Hoarseness – August 2014


Every day I work in my clinic, I meet at least one person whose concern is a raspy, hoarse or abnormal voice. As a general rule, after I examine them with special instruments that enable me to get a close up view of the larynx (voice box), I am able to reassure patients that their condition is not serious, and offer them treatment or management for the condition. However, at least once per week, I will see a patient with a hoarse voice who has developed something more serious. All of us, at one time or another, experience a hoarse voice, especially after a cold, or a period of “vocal abuse” (screaming for, or at your favorite sports team).   By resting the voice, hoarseness from these causes should resolve within weeks. If it persists, I am in favor of patients seeing an Ear Nose and Throat (ENT) specialist for an office laryngeal endoscopy, which is a quick and easy exam for us to perform. Failure to recognize and treat serious abnormalities of the vocal cords can delay vital treatment, causing permanent vocal cord damage, and in cases of malignancy (cancer), endanger life.

Common  Causes and Treatments of Hoarseness

  1. Respiratory infection (cold/flu): Very often, viral or bacterial infections of nose, chest or throat can affect the vocal cords. The coughing and throat clearing that frequently accompanies these infections further aggravates swelling of the vocal cords. Hoarseness from this cause will almost always clear up within several weeks. The usual treatment we recommend in this situation is VOICE REST (i.e. no talking or whispering when possible, avoidance of throat clearing), ample fluid intake, and anti-inflammatories such as ibuprofen.
  2. Vocal abuse (overuse, raising voice, loud singing): I see many patients who, by virtue of their jobs, hobbies, and personalities abuse their voice. Speaking or yelling over background noise, cheering on your child at a soccer game or your favorite pro team, can damage the vocal cords. Many of my patients have jobs or professions (lawyer, preacher, singer, politician, mom) that result in vocal overuse and damage.   The treatment of this situation, logically, is resting the voice, using a public address system if speaking to crowd, avoid voice abuse (screaming, yelling). On occasion, the swelling (edema) of the vocal cords is so severe, we prescribe short courses of steroids like prednisone. If vocal abuse/overuse results in the formation of a nodule or polyp and resting the voice does not result in improvement, the growth can be removed easily.
  3. Growths and tumors: Benign and malignant lesions can form on the larynx. Most commonly malignant (cancer) lesions form as a result of smoking and/or excessive alcohol use. Any lesion that persists longer than 4-6 weeks needs to be removed for biopsy in my opinion, unless that lesion is clearly a benign polyp or nodule in a vocal abuser. The typical symptom of a vocal cord growth is painless, progressive hoarseness. Pain, however, can be a later feature of laryngeal cancer.
  4. Paralysis or weakness of vocal cords: The nerves that move the vocal cords are called the recurrent laryngeal nerves that are situated in the neck under the thyroid gland. Viral infection of the nerves, or injury during neck surgery, can cause paralysis of the vocal cord function by damaging the nerve. In some instances the nerve can recover function over several months. The typical symptom is a very breathy voice, and much effort is required to speak loudly. Also, when the vocal cords do not close normally, the trachea (windpipe) is not protected from throat secretions or liquids, allowing them to enter the air passage causing severe coughing. If the vocal cord remains weak or paralyzed, we can perform endoscopic surgery to permanently reposition the vocal cord so voice is restored. Speech therapy can also be useful if the vocal cord is not totally paralyzed.
  5. Acid reflux into voice box (“laryngopharyngeal reflux” — LPR): Chronic reflux of stomach contents into the esophagus causes heartburn and chest discomfort. The same acid reflux can enter the throat, and the chemicals from the stomach can burn the delicate structures of the voice box. If we suspect a patient has this type of “reflux laryngitis”, we direct our treatment to controlling stomach acid production, and modify the diet and sleeping position to prevent this disorder.

This discussion represents the more typical reasons why a voice might become raspy and hoarse. There are many other possible causes, some minor, some more serious, that I have seen in my patients over many years. ENT doctors such as myself are the only physicians that can easily examine the larynx and vocal cords easily in clinic.   If this symptom is present for over several weeks, I believe it is wise to have this exam performed.

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