Reflux (LPRD): If the reflux makes it all the way up through the upper sphincter and into the back of the throat, it is called LPRD rather than GERD. The structures in the throat (pharynx, larynx, and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of the reflux into this area can result in more damage. Many patients with LPRD do not have heartburn or other classic symptoms of GERD.
Smoking: Smoking is another cause of hoarseness. Because smoking is the major cause of throat cancer, if smokers become hoarse, they should see an otolaryngologist.
Neurological Diseases or Disorders: Hoarseness can also appear in those who have neurological diseases such as Parkinson’s or a stroke, or may be a symptom of spasmodic dysphonia, a rare neurological disorder that usually affects only the voice, but sometimes affects breathing. A paralyzed vocal fold may be the cause of a weak, breathy voice. If the hoarseness persists for more than three months and other causes have been ruled out, a neurologist may be helpful for diagnosis.
Other Causes: These include allergies, thyroid problems, trauma to the voice box, and, occasionally, menstruation. Very serious conditions such as laryngeal cancer can also cause hoarseness, which is why it is important to have chronic hoarseness evaluated promptly by an otolaryngologist
How is hoarseness treated?
Hoarseness caused by a cold or flu may be evaluated by family physicians, pediatricians, and internists who have learned how to examine the larynx. Problems with the voice are often best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologists, speech/language pathologists, and teachers of singing, acting, and public speaking.
Vocal nodules, polyps, and cysts are typically treated with a combination of microsurgery and voice therapy.
How is hoarseness evaluated?
Otolaryngologists will obtain a thorough history of a patient’s hoarseness and general health. They will then evaluate the voice and do a complete ear, nose, and throat exam. This includes examination of the vocal folds by laryngoscopy. Laryngoscopy may be suggested by the otolaryngologist at any time during an evaluation for hoarseness, but if it persists beyond three weeks it should be evaluated and that evaluation should occur within a maximum of 3 months. The evaluation should be immediate if there is concern about a serious underlying cause is suspected.
Doctors usually look at the vocal folds either with a mirror placed in the back of the throat, or with a very small, lighted flexible tube (fiber optic scope) that is passed through the nose to view the vocal folds. Videotaping or stroboscopy (slow-motion assessment) may also help with the analysis. These procedures are well tolerated by most patients. In some cases, special tests designed to evaluate the voice may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in diagnosing and guiding treatment.
Here’s a great video of a patient’s voice box, or larynx, during a flexible laryngoscopic examination done in the office.