Hoarseness

Authored by , Reviewed by Dr Hayley Willacy | Last edited | Meets Patient’s editorial guidelines

This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.


Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.

Synonym: dysphonia

Hoarseness is a subjective term and usually refers to a weak or altered voice. Dysphonia is similar but may also mean difficulty making sounds. Some terms which may be used to describe a voice change are: breathy, harsh, tremulous, weak, reduced to a whisper, or vocal fatigue (voice deteriorates with use)[1].

NB: any patient aged 45 and over with persistent unexplained hoarseness requires investigation to exclude malignancy (see 'Investigation and referral' section, below).

The first part of this article discusses hoarseness as a presenting symptom. The second part covers some common laryngeal conditions causing hoarseness.

Airway emergencies and hoarseness

Hoarseness may be a feature of laryngeal obstruction - so can be a warning of impending airway obstruction.

This may occur in:

  • Infections - acute epiglottitis, diphtheria, croup, laryngeal abscess.
  • Inflammation/oedema - airway burns, anaphylaxis, physical trauma, angio-oedema, hereditary angio-oedema.
  • Vocal cord immobility - laryngeal nerve palsy (depending on the position of the cords) or cricoarytenoid joint disease[2].

Possible signs of laryngeal obstruction are:

  • Dyspnoea, stridor, wheeze, exertional dyspnoea, anxiety or signs of hypoxia.
  • Dysphagia or drooling.
  • Facial or oral oedema.

Management:

  • Do not examine the throat or attempt distressing procedures; allow the patient to find the most comfortable position.
  • Obtain senior help/anaesthetist.
  • Emergency procedures such as tracheostomy may be needed.
  • Treat the specific cause where feasible.

A retrospective analysis of data from a large American claims database found that of almost 55 million individuals, 536,943 patients (ages 0 to >65 years) were given a dysphonia diagnosis (point prevalence rate of 0.98%)[3].

One study screening hoarseness in children aged 6-10 years reported a prevalence of 12.0% (7.8% of girls, 15.8% of boys)[4].

Risk factors for voice problems[5]

  • Smoking (also the main risk factor for laryngeal carcinoma).
  • Excess alcohol consumption.
  • Gastro-oesophageal reflux.
  • Professional voice use - eg, teachers, actors and singers.
  • Environment: poor acoustics, atmospheric irritants and low humidity.
  • Type 2 diabetes (neuropathy, poor glycaemic control)[6].

Sound is produced in the larynx by vibration of the vocal cords. Resonance occurs in the pharynx, nose and mouth; articulation uses the mouth and tongue. Coughing requires adduction of the vocal cords to be effective.

Innervation of the laryngeal muscles is from the vagus nerve via its branches, the superior laryngeal and recurrent laryngeal nerves. The recurrent laryngeal nerve controls abduction and adduction of the vocal cords. This nerve has a long course, from the base of the skull to the mediastinum: on the left side it loops under the aortic arch and on the right under the subclavian artery.

The vocal cords are subject to high forces and so are vulnerable to voice overuse or misuse.

Voice problems are often multifactorial and due to voice overuse. Serious pathology must be excluded (see 'Investigation and referral' section, below).

Causes of hoarseness

Functional dysphonia

  • Where no organic cause is found - a diagnosis of exclusion.
  • A common cause of hoarseness[9]. There are various forms (below).

Infections

  • Acute laryngitis (common), often with upper respiratory infection. Usually viral (may have secondary infection with staphylococci or streptococci).
  • Other infections - fungal or tuberculous.

Benign laryngeal conditions
For details see last section 'Some specific voice disorders and their management'.

  • Voice overuse - common.
  • Benign lesions of the vocal cords - eg, nodules (singer's nodes), polyps and papillomas.

Malignancy

Neurological

Systemic

Causes in children[5]

  • Congenital - eg, laryngeal web, laryngomalacia, congenital cyst.
  • Older children: vocal cord nodules, voice overuse, gastro-oesophageal reflux, papillomas (as for adults).
  • Very rarely, malignancy.

Other causes

  • Various rare causes of hoarseness, from case reports, are described by Ulis[10].

Contributing factors

  • Drying of the laryngeal mucosa - from low humidity, nasal obstruction, smoking, and air pollution, or from medication (eg, antihistamines, inhaled steroids and anticholinergics).
  • Upper respiratory tract infection.
  • Voice overuse (see 'Some specific voice disorders and their management', below).
  • Gastro-oesophageal reflux (reflux laryngitis or laryngopharyngeal reflux).
  • Scarring - eg, after prolonged intubation.
  • Age-related loss of pliability (normal ageing of the voice). 

History

  • Symptoms - duration, onset and pattern of symptoms; check the patient's meaning of 'hoarseness'.
  • Precipitating factors - recent upper respiratory tract infection, change in voice use - eg, shouting or singing..
  • Occupation, normal pattern of voice use, impact of voice problem on the patient's life.
  • Other ENT symptoms - dysphagia, aspiration, throat or ear pain, nasal blockage.
  • Smoking, alcohol.
  • Reflux symptoms - eg, acid taste in the mouth in the morning, throat clearing, cough or 'choking' sensation, sensation of a lump in the throat[14].
  • Past medical history, particularly chest disease, thyroid surgery, neck trauma, and neurological symptoms.

Examination in primary care[15]

  • Signs of airway obstruction - see 'Emergency' under 'Management', above.
  • Laryngeal function - listen to the patient's voice and assess cough and swallowing.
  • Examine the neck - scars, lymph nodes, thyroid gland. Localised tenderness suggests infection or abscess.
  • Any signs of underlying cause - eg, fever, hypothyroidism, tremor, weight loss.
  • Chest or neurological examination may be appropriate.

ENT assessment[12]

  • Inspection of the larynx - by indirect laryngoscopy and/or fibreoptic nasendoscopy.
  • Voice quality can be evaluated using the GRBAS (= Grade (severity), Roughness, Breathy voice, Asthenia (weakness) and Strain) assessment.
  • The Reflux Symptom Index can be used to identify likely gastro-oesophageal reflux.

Initial investigations

National Institute for Health and Care Excellence (NICE) guidance on suspected cancer states that a suspected cancer pathway referral (for an appointment within two weeks) should be considered for laryngeal cancer in people aged 45 and over with persistent unexplained hoarseness[16].

NICE defines 'persistent' as the continuation of specified symptoms and/or signs beyond a period that would normally be associated with self‑limiting problems. The precise period will vary depending on the severity of symptoms and associated features, as assessed by the health professional.

NICE defines 'unexplained' as symptoms or signs that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination and any primary care investigations).

Further investigations

These depend on the clinical picture:

  • Consider investigations for systemic causes where appropriate - eg, thyroid function.
  • Fibreoptic laryngoscopy - does not require general anaesthetic, so enables examination of the larynx while using the voice[8].
  • Stroboscopy (videolaryngostroboscopy) uses fibreoptic images in slow motion to provide pictures of the working larynx[17].
  • Voice pathologists use various other techniques to measure aspects of voice production, such as amplitude, pitch, range and aerodynamic efficiency.

Management depends on the specific cause but voice therapy and other non-surgical management are the first-line treatment for most benign lesions of the larynx.

Non-surgical management

  • Voice hygiene advice:
    • Adequate hydration.
    • Avoidance of vocal strain (shouting, throat clearing, excessive voice use).
    • Smoking cessation, alcohol reduction (both are irritants and alcohol is dehydrating).
    • Reduction in caffeine intake.
  • Treat gastro-oesophageal reflux (if suspected):
    • Dietary advice.
    • Liquid alginate suspension has been found to be effective in small studies but further research is needed. The addition of proton pump inhibitors was found in one study to have no additional beneficial effect[18].
  • Voice therapy:
    • Teaches techniques to maximise vocal effectiveness.
    • Is effective for both organic pathology (eg, nodules and polyps) and non-organic causes (eg, muscle tension dysphonia).
  • Referral to a specialist voice clinic:
    • Is appropriate if the larynx appears normal and there is no improvement with initial voice therapy. Provides detailed voice assessment and specialist investigations such as videostroboscopy.
  • Other therapies:
    • Relaxation techniques and counselling may be helpful where psychological factors are contributing.
    • 'Mental imagery' and 'laryngeal shaking' treatments were used in one uncontrolled trial on patients where no organic cause had been found, with good reported outcomes[10, 19].

Surgical management

  • Laryngeal papillomas require surgery first-line.
  • Persistent nodules and polyps may require surgery.
  • There are various surgical techniques used to treat vocal cord paralysis.
  • Voice therapy is often used as a adjunct to surgery.

Laryngeal nerve palsy or vocal cord paralysis

This may cause a 'breathy' voice, an inefficient cough or airway narrowing. The clinical features depend on whether one or both cords are affected and the position of the cords - whether abducted or adducted. 'Semon's law' suggests that an incomplete paralysis of the recurrent laryngeal nerve affects the abductor muscles first, so that the vocal cord is in the midline. Complete paralysis affects the adductor muscles also, so the cord is fixed midway, in the paramedian position. Electromyography, however, has shown that the situation is far more complex. There is usually some activity, even if there is no detectable movement on laryngoscopy[20].

Surgical techniques such as Teflon® injection or implants, combined with voice therapy, can restore function[21].

Benign lesions of the vocal cords

  • Vocal cord nodules (nodes or singer's nodes). These are epithelial thickenings of the vocal cord, similar to calluses; they are often due to voice overuse. Voice therapy is the main treatment; surgery is occasionally needed[22].
  • Polyps of the vocal folds. These are unilateral (unlike nodules which are normally bilateral). They may need excision to exclude malignancy[22].
  • Papillomas of the larynx[12]. These are lesions caused by the human papillomavirus (HPV). If untreated and large, they may cause airway obstruction. Invasive carcinoma can occur (rarely). They are usually treated surgically. Intralesional antiviral therapy (cidofovir) may be used for recurrent papillomas.
  • Reinke's oedema. This is oedema of the vocal folds, which tends to give a deep, hoarse voice. It is usually linked to smoking plus voice overuse[23]. Smoking cessation and voice therapy may help; surgery has also been used[12].

Voice overuse or misuse[24]

This is a common problem in some occupations such as acting and teaching; it may also follow unaccustomed voice use, such as shouting at a football match. Vocal strain may be exacerbated when attempting to compensate for an acute respiratory infection.

Benign lesions such as nodules ('singer's nodules'), cysts, haemorrhages and varices can occur with voice overuse.

Management involves:

  • Excluding other pathology.
  • An accurate diagnosis (see investigation details above) - fibreoptic laryngoscopy and stroboscopic techniques are useful.
  • A specific programme tailored to the observed pathology can then be devised. Prescribing rest alone may not be effective.
  • Persistent nodules can be excised.

Functional dysphonia[25]

This is a diagnosis of exclusion, where there is neither a structural abnormality of the larynx nor cord paralysis. There are various types of functional dysphonia. Symptoms include vocal fatigue (voice becoming worse with use) and laryngeal discomfort. There may be various interacting causes, such as heavy demands on the voice, poor vocal technique and stress.

Voice therapy is the main treatment. Other treatments used include relaxation techniques, biofeedback and other methods such as mental imagery and laryngeal shaking or laryngeal massage[19]

Spasmodic dysphonia

This is classified as focal laryngeal dystonia. It is characterised by involuntary endolaryngeal constriction during phonation. The cause is unknown but is thought to involve the central nervous system. Symptoms are breaks in the voice or voice tremor. There are two types - adductor and abductor spasmodic dysphonia. 85% are of the adductor type. The gold standard treatment for adductor spasmodic dysphonia is botulinum toxin injection but this requires repeated injections. A comparative trial suggests that surgery in the form of laser thyroarytenoid myomectomy may be a more popular option with patients[26].

Prevention measures include:

  • 'Vocal hygiene' measures (see under 'Non-surgical management', above)[27].
  • Recognising early warning signs of voice problems, such as an unintentional change in pitch, voice fatigue (the voice gets weaker with increasing use) and sore throat not due to infection[28].
  • Biofeedback is sometimes a useful prophylactic measure for high-risk populations (eg, call centre agents)[29].

Further reading and references

  1. Feierabend RH, Shahram MN; Hoarseness in adults. Am Fam Physician. 2009 Aug 1580(4):363-70.

  2. Eddaoudi M, Rostom S, Amine B, et al; The involvement of vocal cords in rheumatoid arthritis: a clinical case. Pan Afr Med J. 2019 Oct 2134:102. doi: 10.11604/pamj.2019.34.102.20490. eCollection 2019.

  3. Cohen SM, Kim J, Roy N, et al; Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope. 2012 Feb122(2):343-8. doi: 10.1002/lary.22426.

  4. Kallvik E, Lindstrom E, Holmqvist S, et al; Prevalence of Hoarseness in School-aged Children. J Voice. 2014 Jul 10. pii: S0892-1997(14)00124-6. doi: 10.1016/j.jvoice.2013.08.019.

  5. Carding P; Voice pathology in the United Kingdom. BMJ. 2003 Sep 6327(7414):514-5.

  6. Hamdan AL, Kurban Z, Azar ST; Prevalence of phonatory symptoms in patients with type 2 diabetes mellitus. Acta Diabetol. 2013 Oct50(5):731-6. doi: 10.1007/s00592-012-0392-3. Epub 2012 Apr 17.

  7. Evans JM, Schucany WG; Hoarseness and cough in a 67-year-old woman. Proc (Bayl Univ Med Cent). 2004 Oct17(4):469-72.

  8. Kim JE, Rasgon B; The hoarse patient: asking the right questions. Perm J. 2010 Spring14(1):51-3.

  9. Van Houtte E, Van Lierde K, D'Haeseleer E, et al; The prevalence of laryngeal pathology in a treatment-seeking population with Laryngoscope. 2010 Feb120(2):306-12.

  10. Ulis JM, Yanagisawa E; What's new in differential diagnosis and treatment of hoarseness? Curr Opin Otolaryngol Head Neck Surg. 2009 Jun17(3):209-15.

  11. Hamdan AL, Sarieddine D; Laryngeal manifestations of rheumatoid arthritis. Autoimmune Dis. 20132013:103081. doi: 10.1155/2013/103081. Epub 2013 Jun 25.

  12. Syed I, Daniels E, Bleach NR; Hoarse voice in adults: an evidence-based approach to the 12 minute consultation. Clin Otolaryngol. 2009 Feb34(1):54-8.

  13. Cooper L, Quested RA; Hoarseness: An approach for the general practitioner. Aust Fam Physician. 2016 Jun45(6):378-81.

  14. Ruiz R, Jeswani S, Andrews K, et al; Hoarseness and laryngopharyngeal reflux: a survey of primary care physician practice patterns. JAMA Otolaryngol Head Neck Surg. 2014 Mar140(3):192-6. doi: 10.1001/jamaoto.2013.6533.

  15. Bhattacharyya A et al; Pocket Tutor Otolaryngology, 2005.

  16. Suspected cancer: recognition and referral; NICE guideline (2015 - last updated December 2021)

  17. Printza A, Triaridis S, Themelis C, et al; Stroboscopy for benign laryngeal pathology in evidence based health care. Hippokratia. 2012 Oct16(4):324-8.

  18. Wilkie MD, Fraser HM, Raja H; Gaviscon(R) Advance alone versus co-prescription of Gaviscon(R) Advance and proton pump inhibitors in the treatment of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol. 2018 Oct275(10):2515-2521. doi: 10.1007/s00405-018-5079-0. Epub 2018 Jul 30.

  19. Voerman MS, Langeveld AP, van Rossum MA; Retrospective study of 116 patients with non-organic voice disorders: efficacy of mental imagery and laryngeal shaking. J Laryngol Otol. 2009 May123(5):528-34. Epub 2008 Sep 2.

  20. Benjamin B; Vocal cord paralysis, synkinesis and vocal fold motion impairment. ANZ J Surg. 2003 Oct73(10):784-6.

  21. Mallur PS, Rosen CA; Vocal fold injection: review of indications, techniques, and materials for augmentation. Clin Exp Otorhinolaryngol. 2010 Dec3(4):177-82. doi: 10.3342/ceo.2010.3.4.177. Epub 2010 Dec 22.

  22. Wang CT, Liao LJ, Lai MS, et al; Comparison of benign lesion regression following vocal fold steroid injection and vocal hygiene education. Laryngoscope. 2014 Feb124(2):510-5. doi: 10.1002/lary.24328. Epub 2013 Oct 2.

  23. Lim S, Sau P, Cooper L, et al; The incidence of premalignant and malignant disease in Reinke's edema. Otolaryngol Head Neck Surg. 2014 Mar150(3):434-6. doi: 10.1177/0194599813520123. Epub 2014 Jan 16.

  24. Franco RA, Andrus JG; Common diagnoses and treatments in professional voice users. Otolaryngol Clin North Am. 2007 Oct40(5):1025-61, vii.

  25. Ruotsalainen JH, Sellman J, Lehto L, et al; Interventions for treating functional dysphonia in adults. Cochrane Database Syst Rev. 2007 Jul 18(3):CD006373.

  26. Schuering JHC, Heijnen BJ, Sjogren EV, et al; Adductor spasmodic dysphonia: Botulinum toxin a injections or laser thyroarytenoid myoneurectomy? A comparison from the patient perspective. Laryngoscope. 2020 Mar130(3):741-746. doi: 10.1002/lary.28105. Epub 2019 Jun 6.

  27. Pasa G, Oates J, Dacakis G; The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logoped Phoniatr Vocol. 200732(3):128-40.

  28. The voice and its disorders in teachers; INSERM Collective Expertise Centre. INSERM Collective Expert Reports [Internet]. Paris: Institut national de la santé et de la recherche médicale 2000-.2006.

  29. Schneider-Stickler B, Knell C, Aichstill B, et al; Biofeedback on voice use in call center agents in order to prevent occupational voice disorders. J Voice. 2012 Jan26(1):51-62. doi: 10.1016/j.jvoice.2010.10.001. Epub 2011 Mar 23.

newnav-downnewnav-up