Hoarseness

How is the voice produced, and what does hoarseness mean?

The voice is produced when air from the lungs sets the vocal folds in the larynx vibrating; proper closure and vibration of the vocal folds determine the quality of the voice. The voice changes when the lining of the vocal folds swells, when a small lesion develops on them, when their movement is restricted or when a gap remains on closure.

Hoarseness is not the name of a disease but a symptom of a problem in the larynx. How long the voice has been changed, how it began, how it varies during the day and what accompanies it are important clues in distinguishing the possible causes.

Common causes

The common, mostly benign causes of hoarseness are:

• Acute laryngitis: Temporary swelling of the vocal folds during an upper respiratory infection; it usually settles on its own within one to two weeks.
• Overuse or misuse of the voice: Prolonged loud speaking, shouting or occupational voice load; it is common among people who use their voice intensively, such as teachers, sales and call-centre staff, and singers.
• Vocal fold nodules, polyps and cysts: Benign lesions that develop on the vocal folds, mostly related to intensive use of the voice.
• Reflux-related irritation of the larynx: Backflow of stomach contents into the larynx is considered among the possible contributing factors in the appropriate clinical context; hoarseness on its own does not establish reflux.
• Vocal fold movement disorders: Involvement of the nerve that moves the vocal folds; it may follow neck or chest surgery, occur in some neurological conditions or arise without an identified cause, and it produces a breathy, weak voice.
• Age-related voice changes: Weakening of the voice as the vocal folds become thinner in later life.
• Chronic irritation: Tobacco smoke, dry air and some inhaled medicines can affect the lining.

Lesions of the vocal folds and larynx that are not benign are among the less common causes of hoarseness. The importance of examination in persistent hoarseness lies in the fact that this distinction can only be made by seeing the larynx directly; the duration or severity of the complaint does not by itself reveal the cause.

When is examination of the larynx (laryngoscopy) needed?

Current guidelines recommend that the vocal folds be seen by laryngoscopy when hoarseness has not resolved within four weeks, or at any time if symptoms or a history suggesting a serious cause are present. Even when hoarseness is of shorter duration, the examination is brought forward in situations such as smoking or alcohol use, a swelling in the neck, difficulty swallowing or shortness of breath.

Laryngoscopy is the direct visualisation of the vocal folds with a thin optical instrument passed through the mouth or nose; it is carried out in the clinic in a short time. Where needed, a stroboscopic examination that shows the vibration of the vocal folds in detail is added. Imaging (CT or MRI) is not needed for every case of hoarseness; guidelines do not recommend requesting imaging before the larynx has been examined.

What is done in the ENT assessment?

The assessment begins with a detailed history: the duration and onset of the voice change, the voice load, smoking and alcohol use, complaints suggesting reflux, accompanying difficulty swallowing, shortness of breath and swelling in the neck, previous surgery and intubation, and the medicines being used.

The voice itself is assessed by listening; the neck is examined; the larynx and vocal folds are examined by laryngoscopy. Depending on the findings, voice therapy, medical treatment or further investigation is planned.

How is the treatment approach decided?

Treatment is planned according to the cause identified; there is no single “hoarseness treatment”.

In acute laryngitis, resting the voice, adequate fluid intake and avoiding irritants are usually sufficient; guidelines do not recommend routine antibiotics for acute hoarseness. Whispering is not regarded as voice rest, because it too can strain the voice-producing mechanism; speaking little and in a relaxed voice is recommended rather than not speaking at all.

In problems due to overuse of the voice and in a proportion of benign lesions such as nodules, voice therapy comes to the fore as the first-line treatment; guidelines recommend voice therapy in these presentations. Reflux is considered among the possible contributing factors in the appropriate clinical context; the guideline, however, recommends against presuming reflux on the basis of symptoms alone and starting reflux medication for isolated hoarseness without visualisation of the larynx. Management is directed by the history, the examination and, where indicated, the laryngeal findings. Guidelines do not recommend the routine use of corticosteroid medicines for hoarseness before the larynx has been examined.

In lesions such as polyps and cysts that do not respond to voice therapy, and in vocal fold movement disorders, surgical options may be considered. Whether they are appropriate is decided by assessing the examination and laryngoscopy findings together with the response to treatment. This page deliberately contains no drug names, doses or treatment durations.