Hoarseness

Hoarseness is an unwanted change in the quality and the level of the voice. It is not a disease on its own. It is a sign of various diseases and risk factors.

How the voice is made

The voice starts as air from the lungs passes between the vocal cords. The muscles of the larynx bring the cords together, and the pressure of the air makes them vibrate. That vibration happens in the surface tissue and creates a wave in the lining, which travels from the middle outwards.

The sound made at the level of the vocal cords then passes through the resonating spaces: the throat, the back of the nose, the nose, the sinuses and the mouth.

For the cords to work normally, the surface of their vibrating free edges must be smooth. A polyp, a nodule, a tumour or any surface irregularity there spoils the character of the voice.

What causes hoarseness

Hoarseness usually comes from a viral infection of the upper airway. The other common causes are

• Laryngitis, which is inflammation of the larynx with swelling of the vocal cords
• Functional voice disorders
• Tumours on the vocal cords
• Inflammation of the cords caused by allergy, infection, reflux, tobacco or injury
• A cold
• Overusing and straining the voice
• Drinks with caffeine and alcohol
• Breathing in toxic substances
• Other conditions such as stroke, cancer, thyroid problems and neurological disease

Voice disorders come from problems inside the larynx and also from problems in the organs outside it that take part in making the voice. Even when the anatomy is normal, abnormal function of the muscles of the larynx causes a voice disorder.

How the doctor makes the diagnosis

A detailed history comes first. Whether the problem is constant or comes and goes, whether it is worse in the morning or in the evening, whether the patient smokes, and whether the voice is strained, all help.

The diagnosis itself is made by examining the vocal cords, with endoscopic systems or with a flexible endoscope passed through the nose.

Why it can be serious

In patients whose hoarseness comes from a paralysed vocal cord, the cords also fail to close the entrance to the lower airway during swallowing. Food and saliva then pass into the lungs and cause disease.

Paralysis of the cords, and masses that narrow this area, cause breathing failure. That limits what the patient can do, and it leads to high blood pressure and heart failure.

Treatment

Treatment follows the cause. Almost every treatment includes using the voice less, or resting it completely for a time, stopping smoking absolutely, drinking more fluid each day, especially warm water, and reducing the acid produced by the stomach.

• Inflamed vocal cords are treated with antibiotics and medicines that reduce swelling.
• Vocal cord nodules are treated first with voice training.
• Polyps and tumours need surgery.
• Some malignant diseases are treated with radiotherapy instead of surgery in the early stage.
• In vocal cord paralysis, the surgeon operates to move the motionless cord towards the midline, or injects material into its free edge.
• Patients diagnosed with acid reflux need a gastroenterological examination.
• Voice disorders caused by overworking the cord muscles are treated with speech therapy and with botulinum toxin injection.

When to see a doctor

Patients who smoke should see an ear, nose and throat specialist as soon as hoarseness appears.

Hoarseness after shouting, or during a flu-like infection, should start to improve within four or five days. If it does not, have it examined.

Hoarseness that lasts more than two weeks can be a sign of cancer in the head and neck. Always see a doctor.

Protecting the voice

The things that harm the vocal cords most are a dry lining, cigarette smoke, stomach acid, and using the voice too much and too hard. Therefore

• Do not smoke.
• Drink plenty of water.
• Do not lie down while the stomach acid is high, which is for 2 to 3 hours after eating.
• Keep the air from becoming dry, in bedrooms above all.
• Treat problems that harm the vocal cords, such as a blocked nose and sinusitis.