Voice Disorders & HoarsenessIt may come as a surprise to you the variety of medical conditions that can lead to voice problems. The most common causes of Abnormal changes in the voice are called “hoarseness.” When hoarse, the voice may sound breathy, raspy, strained, or show changes in volume or pitch (depending on how high or low the voice is). Voice changes are related to disorders in the sound-producing parts (vocal cords or folds) of the voice box (larynx). While breathing, the vocal cords remain apart. When speaking or singing, they come together and, as air leaves the lungs, they vibrate, producing sound. Swelling or lumps on the vocal cords hinder vibration, altering voice quality, volume, and pitch. What are the causes of hoarsenessAcute Laryngitis: is the most common cause of hoarseness and voice loss that starts suddenly. Most cases of acute laryngitis are caused by a viral infection that leads to swelling of the vocal cords. When the vocal cords swell, they vibrate differently, leading to hoarseness. The best treatment for this condition is to stay well hydrated and to rest or reduce your voice use. Serious injury to the vocal cords can result from strenuous voice use during an episode of acute laryngitis. Since most acute laryngitis is caused by a virus, antibiotics are not effective. Bacterial infections of the larynx are much rarer and often are associated with difficulty breathing. Any problems breathing during an illness warrants emergency evaluation. Chronic Laryngitis: is a non-specific term and an underlying cause should be identified. Chronic laryngitis can be caused by acid reflux disease, by exposure to irritating substances such as smoke, and by low grade infections such as yeast infections of the vocal cords in people using inhalers for asthma. Chemotherapy patients or others whose immune system is not working well can get these infections too. Voice Misuse & Overuse: Speaking is a physical task that requires coordination of breathing with the use of several muscle groups. It should come as no surprise that, just like in any other physical task, there are efficient and inefficient ways of using your voice. Excessively loud, prolonged, and/or inefficient voice use can lead to vocal difficulties, just like improper lifting can lead to back injuries. Excessive tensionin the neck and laryngeal muscles, along with poor breathing technique during speech leads to vocal fatigue, increased vocal effort, and hoarseness. Voice misuse and overuse puts you at risk for developing benign vocal cord lesions (see below) or a vocal cord hemorrhage.
Benign Vocal Cord Lesions: Benign non-cancerous growths on the vocal cords are most often caused by voice misuse or overuse, which causes trauma to the vocal cords. These lesions (or “bumps”) on the vocal cord(s) alter vocal cord vibration and lead to hoarseness. The most common vocal cord lesions are nodules, polyps, and cysts. Vocal nodules (also known as nodes or singer’s nodes) are similar to “calluses” of the vocal cords. They occur on both vocal cords opposite each other at the point of maximal wear and tear, and are usually treated with voice therapy to eliminate the vocal trauma that is causing them. Contrary to common myth, vocal nodules are highly treatable and intervention leads to improvement in most cases. Vocal cord polyps and cysts are the other common benign lesions. These are sometimes related to voice misuse or overuse, but can also occur in people who don’t use their voice improperly. These types of problems typically require microsurgical treatment for cure, with voice therapy employed in a combined treatment approach in some cases. Vocal Hemorrhage: If you experience sudden loss of voice following yelling, shouting, or other strenuous vocal tasks, you may have developed a vocal cord hemorrhage. Vocal cord hemorrhage results when one of the blood vessels on the surface of the vocal cord ruptures and the soft tissues of the vocal cord fill with blood. It is considered a vocal emergency and is treated with absolute voice rest until the hemorrhage resolves. If you lose your voice after strenuous voice use, see your Otolaryngologist as soon as possible. Gastroesophageal Reflux (GERD): A common cause of hoarseness is gastro-esophageal reflux, when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal cords. Many patients with reflux-related changes of voice do not have heartburn. Usually, the voice is worse in the morning and improves during the day. These people may have a sensation of a lump or mucus in their throat and have an excessive desire to clear it. Laryngopharyngeal Reflux (LPRD): Reflux of stomach juice into the throat can cause a variety of symptoms in the esophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), swallowing problems, a lump in the throat sensation, or throat pain are common symptoms of stomach acid irritation of the throat. Please be aware that LPRD can occur without any symptoms of frank heartburn and regurgitation that traditionally accompany gastro esophageal reflux disease (GERD).
Laryngeal Cancer: Throat cancer is a very serious condition requiring immediate medical attention. Chronic hoarseness warrants evaluation by an otolaryngologist to rule out laryngeal cancer. It is important to remember that prompt attention to changes in the voice facilitate early diagnosis. Remember to listen to your voice because it might be telling you something. Laryngeal cancer is highly curable if diagnosed in its early stages. (For more information, see Laryngeal Cancer Fact Sheet.) Smoking: Smoking is another cause of hoarseness. Because smoking is the major cause of throat cancer, if smokers become hoarse, they should see an otolaryngologist. Neurological Diseases or Disorders: Hoarseness can also appear in those who have neurological diseases such as Parkinson’s or a stroke, or may be a symptom of spasmodic dysphonia, a rare neurological disorder that usually affects only the voice, but sometimes affects breathing. A paralyzed vocal cord may be the cause of a weak, breathy voice. If the hoarseness persists for more than three months and other causes have been ruled out, a neurologist may be helpful for diagnosis. Other Causes: These include allergies, thyroid problems, trauma to the voice box, and, occasionally, menstruation. Very serious conditions such as laryngeal cancer can also cause hoarseness, which is why it is important to have chronic hoarseness evaluated by an otolaryngologist immediately. How is hoarseness treatedHoarseness due to a cold or flu may be evaluated by family physicians, pediatricians, and internists who have learned how to examine the larynx. When hoarseness lasts longer than two weeks or has no obvious cause, it should be evaluated by an otolaryngologist. Problems with the voice are often best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologists, speech/language pathologists, and teachers of singing, acting, and public speaking. Vocal nodules, polyps, and cysts are typically treated with a combination of microsurgery and voice therapy. How is hoarseness evaluated
When should I see an otolaryngologist
How are vocal disorders treatedThe treatment of hoarseness depends on the cause. Many common causes of hoarseness can be treated simply by resting the voice or modifying how it is used. An otolaryngologist may make some recommendations about voice use behavior, refer the patient to other voice team members, and in some instances recommend surgery if a lesion, such as a polyp, is identified. Not smoking and avoiding secondhand smoke is recommended to all patients. Drinking fluids and taking medications to thin out the mucus may help. How to prevent hoarsenessSpecialists in speech/language pathology (voice therapists) are trained to assist patients in behavior modification to help eliminate some voice disorders. Patients who have developed bad habits, such as smoking or overusing their voice by yelling and screaming, benefit most from this conservative approach. The speech/language pathologist may teach patients to alter their methods of speech production to improve the sound of the voice and to resolve problems, such as vocal nodules. When a patient’s problem is specifically related to singing, a singing teacher may help to improve the patients’ singing techniques. Prevention tips:
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hoarseness and vocal difficulties are outlined below. If you become hoarse frequently or notice voice change for an extended period of time, please see your Otolaryngologist (Ear, Nose, and Throat doctor) for an evaluation.
Vocal Cord Paralysis and Paresis: Hoarseness and other problems can occur related to problems between the nerves and muscles within the voice box or larynx. The most common neurological condition that affects the larynx is a paralysis or weakness of one or both vocal cords. Involvement of both vocal cords is rareand is usually manifested by noisy breathing or difficulty getting enough air while breathing or talking. When one vocal cord is paralyzed or weak, voice is usually the problem rather than breathing. One vocal cord can become paralyzed or weakened (paresis) from a viral infection of the throat, after surgery in the neck or chest, from a tumor or growth along the laryngeal nerves, or for unknown reasons. Vocal cord paralysis typically presents with a soft and breathy voice. Many cases of vocal cord paralysis will recover within several months. In some cases however, the paralysis will be permanent, and may require active treatment to improve the voice. Treatment choice depends on the nature of the vocal cord paralysis, the degree of vocal impairment, and the patient’s vocal needs. While we are not able to make paralyzed vocal cords move again, there are good treatment options for improving the voice. One option includes surgery for unilateral vocal cord paralysis that repositions the vocal cord to improve contact and vibration of the paralyzed vocal cord with the non-paralyzed vocal cord. There are a variety of surgical techniques used to accomplish this. Voice therapy may be used before or after surgical treatment of the paralyzed vocal cords, or it can also be used as the sole treatment. (For more information, see Vocal Cord Paralysis Fact Sheet.)
Otolaryngologists will obtain a thorough history of a patient’s hoarseness and general health. They will then evaluate the voice and do a complete ear, nose, and throat exam. This includes examination of the vocal cords. Doctors usually look at the vocal cords either with a mirror placed in the back of the throat, or with a very small, lighted flexible tube (fiberoptic scope) that is passed through the nose to view the vocal cords. Videotaping or stroboscopy (slow-motion assessment) may also help with the analysis. These procedures are well tolerated by most patients. In some cases, special tests designed to evaluate the voice may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in diagnosing and guiding treatment.
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