Synonyms: Hoarse, raspy or breathy voice, dysphonia
Contents
Understanding the symptom: why am I hoarse?
Do I need a doctor to evaluate my hoarse voice?
Conservative measures for new onset hoarseness.
What your doctor needs to know.
What to expect from your doctor.
But what should your doctor do for you?
The differential diagnosis of hoarseness.
Disclaimer: This information is meant to improve the interaction between you and your doctor. It is NOT meant to replace this interaction! There is no substitute for a history and physical examination administered by a competent physician. If you inappropriately use this information to treat yourself, you may be endangering your health.
Understanding the symptom. Why am I hoarse?
First, some definitions. The larynx (pronounced "lair-inks," not "lar-nicks") is the structure that is commonly called the "voice box." The vocal cords are contained within the larynx, and are a pair of muscular/ligamentous structures that are joined together to form a "V." The point of the V is immediately behind the thyroid cartilage (Adam's apple.) The vocal cords are situated immediately above the trachea (windpipe.) When we breathe, the V is open; when we speak, the vocal cords move together: ||.
The vocal cords also close when you swallow or cough. By closing during a swallow, the vocal cords help prevent food or drink from going into the trachea (the medical term for choking on food, drink or saliva is aspiration.)
Many things contribute to the production of a voice that is recognizable and unique. The shape of your oral cavity and nasal cavity are extremely important; masses (such as nasal polyps), inflammation (such as tonsils enlarged due to infection), and trauma (such as a broken nose) can all cause a very fundamental change in an individual's voice. Voice production depends on the coordinated activity of the muscles of the lips, tongue and soft palate; control of this muscle activity is learned. (A person's accent is one voice quality that is learned, not inherited.) Any illness which effects our ability to use these muscles can result in poor speech quality. Such speech may be described as slurred or strained but is not typically hoarse.
The larynx affects the overall pitch and quality of the voice but is a relatively less important factor in determining the uniqueness of the voice. Poor voice quality is perceived by the listener as hoarseness. Raspiness and breathiness are two other adjectives which may accurately describe poor voice quality. Such voice changes are almost always related to a problem either in the vocal cords or in the nerves which supply the vocal cords.
As noted above, the vocal cords move together during speech. We also exhale air from our lungs during speech. (Try inhaling and speaking at the same time. It's possible, but it certainly isn't easy.) The exhaled air is pushed past the closed vocal cords, causing them to vibrate. This is essentially the same process as what occurs when a musician plays a woodwind instrument. The musician blows air past a reed, causing the reed to vibrate, producing a simple sound. The rest of the instrument (which is analagous to our throat, oral cavity, nasal cavity, tongue, lips and soft palate) shapes this basic sound to produce music (voice.) Just as a broken reed would produce extremely poor music, regardless of the musician's ability, anything which alters the ability of the vocal cords to vibrate will produce a hoarse voice.
If any danger signs are present (see below), you need a doctor. If your hoarseness is of less than three weeks duration and is clearly related to a recent cold or flu, you can safely wait it out and treat yourself. Similarly, if you know that you become hoarse in particular situations (following a public speaking engagement, for example), you may want to consult with a speech therapist or ear, nose and throat specialist, but there is certainly no urgency to this.
Wondering how to use this information?
Refer to Symptom Guide Help for a bit of advice.
Danger Signs
If any of the following symptoms are present, you should see a doctor as soon as possible.
Difficulty breathing
Needless to say: if, in addition to your hoarseness, you are having difficulty breathing, you should be calling 911 and not surfing the web.
A lump in the neck
If the lump has grown slowly over the course of many weeks or months, this may be a sign of cancer. If the lump has grown quickly over the course of hours or days, and is tender, this may be a sign of infection; if hoarseness or other voice change is also present, the infection may be narrowing the airway. See a doctor immediately.
Recent trauma (including surgery) to the throat, neck or chest
Hoarseness persisting for 4 weeks or more
Although this is usually due to some chronic inflammatory condition (such as exposure to cigarette smoke or acid reflux), or chronic trauma (such as vocal abuse), this may also be an early indication of cancer of the larynx. The only way to tell the difference is to have someone (a doctor, that is!) take a look.
Hoarseness associated with any one of the following: a long history of smoking; alcoholism (or any regular consumption of alcoholic drinks); difficulty swallowing; pain with swallowing; ear pain; cough present for more than 3 weeks; recent unexplained weight loss, fevers, chills, night sweats.
Conservative measures for new onset hoarseness
First, read Do I need a doctor? to determine whether it is a good idea for you to attempt to treat yourself. Pay particular attention to the Danger Signs.
Laryngitis is any inflammatory condition of the vocal cords. Acute laryngitis (laryngitis less than 3 weeks duration) is usually due to a viral infection. Often, but not always, it starts as a cold or flu. Treat this as you would treat the common cold, with particular emphasis on adequate hydration (try to drink eight to ten 8 ounce glasses of a decaffeinated, nonalcoholic beverage each day.) Limit your exposure to tobacco and other toxic fumes. Avoid alcohol and caffeinated drinks. If you exercise and lose additional water, increase your water intake accordingly. Try to avoid activities which are particularly rough on the vocal cords: yelling, singing, whispering, excessive throat-clearing, and speaking for long periods of time on the telephone. In other words, try to limit your vocal activity to speaking in normal conversational tones.
What your doctor needs to know.
The questions below are specific to your voice problem. Your doctor will also need to know your general medical history. This includes: any problems for which you are under a doctor's care; problems for which you take medications; a list of all of your medications, including over the counter drugs, vitamins and herbal remedies; a list of the operations you have had; whether you are allergic to any medications; whether you drink alcohol, smoke tobacco, or use other drugs; whether there are any illnesses that run in your family.
If any danger signs are present, bring these to your doctor's attention immediately.
The basics: how long have you been hoarse? Is this problem constant or intermittent? Did any symptoms precede or accompany the onset of hoarseness (for example, did you have a sore throat, or postnasal drainage, followed by hoarseness? Did you have a cough for several days or weeks before becoming hoarse?) Does anything make the hoarseness better; does anything make it worse? Are there any other symptoms which accompany the hoarseness? (Really think about this one; a symptom which may seem unrelated to you may provide an important clue to your doctor.)
Have you been exposed to anyone recently who is sick with a sore throat or cough? Are you experiencing fever, chills, night sweats, sore throat, pain with swallowing, difficulty swallowing (food "sticks" in your throat), or ear pain?
What is your occupation? Do you talk on the phone a great deal? Are you a professional voice user (e.g., school teacher, clergyman, lawyer, performer)? If so, have you been using your voice more than usual? Have you ever worked with a voice coach? Have you been abusing your voice (by screaming at toddlers, for example?)
Do you drink any alcoholic drinks, and/or do you smoke tobacco, marijuana, or any other drug? If so, how much, how often, and for how many years? How many cups of coffee, tea or other caffeinated beverages do you drink in a day? Do you drink coffee and alcohol with dinner? How many nonalcoholic, noncaffeinated drinks do you drink during the day?
Do you ever have heartburn? Do you clear your throat constantly? Do you have a sensation as if there is a ball in the back of your throat, which you are unable to clear? Are you overweight? How much time typically elapses between the last meal of the day, and the time when you go to sleep? Do you snack during this time period?
If you have a cough, is it productive or nonproductive? If productive, what is the quality and color of the mucus? Is your cough worse in the morning? Are you able to breathe through your nose? Do you have postnasal drainage? Do you sneeze a great deal, and do your eyes and/or nose itch?
Your doctor needs to take a thorough history, including a complete medical history, in order to determine the possible causes for your hoarseness.
Ideally, the physical examination should include an examination of the heart and lungs (by stethoscope, and possibly also by chest X-ray), palpation of the neck to see if any unusual lumps or any tender areas are present, an examination of the function of the other cranial nerves (see box, below), and an examination of the larynx, using either a mirror and headlight or a flexible fiberoptic scope.
Examination of the larynx with a mirror is a fairly difficult skill to acquire. Many primary care physicians and even some ENTs do not routinely examine the larynx with a mirror. Use of the flexible fiberoptic scope is a more easily-acquired skill, so this is becoming an increasingly common method for examining the larynx. The equipment is expensive, however, so most primary care physicians do not perform this test.
While an ideal physical examination would certainly include an examination of the larynx, this can safely be omitted, but only if a thorough history has been taken, and no danger signs are present. Needless to say, if danger signs are present, and/or if the history is worrisome for cancer or some other life-threatening condition, then examination of the larynx is essential.
The cranial nerves are nerves which directly exit the brain (all other nerves ultimately trace their origin in the spinal cord.) There are 12 paired cranial nerves. For example, the first cranial nerve is the olfactory nerve, which is critical to our sense of smell; the second cranial nerve is the optic nerve, which is critical to our sight. The tenth cranial nerve is the vagus nerve. This nerve has many functions, among which, a branch of the vagus (the recurrent laryngeal nerve) innervates the larynx.
If any danger signs are present, your doctor should refer you to an ear, nose and throat specialist at once. Your doctor should also refer you to an ENT if he is uncertain as to your diagnosis or is uncomfortable treating your problem. Hoarseness present for more than 4 to 6 weeks must be referred to an ENT. Even if the diagnosis is obvious, an ENT will probably have treatment options for you that are not available to (or known by) your primary care doctor.
Your doctor should inform you of your diagnosis, or give you a list of likely diagnoses. He should clearly indicate how you will be treated, and what he will do if you do not respond to treatment or if your voice problem persists or worsens.
In some cases, other studies may be necessary before your doctor can determine your diagnosis. These studies may include an MRI, CT ("CAT scan"), or blood tests.
Your doctor should be persistent. He should investigate your problem until a diagnosis has been determined and treatment has proven effective.
Patients with sudden, severe stridor (noisy breathing, often associated with "air hunger" or shortness of breath) should be be evaluated by an ENT at once, or by an emergency medicine physician if an ENT is not readily available.
The list which follows is intended to stimulate discussion between you and your physician, particularly if your hoarseness has persisted for several weeks (or more), or has proven difficult to diagnose and treat. Hypochondriacs should skip this section.
On a more cynical note, readers whose health care is administered through a managed care program may have encountered difficulty obtaining referrals to specialists. Sometimes, an informed patient can obtain a referral by gently informing their physician that he is not really capable of determining the diagnosis. The differential diagnosis which follows may provide you with the necessary ammunition. (For example, the question, "But doctor, how do you know that this isn't a cancer of my vocal cords?" can be a very effective prod.)
While not complete, this list will serve to illustrate the great variety of illnesses that are associated with poor voice quality.
Infection and inflammation: most hoarseness which is of short duration is viral inflammation of the vocal cords (laryngitis.) Chronic hoarseness can be due to bacterial infection (for example, tuberculosis may involve laryngeal TB, which aside from being highly contagious, also causes hoarseness.) Chronic reflux of stomach contents can also lead to vocal cord inflammation and hoarseness. Exposure to toxic fumes can cause chronic laryngitis (cigarette smoke is certainly the most common toxic fume exposure!)
Acute onset of hoarseness associated with severe neck pain, fever, chills, and/or a mass in the neck can be due to a deep neck infection. This is an emergency; you need to see a doctor immediately.
Trauma: blunt or penetrating trauma to the neck, throat or chest can injure the larynx or the nerves which supply the larynx. Blunt trauma may result, for example, from a car accident or from assault. Penetrating trauma is usually due to a knife or gunshot wound, but surgery should also be considered a special form of trauma.
Congenital/hereditary: some infants are born with vocal cord paralysis. Another uncommon congenital abnormality is a "laryngeal web." Some very young children develop warts on their vocal cords (the medical term for this is laryngeal papillomatosis or respiratory papillomatosis) which may be due to exposure to the wart virus when the child is in the womb.
Tumors: the best known example of this would be vocal cord cancer associated with tobacco smoke, but many other tumors, both benign and malignant, can involve the vocal cords. Even lung cancer can cause hoarseness, since the nerve for the left vocal cord loops down very low into the chest.
Iatrogenic (hoarseness due to medical treatment): any neck surgery can cause hoarseness due to injury of the nerves which supply the vocal cords. Carotid endarterectomy, thyroidectomy, and cervical spine surgery are three common examples. Hoarseness is also not uncommon following any general anesthetic in which a tube is placed into the lungs to "breathe for the patient" while he/she is under general anesthesia (the medical term for this is endotracheal intubation.) Usually, this type of hoarseness lasts only a few days, at most.
Degenerative problems: rheumatoid arthritis can limit the motion of the cricoarytenoid joint, leading to hoarseness because the vocal cord cannot move well (or at all.) Aging can also cause changes in the larynx which lead to the "creaky voice" that some elderly folks have (presbyphonia.)
Metabolic or hormonal problems
Hypothyroidism (low thyroid hormone level.) Other symptoms of hypothyroidism include muscle weakness, chronic fatigue, weight gain, intolerance of cold, coarse hair, "ashen" skin color, tongue enlargement.
Heart and vascular disease: just as lung cancer can cause hoarseness by damaging the nerve to the left vocal cord, certain forms of heart disease can lead to hoarseness by putting pressure on this same nerve.
Psychophysiologic hoarseness: overuse or abuse of the voice can lead to the formation of nodules on the vocal cords (known as "singer's nodules" or "screamer's nodules.") Other "bad vocal habits" can lead to poor voice quality (dysphonia). Examples are muscle tension dysphonia and plica ventricularis.
Idiopathic disorders (disorders for which the cause is unknown)
Sarcoidosis
Spasmodic dysphonia