Hoarseness can be observed at any age due to various reasons. Generally, hoarseness complaint is seen equally in both sexes; however, different etiologies of hoarseness can be more frequent in males or females.
In order for good phonation to happen, free edges of both vocal folds must be straight and must touch each other regularly during closed phase of glottal cycle. Various laryngeal disorders may cause hoarseness. Quality of voice may change between total aphonia (no phonation) and mild voice change. Baby may cry without any voice or his voice may be weak, coarse, wheezy, scratchy or husky; besides hoarseness he may be breathless. There are different laryngeal diseases that cause different voice problems with or without airway obstruction in children and adults.
Hoarseness (also called dysphonia) is a change in the quality of voice. Voice sounds muffled, raspy, strained, breathy, weak, higher or lower in pitch, inconsistent, or fatigued, often making it harder to talk and hear. This generally occurs when there is a problem in the vocal cords of the larynx. Vocal cords produce sound. Vocal cords are open during inspiration. However, they close during phonation and vibrate depending on the energy of exhaled air from the lungs. Any disorder that changes the vibration or closure of the vocal cords results in hoarseness.
If you are a tobacco smoker and your voice is hoarse for more than a month, you should see an ear nose throat doctor. This is also true if you do not smoke. Severely disturbed voice should make one see a voice doctor. If your voice quality can be described as raspy, strained, breathy, weak, higher or lower in pitch, inconsistent, fatigued, or shaky voice, you should visit a laryngologist. Breathing difficulty is a medical emergency and one should immediately consult a doctor. Neck pain during speaking indicates poor phonation technique and is another reason to visit an ENT specialist. Vocal professionals (singer, teacher, public speaker, actor, actress) who cannot do their job need to be examined by their voice doctor.
The four common causes of hoarseness are vocal nodules, vocal polyps, vocal fold paralysis and laryngeal papillomatosis. Please read the corresponding tabs under the heading “Diseases”.
The most common cause of poor voice quality is acute laryngitis which is acute inflammation of larynx due to viruses, bacteria, fungi, allergens, reflux or vocal trauma. Laryngeal examination reveals redness and swelling of laryngeal and vocal fold mucous membrane, membrane formation on laryngeal mucosa, pus drainage, swelling and narrowing of mucosa below vocal cords. The most common cause of acute laryngitis is viral laryngitis, that happens during viral upper respiratory tract infection. A common cold, rhinitis, nasopharyngitis, tonsillitis, pharyngitis and influenza may go down the respiratory tract to involve the larynx. Hoarseness develops, throat pain increases; swallowing difficulty, barking cough, dry cough or respiratory difficulty may be observed. Voice strain, such as screaming and shouting can make your vocal cords swell and/or bleed below mucosa. You can seriously damage your vocal cords if you continue talking during acute laryngitis. Allergy to inhaled substances, such as pollens or dust mites may also cause acute laryngitis during allergy season or all year around. Inhalation of various chemicals (cleaning substances, detergents, fumes, insecticides) may damage laryngeal mucosa and lead to inflammation of larynx. This is true for coal mine workers, who inhale coal dust during work. Reflux of stomach contents to throat may burn laryngeal mucosa and cause acute or chronic laryngitis. All tobacco smokers have some degree of laryngitis ranging between acute and chronic laryngitis.
Treatment of acute laryngitis depends on its cause. The patient should stop smoking tobacco, quit inhaling chemicals, prevent exposure to allergens, receive treatment for reflux. The patient should stop speaking; this is called absolute voice rest. He should refrain from speaking, shouting, even whispering; he must communicate using paper and pen. The patient will be prescribed high dose corticosteroids (250 mg methylprednisolone intravenously as an initial bolus dose, 1 mg/kg prednisone orally as a single dose in the morning). If the etiology of laryngitis is bacteria, antibiotics are given. If the cause is viral, antiviral drugs may be prescribed. For thick secretions mucolytics may be advised. Cold steam inhalation, increased liquid intake are other supporting remedies.
Laryngitis can be acute or chronic depending on the length of exposure to causative agents. Acute one are easier to treat, however, chronic laryngitis usually does not respond well to treatment. In case of chronic laryngitis vocal cord mucosa thickens, there is no vibration during phonation; there may be crusting on vocal cords. All tobacco smokers have some degree of laryngitis on their vocal cords. Professional voice users should postpone their performance if they have severe laryngitis; in case of mild laryngitis, corticosteroids may help him or her to continue the performance. Severity of laryngitis should be determined by an experienced laryngologist. Laryngitis heals completely without any sequelae if treatment principles are followed; however, if the patient continues to use his voice during laryngitis, permanent scar may form on vocal cords and permanent voice disorder results.
Two cases of chronic laryngitis due to reflux
Pre-cancerous lesions of vocal folds
Pre-cancerous lesions of vocal folds are erythroplakia and leukoplakia. Erythroplakia on vocal fold is a red lesion; whereas leukoplakia is a white lesion. Both are precancerous lesions. Both can cause hoarseness. The risk of cancer development of erythroplakia is higher than that of leukoplakia. Pathologically they can be parakeratosis, hyperkeratosis, hyperplasia or dysplasia (mild or severe). If there is dysplasia, dysplastic lesion may recur after excision; in the long run it may turn into cancer. For treatment, both lesions must be excised, so that their pathologic diagnosis is determined and the patient must be followed up regularly for a long time.
Neurological diseases or disorders
Hoarseness can occur with Parkinson’s disease or after a stroke. Parkinson’s disease causes gap between vocal folds during phonation; it is treated by injection of filling material into the vocal cords. Spasmodic dysphonia can cause hoarseness or difficulty in speaking. It is characterized by spasms during speaking causing blocks in speech or breathy periods during speech. Botox injection into vocal cords corrects voice temporarily.
Aging causes vocal cord atrophy
During aging process the vocal cords become thinner. They have a decreased mass and bulk and become floppy due to their decreased tone. This is not due to too much talking or too loud talking or very little talking, it’s just a part of aging process. A hoarse voice that varies from one day to another day is common. The power of voice is diminished. During examination flaccid and atrophic vocal folds do not touch each other during phonation; there is glottal gap during phonation. Treatment for vocal cord atrophy includes voice therapy and vocal cord injection, but reassurance that hoarseness is not due to cancer may be all that the patient needs. Filling material injection to vocal folds in the office under topical anesthesia brings vocal folds together, corrects voice and increases its power.
Vocal cord hemorrhage
Blood vessels supplying vocal cords may dilate to form telangiectasias or build a ball of vessels under vocal cord mucosa. When there is a bleeding into the vocal cord, voice turns hoarse and voicing requires increased effort and is usually painful. Some ladies develop this bleeding during their menstrual cycle. The users of aspirin and other anticoagulant drugs have increased tendency towards vocal cord hemorrhage. One should always question the use of such drugs.
Bleeding into the vocal cord happens during shouting, yelling, screaming and other strenuous vocal activity. Patients usually suffer from complete loos of voice after such activities, during which a blood vessel or blood blister breaks and fills the vocal cord with blood. This is a vocal emergency for a voice professional (musicians, actors, actresses, politicians).
Diagnosis is performed by examining vocal folds with flexible endoscopy or stroboscopy. Hemorrhage area is visualized as red or purplish region within vocal fold or folds.
For treatment the patient should perform a complete voice rest. Complete voice rest means no voicing at all, even no whispering. The patient communicates using pen and paper. The patient is advised to drink plenty of liquids or inhale cold mist in order to humidify vocal folds. He should refrain from throat clearing. To liquefy saliva mucolytic agents may be prescribed. Corticosteroids should NOT be used for treatment of vocal cord hemorrhage, because they delay resorption of blood. Blood within vocal fold will resorb spontaneously in time. However, surgical evacuation of blood from the vocal fold is another option that can be advised in order to decrease waiting time for spontaneous resolution of hemorrhage.
Reflux means entry of acidic or non-acidic stomach contents into the esophagus. Classic heartburn and indigestion are symptoms of gastroesophageal reflux, which is caused by acid or bile reaching the esophagus. When the reflux material reaches the throat, we call it laryngopharyngeal reflux. Reflux material burns and damages vocal fold mucosa and leads to inflammation; we call this reflux laryngitis. If the reflux continues and is not treated, acute laryngitis will turn into chronic laryngitis, which is characterized by thickening of vocal cord and laryngeal mucosa. Besides laryngitis, reflux causes arytenoid swelling and redness and thickening of posterior part of larynx, which is called pachydermi laryngis. Reflux does not cause other lesions on vocal folds, however, it potentiates them. Treatment of reflux requires life changes, such as not overeating, not lying down after meals, not bending over after meals, elevating the head of the bed. Avoiding gaseous liquids (cola, soda etc.), not eating industrially produced junk food, avoiding tobacco smoke and alcohol, decreasing citrus fruit and juice intake, consuming plain yogurt and sour milk instead of milk, terminating eating and drinking 3 hours before bedtime are other suggestions to decrease reflux episodes. Proton pump inhibitors once or twice daily on an empty stomach, histamine-2 receptor blockers before bedtime, antacids after meals and prokinetics are medications used to treat reflux.
Tobacco smoking causes hoarseness by inducing various lesions on vocal cords and increases the risk of developing lip, tongue, mouth, throat, esophageal, lung and laryngeal cancers. Smoking can also cause swelling on your vocal cords. This swelling is called Reinke’s edema, which lowers the pitch of voice and can block the airway in severe cases. Low pitch of voice is not troublesome for man, however, it may be disastrous for a lady, because she may be called gentleman on the phone. Smokers also develop pre-cancerous red and white lesions on vocal cords. Smokers who develop hoarseness should see an ENT doctor immediately.
Allergies to inhaled substances, such as pollens, coal dust, can cause acute and chronic laryngitis. Decreased levels of thyroid hormones in blood may cause swelling of vocal folds, called Reinke’s edema and decrease pitch of voice. Poor voice use, such screaming, shouting and yelling, traumatizes vocal cords and causes vocal cords to swell (called edema) or bleed inside the vocal cord (called vocal cord hemorrhage).
Depending on the cause of hoarseness, long-term concerns range from permanent hoarseness, inability to effectively communicate with others, loss of work for vocal professionals, to major surgery or death from cancer and cancer-related treatments. That’s why it’s very important to see a laryngologist for persistent hoarseness.
Web is a fibrous tissue adhesion between vocal folds. Three fourth of webs are observed between vocal folds. One fourth of webs may be seen above and below vocal folds. Glottic web is a fibrous structure similar to webbing in duck’s feet. Web is visualized between the anterior portion of vocal folds. The length and thickness of webs may differ. Web forms approximately 5% of all congenital laryngeal disorders. Acquired web is more common than congenital web. Acquired webs appear after surgical laryngeal trauma or external neck trauma involving the larynx. Postsurgical web is a complication of surgery and is due to faulty surgical technique. Symptoms depend on the length of glottic web. In congenital web, parents may say that their baby does not cry. Alternatively, the cry may be weak or hoarse. As the web lengthens, respiratory distress may appear, because web narrows the airway. Child’s respiration is noisy during both inspiration and expiration; this is called biphasic stridor.
Laryngeal endoscopy visualizes and makes the correct diagnosis of web. In case of a congenital web the doctor should always think about the possibility of co-existence of airway narrowing below and above vocal folds and should perform necessary diagnostic steps which includes examination under general anesthesia or computerized tomography of larynx.
There are many surgical treatment options for web. The most frequently chosen form of treatment of web is excision of web under microscope and placement of a keel between vocal folds to prevent reformation of web. The keel is removed from larynx within several weeks. Voice and airway improves after surgery; however, one should not expect or promise totally normal voice postsurgically; because web is scar tissue and vocal folds remain scarred after removal of web.
Cyst is a fluid-filled mass under vocal cord mucosa. There are two types of cysts: Congenital and acquired. Congenital cysts are present at birth, are white in color and are due to trapped epithelium (squamous or respiratory) underneath vocal cord mucosa, and are called epidermoid cyst. Acquired cysts develop later in life due to poor voice use, which traumatizes opening point of a mucous gland and leads to collection of gland secretion behind obstructed drainage; hence, this cyst is also called a retention cyst. Both cysts are seen on one of the vocal cords; however, there may be a reactive thickening on the other vocal cord due to repeated trauma of the cyst. Hoarseness, easy fatigability of voice, diplophonia, pain in the neck and throat after long term speaking, total loss of voice after fatigue and foreign body sensation in throat are common complaints of a patient with a vocal cord cyst. Diagnosis is done by examining vocal cords with a flexible or rigid scope. Treatment of cyst involves surgical excision under microlaryngoscopy. Surgery should not be delayed, because spontaneous rupture of a cyst may lead to sulcus vocalis, which causes permanent hoarseness. So, surgical removal of a cyst before its spontaneous rupture is the ideal form of treatment.
Acquired retention cyst
Congenital epidermoid cyst
Vocal cord edema, Vocal cord swelling, Reinke’s edema
It is a type of chronic laryngitis. It develops due to tobacco smoking and voice misuse. There is a gelatinous fluid collection within the superior surface of vocal cord. Contrary to other forms of chronic laryngitis, there is no thickening of vocal fold mucosa. It is usually observed on both vocal folds; rarely it may be on one vocal cord only. Vocal folds appear like fluid filled bags or piece of grapes; these bags fall into lumen during inspiration and blown superiorly during expirium. It is due to burning or damage of tobacco smoke to upper surface of vocal cords. Reinke’s edema causes decreased pitch of voice; thus, women above the age of 40 years apply to doctors more frequently because of voice change; because they are called “gentleman, mister or sir” at the door or on the phone. Man with Reinke’s edema have hoarseness and low pitched voice; however, they are happy with low pitch voice, because it makes them more prestigious and effective. Long lasting Reinke’s edema takes the form of a polyp and fall into lumen. Reinke’s edema may enlarge to cause airway obstruction and dyspnea. Weight of vocal cords is increased due to fluid collection; therefore, phonation becomes harder and more painful. Patients complain of hoarseness, scratchy and husky voice and difficulty during phonation.
Diagnosis is done by examining vocal cords with a flexible or rigid scope. Surgery is usually necessary for treatment. Fluid and excess of vocal cord mucosa is removed using microlaryngoscopy; vocal cords attain normal size and weight. Suturing of mucosal edges is required to decrease time for healing. Some surgeons prefer to operate two vocal cords in two stages to prevent web formation. However, if the surgeon preserves anterior tip of vocal cords, single surgery in enough for treatment. After surgery the patient is asked to perform complete voice rest for 7 days; when he starts talking after voice rest his voice is hoarse and scratchy; however, voice will improve slowly in time and become normal in 2-3 months. Healing of vocal cords after surgery for Reinke’s edema lasts 2-3 months, because damage induced by tobacco smoke burns mucosa and slows down healing process. Voice therapy is necessary before or after surgery to terminate wrong phonation attitude that causes Reinke’s edema. For early Reinke’s edema voice therapy alone may correct vocal cords.
Clinically there is a polypoid mass on posterior part of one or both vocal cords. It is caused by vocal abuse, habitual throat clearing and laryngopharyngeal reflux. Endotracheal intubation was once thought to cause contact granuloma; however, we know today that intubation granuloma is a different disease entity from contact granuloma; it is seen equally in both sexes; it has high spontaneous resolution rate; and low recurrence rate when excised. Intubation granuloma occurs due to trauma of intubation tube to posterior part of vocal cords; intubation tube is inserted into the airway of patients operated under general anesthesia or staying in intensive care unit. However, contact granuloma is 5-10 times more common in males compared to females; it rarely disappears spontaneously and it has high recurrence rate (90 %) when excised surgically. Shouting, screaming and habitual throat clearing causes vocal cords to hit each other strongly damaging posterior vocal cord mucosa leading to an ulcer; ulcer tries to heal by granulation tissue, but it cannot heal because of continuing vocal trauma; thus more granulation tissue comes leading to a well-defined pinkish or red mass on posterior vocal cord. Its position is specific; biopsy is not necessary for diagnosis. It is common in men in middle ages. Contact granuloma is seen on posterior 1/3 of vocal cords; all other aforementioned lesions are observed on anterior 2/3 of vocal cords. Patients complain of hoarseness, scratchy and husky voice and difficulty during phonation. Patients are usually loud speaking, shouting and tense people. Diagnosis is done by clinical examination alone using a flexible or rigid scope. Treatment is by botulinum toxin injection to vocalis muscle under topical anesthesia as an office procedure. Voice therapy and anti-reflux treatment are other alternatives; however, they usually do not help. Surgical excision of mass alone or office evaporation of lesion using laser should not be performed for treatment of contact granuloma; because this leads to recurrence in all patients. Botox causes transient paralysis of vocal folds; during this paralysis period ulcer on vocal process finds time to heal and granuloma disappears in 75 % of patients. For the other 25 % of patients surgical excision of granuloma and intraoperative botox injection to vocal folds can be performed in order to prevent recurrence of granuloma.
If botox dose is high, patient may experience aspiration of food and liquids and may cough due to aspiration; or he may not swallow food and liquid and complain of dysphagia. This is a temporary situation and will be over in 1-2 weeks. If granuloma recurs in the future, botox injection may be repeated.
Sulcus is a cleft, slit, depression or groove along free edge of vocal cords. The cleft is due to a congenital absence of one layer of vocal cord mucosa. It may be congenital or may be acquired due to voice misuse. It may also be acquired due to spontaneous rupture of vocal cord cyst. On the location of sulcus there is no vibration on vocal cords. Patient has severe hoarseness. Vocal cords don’t touch each other during phonation because of cleft; this gap causes a lot of air escape during phonation; thus, voice is not strong enough. Patients complain that people don’t hear him in noisy environments. Because he is using a lot of effort for speech, he gets tired easily; there may be pain in the neck due to excessive muscle action to bring vocal cords together. Diagnosis is done by clinical examination with a flexible or rigid scope using stroboscopy. Stroboscopy shows absence of vibration on vocal cords and gap between vocal cords during phonation.
Voice therapy helps the patient to cope with better and stronger voice by correcting maladaptive behaviors. There are multiple options for surgery of sulcus vocalis. Filling material injection to vocal cords helps to bring vocal cords together during phonation. Silicon implant to one or both vocal cords may serve the same purpose. Short sulcus is a good candidate for microscopic excision and suture closure of the defect. For longer, larger and deeper sulcus, tissue deficit of mucosa may be attenuated by using fat or fascia implantation below sulcus area. Normal voice cannot be attained after any treatment. Voice quality usually does not change; however, intensity of voice is increased. People will hear the patient much more easly after treatment.
Sulcus on both vocal cords before surgery and fascia implantation and fat injection to both vocal cords.
Functional voice disorders
Functional voice disorders are the presence of a voice problem due to misuse of vocal cords when both the larynx and vocal cords are physically normal. Tense talking and contracting neck muscles excessively during speech are examples of functional voice problems; this is commonly called muscle tension dysphonia. If functional voice disorder lasts long enough, it may lead to aforementioned organic vocal cord diseases, such as nodules and polyps. The use false vocal folds for phonation is another example of functional voice disorders; this situation is called dysphonia plica ventricularis. False vocal folds are two symmetrical folds just above the true vocal cords. Functional voice disorders are very common among professional voice users and they affect their mental status and professional positions negatively. Patient complains of disturbed quality of voice, easy fatigability when using voice vet pain in the neck during phonation. Diagnosis is performed using flexible and rigid endoscopy and stroboscopy. During examination, tension in neck muscles, retracted lips and tongue and higher position of larynx in the neck may be noted. Vocal cords and their vibrations are normal. The use of false vocal folds, anteroposterior and/or lateral compression of larynx during phonation may be visualized. Treatment is voice therapy. During voice therapy false phonation technique is replaced by correct technique.
Psychogenic problems may affect voice. Mental problem leads to complete loss of voice, called aphonia. The patient speaks like whispering and is unable to phonate. Vocal cords are completely normal; however, they stay open during phonation and do not vibrate.
Correction of voice is usually easy with a simple voice therapy maneuver; however, some patients may be resistant to therapy. After correction of voice treatment of underlying psychological disorder must be tried; otherwise, recurrence of aphonia is common. Surgical treatment of functional aphonia is a malpractice and should not attempted.