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.  Hoarseness refers to a difficulty making sounds when trying to speak. Vocal sounds may be weak, breathy, scratchy, or husky, and the pitch or quality of the voice may change.  Hoarseness is most often caused by a problem with the vocal cords. The vocal cords are part of your voice box (larynx) located in the throat. When the vocal cords become inflamed or infected, they swell. This can cause hoarseness.

WHAT ARE THE CAUSES OF HOARSENESS?

The most common cause of hoarseness is a cold or sinus infection, which most often goes away on its own within 2 weeks.  A rare but serious cause of hoarseness that does not go away in a few weeks is cancer of the voice box.  Hoarseness may be caused by Acid reflux (gastroesophageal reflux), Allergies, Breathing in irritating substances, Cancer of the throat or larynx, Chronic coughing, Colds or upper respiratory infections, Heavy smoking or drinking, especially together, Overuse or abuse of the voice (as in shouting or singing), which may cause swelling or growths on the vocal cords.  Less common causes include Injury or irritation from a breathing tube or bronchoscopy, Damage to the nerves and muscles around the voice box (from trauma or surgery), Foreign object in the esophagus or trachea, Swallowing a harsh chemical liquid, changes in the larynx during puberty, Thyroid or lung cancer or an Underactive thyroid gland.

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.

Voice Misuse:  having to speak in noisy situations, excessive use, telephone use with the handset cradled to the shoulder, using inappropriate pitch (too high or too low) when speaking or not using amplification when speaking in public.

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 hear burn 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: allergies, thyroid problems, trauma to the voice box and, 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.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 three months. The evaluation should be immediate if there is concern about a serious underlying cause is suspected.

Doctors usually look at the vocal folds with a mirror placed in the back of the throat or with a very small, lighted flexible tube (fiberoptic scope) that is passed through the nose to view the vocal folds. Videotaping or stroboscopy, a 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.  The treatment of hoarseness depends on the cause. Many common causes of hoarseness can be treated simply by resting the voice or modifying how it is used. During an assessment, the Otolaryngologist will make recommendations about voice use behavior, refer the patient to other voice team members, and in some instances recommend surgery if a lesion, such as a polyp, is identified. Not smoking and avoiding secondhand smoke is recommended to all patients. Drinking fluids and taking medications to thin out the mucus may help.

WHEN SHOULD I SEE AN OTOLARYNGOLOGIST?
  • If hoarseness lasts longer than three weeks, especially if you smoke
  • If you do not have a cold or flu
  • If you are coughing up blood
  • If you have difficulty swallowing
  • If you feel a lump in the neck
  • If you observe loss or severe changes in voice lasting longer than a few days
  • If you experience pain when speaking or swallowing
  • If difficulty breathing accompanies your voice change
  • If your hoarseness interferes with your livelihood
  • If you are a vocal performer and unable to perform

HOW TO PREVENT HOARSENESS

Specialists in speech/language pathology (voice therapists) are trained to assist patients in behavior modification to help eliminate some voice disorders. Patients who have developed bad habits, such as smoking or overusing their voice by yelling and screaming, benefit most from this conservative approach. The speech/language pathologist may teach patients to alter their methods of speech production to improve the sound of the voice and to resolve problems, such as vocal nodules. When a patient’s problem is specifically related to singing, a singing teacher may help to improve the patients’ singing techniques.

  • If you smoke, quit.
  • Avoid agents that dehydrate the body, such as alcohol and caffeine.
  • Avoid secondhand smoke.
  • Stay hydrated; drink plenty of water.
  • Humidify your home.
  • Watch your diet; avoid spicy foods.
  • Try not to use your voice too long or too loudly.
  • Use a microphone if possible in situations where you need to project your voice.
  • Seek professional voice training.
  • Avoid speaking or singing when your voice is injured or hoarse.

Hoarseness may be short-term or long-term. Rest and time may improve hoarseness. Hoarseness that continues for weeks or months should be checked by a health care provider.Things you can do at home to help relieve the problem include:Talk only when you need to until hoarseness goes away, Drink plenty of fluids to help keep your airways moist. Use a vaporizer to add moisture to the air you breathe, Avoid actions that strain the vocal cords such as whispering, shouting, crying, and singing, take medicines to reduce stomach acid if hoarseness is due to gastroesophageal reflux disease (GERD).DO NOT use decongestants which can dry out the vocal cords, If you smoke, cut down, or stop at least until hoarseness goes away.

References

Chang JI, Bevans SE, Schwartz SR. Otolaryngology clinic of North America: evidence-based practice: management of hoarseness/dysphonia. OtolaryngolClin North Am. 2012 Oct;45(5):1109-26. PMID: 22980688 www.ncbi.nlm.nih.gov/pubmed/22980688.

MedlinePlus  https://medlineplus.gov/ency/article/003054.htm

Chio SS, Zalai GH. Voice disorders. In: Flint PW, Haughey BH, Lund LJ, et al, eds. Cummings Otolaryngology: Head & Neck Surgery. 5th ed. Philadelphia, PA: Elsevier Mosby; 2010:chap 203.

Updated by: AshutoshKacker, MD, BS, Professor of Clinical Otolaryngology, Weill Cornell Medical College, and Attending Otolaryngologist, New York-Presbyterian Hospital, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie, PhD, and the A.D.A.M. Editorial team.