Persistent hoarseness

What is hoarseness?

Voice is produced when the two vocal folds (vocal cords) in the voice box (larynx) come together and vibrate as you breathe out. When the vocal folds are swollen, develop a growth or cannot close fully, the voice changes. In this condition, medically called dysphonia, the voice may sound husky, rough, breathy, strained, weak, shaky, or lower or higher than usual, and it may tire quickly.

Most hoarseness is linked to a cold or upper respiratory infection and usually clears up on its own within 1–2 weeks. Hoarseness that lasts longer, however, is a symptom whose cause must be looked into.

Common causes

• Acute laryngitis: temporary inflammation of the vocal folds after a cold, a viral infection or straining the voice.
• Overuse or misuse of the voice: talking loudly, shouting or singing for long periods; common in heavy voice users such as teachers, singers and call-centre staff.
• Reflux: stomach contents rising up to the voice box (gastro-oesophageal or laryngopharyngeal reflux) can irritate the vocal folds.
• Benign vocal fold lesions: nodules, polyps and cysts are usually linked to long-term vocal strain.
• Smoking: the main risk factor for vocal fold swelling (Reinke's oedema), precancerous changes and laryngeal cancer; alcohol adds to this risk.
• Vocal fold paralysis: neck, thyroid or chest surgery, a prolonged breathing tube (intubation) or a disease affecting the nerve can stop a vocal fold moving properly; the voice becomes breathy and weak.
• Laryngeal cancer and precancerous lesions: especially in smokers, persistent hoarseness may be the first sign.
• Other causes: age-related thinning of the vocal folds, neurological conditions such as Parkinson's disease, allergies and thyroid problems.

When to see a doctor

What happens at the appointment

The doctor asks how long the hoarseness has lasted, how you use your voice, about smoking and alcohol, reflux symptoms, previous operations and medicines, and examines your neck, mouth and throat. The way to see the vocal folds directly is a voice box examination (laryngoscopy):

• Flexible laryngoscopy: after the nose is usually sprayed with a numbing and/or decongestant spray, a thin, flexible tube with a camera on the tip is passed through the nose. It takes a few minutes; you stay awake and can talk and breathe, although it may feel slightly uncomfortable.
• Rigid laryngoscopy: a rigid endoscope is placed through the mouth while the tongue is gently held, giving a magnified view of the vocal folds.
• Stroboscopy: a special light lets the vocal fold vibration be watched as if in slow motion, helping to assess small lesions and vibration problems.
• Further tests if needed: if something looks suspicious, examination of the voice box under a microscope under general anaesthesia (microlaryngoscopy) with a tissue sample (biopsy) may be planned. Scans such as CT or MRI are requested according to the examination findings, not before the voice box has been seen.

A definite diagnosis and treatment decision are made at examination.

Treatment options

Treatment depends entirely on the cause; the same symptom can come from very different conditions.

• Voice therapy: exercises with a speech and language therapist teach you to use your voice in a healthier, less strained way. It is the first-line treatment for nodules and many functional voice problems, and may also be advised before surgery and afterwards.
• Medicines: reflux treatment may be given if there are signs or symptoms of reflux at examination, and allergy treatment if allergy is present. Antibiotics and steroids are not routinely needed for hoarseness.
• Surgery: microscopic vocal fold surgery (microlaryngeal surgery) may be used for polyps and cysts that do not respond to voice therapy, and for suspicious or cancerous lesions. For vocal fold paralysis, injections or operations that move the vocal fold towards the midline may be options.
• Other: botulinum toxin injections are used for some neurological voice disorders such as spasmodic dysphonia. In laryngeal cancer, treatment depends on the stage and includes surgery, radiotherapy and, where needed, drug treatments, planned by a multidisciplinary team.

An important note: reflux medicines do not replace the examination that looks for the cause of hoarseness. The AAO-HNSF guideline advises against starting reflux medicine on suspicion alone in people whose only symptom is hoarseness and whose voice box has not been examined. Taking reflux medicine for weeks and waiting can delay the diagnosis of a problem that could have been found at an early stage.

Looking after your voice

• Drink enough water through the day; keeping the vocal folds moist helps them vibrate.
• Do not smoke and avoid second-hand smoke; limit alcohol and excess caffeine.
• Avoid shouting over noise; if you use your voice heavily for work, use a microphone and take voice breaks during the day.
• Do not whisper when you are hoarse — whispering also strains the vocal folds. Talk as little and as gently as possible.
• Humidify dry air, and sip water instead of repeatedly clearing your throat.
• If you have reflux symptoms, avoid heavy meals late in the evening and follow your doctor's advice.