General education only; not a substitute for examination or diagnosis.
What this area covers
The larynx (voice box) sits at the front of the neck; it allows breathing, protects the airway during swallowing and produces the voice. Voice is created when air from the lungs makes the two vocal folds (vocal cords) vibrate. Even a small change on the surface of the vocal folds can noticeably affect voice quality.
Hoarseness (dysphonia) is very common; according to the AAO-HNSF guideline, nearly one-third of people experience it at some point in their lives. The main conditions in this area are:
- Laryngitis: inflammation of the vocal folds due to infection, voice overuse or reflux; acute laryngitis usually settles on its own.
- Vocal fold nodules: benign, callus-like swellings, usually on both sides, caused by heavy or strained voice use.
- Polyps and cysts: benign vocal fold lesions, usually on one side.
- Reinke's oedema: fluid build-up in the superficial layer of the vocal folds; it is strongly linked to smoking and lowers the pitch of the voice.
- Leukoplakia: a white patch on a vocal fold; it may be benign but can contain precancerous change (dysplasia) or cancer, so it needs assessment.
- Vocal fold paralysis: damage to the nerve that moves the vocal folds from thyroid, neck or chest surgery, intubation, a tumour or an unknown cause; it can produce a breathy, weak voice and coughing on swallowing.
- Recurrent respiratory papillomatosis: benign, wart-like growths caused by human papillomavirus (HPV) that tend to recur.
- Voice disorders of neurological origin, such as spasmodic dysphonia.
- Laryngeal cancer: smoking and alcohol are the main risk factors; cancers arising on the vocal folds can cause hoarseness at an early stage.
Symptoms
- Hoarseness; a rough, raspy or breathy voice.
- Change in pitch, voice breaks or inability to raise the voice.
- Tiring quickly when speaking and needing more effort to talk.
- A sensation of something in the throat, frequent throat clearing and dry cough.
- Pain when speaking or swallowing, or pain spreading to the ear.
- Coughing or choking when drinking liquids.
- Noisy breathing on inhaling (stridor) or breathlessness.
When to see a doctor
Situations that need emergency care
In the following situations go to an emergency department without delay or call 112 (the emergency number in Türkiye):
- Breathlessness or a harsh, whistling sound on breathing in.
- Coughing up blood.
- Being unable to swallow, drooling because saliva cannot be swallowed, or rapidly increasing throat swelling.
- Sudden loss of voice with breathing difficulty after a neck injury or recent surgery or intubation.
Situations that need a planned appointment
- According to the AAO-HNSF 2018 guideline, hoarseness that does not resolve or improve within 4 weeks should be assessed with laryngoscopy; NIDCD advises seeing a doctor for hoarseness lasting more than three weeks.
- If a serious cause is suspected, early assessment is needed regardless of duration: smoking, a neck lump, recent head, neck or chest surgery or intubation, and professional voice use are among these factors.
- The UK NICE NG12 guideline recommends considering a suspected cancer pathway referral for laryngeal cancer in people aged 45 and over with persistent, unexplained hoarseness or an unexplained neck lump.
- Hoarseness together with difficulty swallowing or pain spreading to the ear.
This information is for general education. A definite diagnosis and treatment decision is made after an examination in which the vocal folds are visualised.
How it is diagnosed
- History: duration, voice-use habits and occupational voice demands, smoking and alcohol, reflux symptoms, previous surgery or intubation and neurological conditions are reviewed.
- Head and neck examination: the neck is felt and the mouth and throat are inspected.
- Laryngoscopy: the vocal folds are examined with a rigid endoscope through the mouth or a flexible one through the nose, usually in clinic after a numbing spray. The AAO-HNSF recommends laryngoscopy before voice therapy is started.
- Videolaryngostroboscopy: a special light shows vocal fold vibration as if in slow motion, helping to distinguish nodules, cysts, scarring and early surface lesions.
- Voice assessment: perceptual rating of the voice, acoustic and aerodynamic measurements, and quality-of-life questionnaires such as the Voice Handicap Index.
- Imaging: the AAO-HNSF advises against CT or MRI for a voice complaint before the larynx has been visualised. CT, MRI or PET-CT may be used to investigate the nerve pathway in vocal fold paralysis or to stage a suspected cancer.
- Biopsy: taken when leukoplakia or cancer is suspected, usually by microlaryngoscopy under general anaesthesia.
Treatment options
Voice care, voice therapy and observation
- Voice care: drinking enough fluids, avoiding shouting and long conversations in noisy places, cutting down alcohol and resting the voice.
- Voice therapy: delivered by a speech and language therapist; the AAO-HNSF strongly recommends it for causes that respond to it. It is first-line for nodules and muscle-tension voice disorders and also supports recovery before and after surgery.
- Stopping smoking: a key part of treatment for Reinke's oedema and leukoplakia and for reducing laryngeal cancer risk.
Medical treatment
- The AAO-HNSF advises against routine antibiotics for hoarseness, and against routinely starting corticosteroids, or reflux medication based on symptoms alone, before the larynx has been examined.
- If examination findings support reflux, lifestyle advice and reflux treatment can be planned.
- For spasmodic dysphonia, botulinum toxin injection into the laryngeal muscles is the recommended treatment and is repeated at intervals.
Surgical and procedural treatment
- Phonomicrosurgery: performed through the mouth under general anaesthesia with a microscope or endoscope for polyps, cysts and Reinke's oedema that do not respond to voice therapy, and for leukoplakia. Preserving the vibrating surface of the vocal fold is the key aim.
- Injection laryngoplasty: filler is injected into the vocal fold when it cannot close properly because of paralysis or thinning; temporary or longer-lasting materials may be used, and in some patients it can be done under local anaesthesia.
- Thyroplasty (medialisation thyroplasty): an implant placed through a small neck incision pushes the paralysed vocal fold towards the midline; it is usually considered for permanent paralysis.
- In papillomatosis the growths need surgical removal; because they tend to recur, more than one procedure may be needed.
- For laryngeal cancer, treatment is planned by a multidisciplinary board according to stage; options include voice-preserving transoral surgery or radiotherapy in early disease, and chemoradiotherapy or partial or total removal of the larynx in advanced disease.
Before and after surgery
- Before surgery, up-to-date laryngoscopy or stroboscopy findings and an anaesthetic assessment are needed. Blood thinners are changed only on the advice of the doctor who manages them.
- Phonomicrosurgery is done through the mouth and leaves no external scar; most people go home the same day or after a short stay.
- A few days of voice rest followed by gradual voice use may be advised after surgery; the duration depends on the lesion and the procedure.
- Mild sore throat and temporary tongue numbness or taste change can occur. Not smoking is important for healing.
- Voice therapy is usually resumed soon after surgery.
- Seek care immediately for breathlessness, noisy breathing, coughing up blood, high fever or increasing neck swelling.
Follow-up
- The AAO-HNSF recommends documenting whether hoarseness has resolved, improved or worsened, and any change in quality of life, after treatment or observation.
- Patients diagnosed with leukoplakia or dysplasia have regular laryngoscopy because of the risk of recurrence.
- In vocal fold paralysis, nerve function may recover on its own over months, so decisions about permanent procedures are often made after a period of observation.
- Follow-up after papillomatosis or laryngeal cancer treatment is long term, with more frequent visits especially in the first years.
Frequently asked questions
According to the AAO-HNSF guideline, hoarseness that has not improved within 4 weeks should be assessed with laryngoscopy; NIDCD advises seeing a doctor after three weeks. If you smoke, have a neck lump, have had recent surgery or intubation, or have breathing difficulty, you should be seen without waiting.
Reflux can be one cause of hoarseness. However, the AAO-HNSF advises against starting reflux medication based on symptoms alone without examining the larynx, because this can delay diagnosis of more serious causes. The vocal folds should be examined first.
Most nodules shrink or stop causing symptoms with voice therapy and voice care. Surgery is considered in selected patients who still have significant symptoms despite an adequate course of voice therapy, and voice therapy remains important afterwards.
The result depends on the type and size of the lesion, how much the vibrating layer of the vocal fold is involved, and voice use after surgery. In many patients the voice improves considerably, but some change can remain, for example due to scarring. Realistic expectations are discussed before surgery.
Smoking can irritate the vocal folds and cause Reinke's oedema and leukoplakia, and it is the most important risk factor for laryngeal cancer. Stopping smoking helps both voice recovery and lowering cancer risk.
Depending on the cause, nerve function may recover on its own over months. During this time voice therapy and, if needed, temporary injection laryngoplasty can be used. If paralysis is permanent, options such as longer-lasting injection or thyroplasty are considered.
Sources
The general information on this page is based on the guideline and institutional sources below. Individual diagnosis and treatment decisions require an examination.