Hoarseness is an abnormal voice characteristic in which the voice has a coarse, breathy quality. Usually, it is benign and self-limited, but it may be an early indication of vocal cord carcinoma. Dysphonia is the impairment of voice production as diagnosed by a clinician, often used interchangeably with the complaint of hoarseness, which is a symptom of altered voice quality. While many patients experience dysphonia as a natural part of the aging process, it can be a symptom of a serious underlying condition. Clinicians need to recognize that when patients present with dysphonia for longer than four weeks and/or when it is associated with risk factors or other concerning signs and symptoms, further evaluation is warranted.[rx][rx][rx]
If you are hoarse, your voice will sound breathy, raspy, or strained, or will be softer in volume or lower in pitch. Your throat might feel scratchy. Hoarseness is often a symptom of problems in the vocal folds of the larynx.
Types
Voice disorders can be classified as follows:
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Structural organic voice disorders result from physical changes in the laryngeal anatomy, such as edema, vocal nodules, and presbylarynx.
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Neurogenic organic voice disorders include vocal tremors, spasmodic dysphonia, paralysis of the vocal folds, etc. These problems relate to abnormalities of central or peripheral nervous system innervation to the larynx.
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Functional voice disorders (VFD) are caused by insufficient or improper use of the larynx and diaphragm without any identifiable physical structural abnormality or neurological dysfunction. These disorders often have a noticeable adverse impact on social and occupational function. Although there is a vast amount of literature relating to the topic, there is no consensus regarding foundational concepts or methodology of evaluation of voice disorders, as very few authors have rigorously investigated the most effective vocal assessment or video laryngoscopic examination techniques required to produce a consistent and definitive diagnosis of VFD. The most common VFDs are vocal fatigue, muscle tension dysphonia or aphonia, diplophonia, and ventricular phonation.[rx][rx]
How does our voice work?
The sound of our voice is produced by the vibration of the vocal folds, which are two bands of smooth muscle tissue that are positioned opposite each other in the larynx. The larynx is located between the base of the tongue and the top of the trachea, which is the passageway to the lungs (see figure).
When we’re not speaking, the vocal folds are open so that we can breathe. When it’s time to speak, however, the brain orchestrates a series of events. The vocal folds snap together while air from the lungs blows past, making them vibrate. The vibrations produce sound waves that travel through the throat, nose, and mouth, which act as resonating cavities to modulate the sound. The quality of our voice—its pitch, volume, and tone—is determined by the size and shape of the vocal folds and the resonating cavities. This is why people’s voices sound so different.
Individual variations in our voices are the result of how much tension we put on our vocal folds. For example, relaxing the vocal folds makes a voice deeper; tensing them makes a voice higher.
The larynx is the guardian of the airway. As such, its function is to provide a passage for air to enter the tracheobronchial tree, to prevent the passage of food, saliva, and other swallowed substances from entering the airway, and to provide a sound source for phonation. The true vocal cords are actually muscles stretched across the top of the trachea and arranged in a V configuration. The major motor nerve supply to the vocal cords is the recurrent laryngeal nerve, which is a branch of the vagus. On both sides, the nerves pass out of the jugular foramen in the base of the skull, down through the neck into the upper chest as the vagus nerve, and then ascend back into the neck in the groove between the esophagus and the trachea as the recurrent laryngeal nerves. In this location, they are very vulnerable to injury during thyroid surgery. On inspiration, the angle between the cords widens as the cords abduct, and the angle decreases as the cords adduct during phonation and swallowing. Sound is created by the vibration of the free edge of the cords, which occurs as expired air is forced through adducted cords.
Repeated forceful vocal cord adduction with high-velocity expiratory airflow, which occurs with shouting, can be very injurious to the vocal cords. Hoarseness may develop because of generalized swelling or by producing a small intramucosal hematoma at the point of maximum amplitude of vibration on the free edge of the cord. This hematoma can become organized and go on to form a small nodule, the so-called singer’s nodule. Anything that interferes with the vibration of the free edge of the cord or that produces incomplete closure of the glottis can cause hoarseness. This includes benign vocal cord lesions such as polyps or papillomas, malignant lesions such as carcinoma, or neurologic dysfunction or injury of the vagus or, more specifically, the recurrent laryngeal nerve.
Causes
Your doctor will ask you about your health history and how long you’ve been hoarse. Depending on your symptoms and general health, your doctor may send you to an otolaryngologist (a doctor who specializes in diseases of the ears, nose, and throat). An otolaryngologist will usually use an endoscope (a flexible, lighted tube designed for looking at the larynx) to get a better view of the vocal folds. In some cases, your doctor might recommend special tests to evaluate voice irregularities or vocal airflow.
Hoarseness can have several possible causes and treatments, as described below:
Laryngitis. Laryngitis is one of the most common causes of hoarseness. It can be due to temporary swelling of the vocal folds from a cold, an upper respiratory infection, or allergies. Your doctor will treat laryngitis according to its cause. If it’s due to a cold or upper respiratory infection, your doctor might recommend rest, fluids, and nonprescription pain relievers. Allergies might be treated similarly, with the addition of over-the-counter allergy medicines.
Misusing or overusing your voice. Cheering at sporting events, speaking loudly in noisy situations, talking for too long without resting your voice, singing loudly, or speaking with a voice that’s too high or too low can cause temporary hoarseness. Resting, reducing voice use, and drinking lots of water should help relieve hoarseness from misuse or overuse. Sometimes people whose jobs depend on their voices—such as teachers, singers, or public speakers—develop hoarseness that won’t go away. If you use your voice for a living and you regularly experience hoarseness, your doctor might suggest seeing a speech-language pathologist for voice therapy. In voice therapy, you’ll be given vocal exercises and tips for avoiding hoarseness by changing the ways in which you use your voice.
Gastroesophageal reflux (GERD). GERD—commonly called heartburn—can cause hoarseness when stomach acid rises up the throat and irritates the tissues. Usually, hoarseness caused by GERD is worse in the morning and improves throughout the day. In some people, the stomach acid rises all the way up to the throat and larynx and irritates the vocal folds. This is called laryngopharyngeal reflux (LPR). LPR can happen during the day or night. Some people will have no heartburn with LPR, but they may feel as if they constantly have to cough to clear their throat and they may become hoarse. GERD and LPR are treated with dietary modifications and medications that reduce stomach acid.
Vocal nodules, polyps, and cysts. Vocal nodules, polyps, and cysts are benign (noncancerous) growths within or along the vocal folds. Vocal nodules are sometimes called “singer’s nodes” because they are a frequent problem among professional singers. They form in pairs on opposite sides of the vocal folds as the result of too much pressure or friction, much like the way a callus forms on the foot from a shoe that’s too tight. A vocal polyp typically occurs only on one side of the vocal fold. A vocal cyst is a hard mass of tissue encased in a membrane sac inside the vocal fold. The most common treatments for nodules, polyps, and cysts are voice rest, voice therapy, and surgery to remove the tissue.
Vocal fold hemorrhage. Vocal fold hemorrhage occurs when a blood vessel on the surface of the vocal fold ruptures and the tissues fill with blood. If you lose your voice suddenly during strenuous vocal use (such as yelling), you may have a vocal fold hemorrhage. Sometimes a vocal fold hemorrhage will cause hoarseness to develop quickly over a short amount of time and only affect your singing but not your speaking voice. Vocal fold hemorrhage must be treated immediately with total voice rest and a trip to the doctor.
Vocal fold paralysis. Vocal fold paralysis is a voice disorder that occurs when one or both of the vocal folds don’t open or close properly. It can be caused by injury to the head, neck or chest; lung or thyroid cancer; tumors of the skull base, neck, or chest; or infection (for example, Lyme disease). People with certain neurologic conditions such as multiple sclerosis or Parkinson’s disease or who have sustained a stroke may experience vocal fold paralysis. In many cases, however, the cause is unknown. Vocal fold paralysis is treated with voice therapy and, in some cases, surgery. For more information, see the National Institute on Deafness and Other Communication Disorders (NIDCD) fact sheet, Vocal Fold Paralysis.
Neurological diseases and disorders. Neurological conditions that affect areas of the brain that control muscles in the throat or larynx can also cause hoarseness. Hoarseness is sometimes a symptom of Parkinson’s disease or a stroke. Spasmodic dysphonia is a rare neurological disease that causes hoarseness and can also affect breathing. Treatment in these cases will depend upon the type of disease or disorder. For more information, read the NIDCD fact sheet, Spasmodic Dysphonia.
Other causes. Thyroid problems and injury to the larynx can cause hoarseness. Hoarseness may sometimes be a symptom of laryngeal cancer, which is why it is so important to see your doctor if you are hoarse for more than three weeks. Read the National Cancer Institute fact sheet, Head and Neck Cancer–Patient version. Hoarseness is also the most common symptom of a disease called recurrent respiratory papillomatosis (RRP), or laryngeal papillomatosis, which causes noncancerous tumors to grow in the larynx and other air passages leading from the nose and mouth into the lungs.
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Acute laryngitis (42.1%)[rx]
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Chronic laryngitis (9.7%)
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Functional dysphonia
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Muscle tension dysphonia
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Benign lesions
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Vocal fold nodules
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Vocal fold cysts
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Malignant tumors
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Squamous cell carcinoma
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Lymphoma
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Neurological conditions
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Multiple sclerosis
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Vocal tremor
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Laryngeal dystonia/Spasmodic dysphonia
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Parkinson’s disease
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Amyotrophic lateral sclerosis
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Myasthenia gravis
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Systemic conditions
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Hypothyroidism
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Rheumatoid arthritis
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Systemic lupus
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Wegener’s granulomatosis
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Sarcoidosis
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Amyloidosis
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Tuberculosis
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Aging
How will my doctor diagnose what is wrong?
Your doctor will ask you about your health history and how long you’ve been hoarse. Depending on your symptoms and general health, your doctor may send you to an otolaryngologist (a doctor who specializes in diseases of the ears, nose, and throat). An otolaryngologist will usually use an endoscope (a flexible, lighted tube designed for looking at the larynx) to get a better view of the vocal folds. In some cases, your doctor might recommend special tests to evaluate voice irregularities or vocal airflow.
History and Physical
Clinical evaluation for dysphonic patients is carried out in three steps:
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History Taking
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Physical Evaluation
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Examination
The history-taking involves ascertaining medical, surgical, psychological, or traumatic information that leads to diagnosing and tailoring treatment to the patient. Part of this process is vocal evaluation, which requires understanding the anomaly and how it affects activities of daily life, such as professional commitments or personal communication. Listening to the pitch, volume, and quality of the voice will help the clinician determine the type of problem. Detailed vocal evaluation leads to a better understanding of the underlying pathology and, therefore, a more appropriate intervention.[rx]
The history obtained in voice evaluation should include the description of the voice problems, such as the quality of the voice, fatigability, pitch range, loudness, phonatory effort, breathlessness or presence of conversational dyspnea, and/or impaired singing voice. Patients should also be questioned about past voice disorders and treatments, surgeries, medical history, current medications, environmental factors, and voice habits (hygiene). Understanding which component the patient finds most bothersome is critical.[rx]
Associated signs and symptoms with dysphonia that would be concerning for laryngeal malignancy may include weight loss, aspiration, and/or dysphagia. In later stages of laryngeal cancer, dyspnea and otalgia may be present. Other symptoms to ask about include cough and hemoptysis, which could indicate signs of malignancy. Questions about the history of reflux such as heartburn are also pertinent. Patients presenting with dysphonia should be screened for a history of smoking, alcohol use, neck radiation, and/or a family history of head and neck cancer.[rx][rx] Patients with an underlying neurological condition may present with dysphagia, tongue deviation or tremor, hand or extremity tremor, gait abnormalities, and/or cognitive delay.
Physical examination includes a complete ear, nose, and throat examination after assessing voice quality, loudness, and range. The purpose of the assessment is to focus on nasal airway patency, pharyngeal function, and velopharyngeal competency. Some patients may need pulmonary function studies if they exhibit insufficient expiratory force or volume that leads to an alteration of the voice, compromising the normal pattern of synchronized respiration and phonation. Hearing evaluation may also be important, as hearing loss can influence a patient’s perception of their own voice and therefore alter its production.
Hoarseness may be the only abnormal physical exam finding. Voice can be assessed both formally and informally while engaging the patient in conversation, at which time the clinician can evaluate the following components of voice: quality, pitch, nasality, loudness, prosody, and articulation. It is also important to note if any of the following are present: aphonia, tremor, glottic fry, diplophonia (two spontaneous pitches perceived simultaneously), and wet voice.
An auditory-perceptual evaluation of the voice is performed; the two most common systems are the GRBAS and CAPE-V scales. The GRBAS scale is the gold standard in evaluating the perception of voice and assesses the following components: grade (degree of voice dysfunction), roughness (irregularity), breathiness (air escape), asthenia (weakness), and strain (excessive effort) with each parameter graded on a 4 point scale with 0 being normal and 3 being severe.[rx]
In addition to the perceptual voice assessment, a full head and neck examination should be performed at the initial encounter. Attention should be given to the patient’s respiratory pattern, noting any patterns of breath-holding or habitual use of residual air.
Evaluation
Several patient questionnaires have been created and validated to help with the initial evaluation and ongoing management to assess for response to treatment. The Voice Handicap Index (VHI-10) provides insight into the functional and emotional aspects of the patient’s voice disturbance and is the most widely used patient survey.[rx] Other surveys include the Voice Handicap Index (VHI), Voice-Related Quality of Life (VRQoL), and Glottal Function index (GFI), which evaluates glottic insufficiency.[rx][rx]
Patients are referred to the Otolaryngologist for an in-office laryngoscopy, which evaluates both the laryngeal structure and function. The most commonly used instruments are mirrors, flexible fiberoptic laryngoscopes, or rigid endoscopes. During a flexible or rigid endoscopy, patient examinations can be easily recorded and documented while the patient is vocalizing. These examinations provide valuable knowledge as the vocal folds can be directly visualized and may identify mucosal abnormalities that may not necessarily be seen on computed tomography scans or magnetic resonance imaging.[rx] Radiographic imaging is not recommended as part of the routine evaluation, especially before an endoscopic evaluation.
Videostroboscopy uses pulsed light synchronized with the patient’s vocal frequency to give the illusion of slow-motion mucosal oscillation of the vocal fold. This is the single best diagnostic instrument in evaluating dysphonia to obtain information on mucosal pliability. The following components of the glottic cycle are obtained through stroboscopy: uniformity of glottic cycles (regularity), mucosal waveform, the symmetry of the folds in both the lateral and vertical planes, and pattern of incomplete versus complete versus partial closure. Stroboscopy is useful because it can detect abnormalities that may not be seen on a flexible or rigid endoscopy exam. Patients with malignant tumors may also benefit from surveillance via stroboscopy.
Treatment
How is hoarseness treated?
Treatment depends on the condition causing the hoarseness. The conditions and their treatments include:
- Using your voice too much. Rest your voice (don’t use it for time). Drink water.
- A cold or sinus infection. Let the common cold run its course, or take over-the-counter cold medicines.
- Laryngitis. Talk to your healthcare provider. You may be prescribed antibiotics or corticosteroids.
- Gastroesophageal reflux (GERD). There are a variety of treatment options for GERD, including antacids and proton pump inhibitors.
- Vocal fold hemorrhage. Voice rest.
- Neurological diseases and disorders. There are a variety of treatment options for each neurological disease and disorder.
- Vocal nodules, cysts, and polyps. Dietary changes and voice therapy with a speech-language pathologist. Surgery is sometimes recommended.
- Vocal fold paralysis. A simple procedure performed by an ENT may push a paralyzed vocal fold back toward the center, or a more complicated surgery may be necessary.
- Laryngeal cancer. Treatment options include radiation therapy, chemotherapy, immunotherapy, and surgery.
- Recurrent respiratory papillomatosis (RRP/laryngeal papillomatosis). Like nodules, papillomas are benign (noncancerous) growths. Procedures are done to remove the growths and make sure your airways are clear.
- Muscle tension dysphonia. Treatment options observation or voice therapy with a speech-language pathologist.
Medications
If you experience hoarseness repeatedly because you use your voice so much every day, you might need to see a speech-language pathologist for voice therapy. There are exercises you can do and you’ll be taught how to use your voice to avoid hoarseness.
Treatment options for the underlying diagnosis of dysphonia may include speech and language therapy, medical management, surgery, and/or a combination of the above.[rx] Clinical practice guidelines recommend against the initial treatment of dysphonia with medications such as proton-pump inhibitors, antibiotics, and/or steroids before evaluation by an otolaryngologist or laryngologist.[rx][rx][rx]
Generally, steroids and antibiotics are not given for dysphonia with unclear etiology.
Speech and language therapy is typically the first-line treatment option for patients with dysphonia who do not otherwise meet indications for surgical intervention (e.g., no suspicion of malignancy and/or vocal cord immobility identified on laryngoscopy or video stroboscopy examination). Speech therapy is often successful and still the first line, even when patients present with benign vocal fold nodules.
Surgery is an option for patients with benign vocal fold lesions that do not respond to speech therapy. Meanwhile, patients who present with laryngeal dystonias may require interventions such as botulinum toxin injections, which have shown benefit in patients with disorders such as laryngeal dystonia/spasmodic dysphonia.[rx] Patients with vocal fold granulomas may respond to steroid injections, which can be performed in the office or the operating room. Patients with vocal fold immobility may require temporary measures such as injection of collagen-based products or calcium hydroxyapatite, which can also be performed in the office.[rx] Alternatively, for permanent results, surgery can be performed to medialize the vocal fold with or without addressing the arytenoid, which not only addresses dysphonia but also serves to prevent the risk of aspiration and subsequent development of pneumonia.[rx] This procedure is especially useful in post-stroke patients who may not recover from an injury or in iatrogenic recurrent laryngeal nerve injury from a thyroidectomy, spinal surgery, chest surgery, or an invasive lung tumor.
Patients diagnosed with laryngeal cancer may require chemotherapy, radiation, surgery, or a combination of these modalities, depending on the stage of their presentation.[rx]
What research is being done to better understand and treat hoarseness?
Researchers funded by the NIDCD are working with teachers to devise strategies to help them reduce the stress and strain on their voices. In one study, the teachers use a voice “dosimeter” that takes into account the frequency and loudness of their speech along with the duration of vibration in their vocal folds to determine their daily “dose” of vocal use. The researcher hopes to establish a safe level of voice use, as well as recommended recovery times from prolonged speaking.
In another study, researchers are working with two groups of student teachers in the United States and China to test the effectiveness of voice hygiene education on its own and with voice production training. The researcher hopes to see how successfully the techniques prevent future voice problems in teachers who have healthy voices at the beginning of the study versus those who already may have some voice problems.
If my voice is hoarse, when should I see my doctor?
You should see your doctor if your voice has been hoarse for more than three weeks, especially if you haven’t had a cold or the flu. You should also see a doctor if you are coughing up blood or if you have difficulty swallowing, feel a lump in your neck, experience pain when speaking or swallowing, have difficulty breathing, or lose your voice completely for more than a few days.
References
Sudden Deafness
Dysphonia
Dr. MD Harun Ar Rashid, FCPS, MD, PhD, is a highly respected medical specialist celebrated for his exceptional clinical expertise and unwavering commitment to patient care. With advanced qualifications including FCPS, MD, and PhD, he integrates cutting-edge research with a compassionate approach to medicine, ensuring that every patient receives personalized and effective treatment. His extensive training and hands-on experience enable him to diagnose complex conditions accurately and develop innovative treatment strategies tailored to individual needs. In addition to his clinical practice, Dr. Harun Ar Rashid is dedicated to medical education and community outreach, often participating in initiatives that promote health awareness and advance medical knowledge. His career is a testament to the high standards represented by his credentials, and he continues to contribute significantly to his field, driving improvements in both patient outcomes and healthcare practices.
