Hoarseness (Voice Changes)

Hoarseness – medically termed dysphonia – is any abnormal change in the quality, pitch, loudness, or effort of the voice. The voice may sound rough, raspy, breathy, strained, or weak, or it may be lower or higher in pitch than usual. In some cases, voice production becomes effortful or intermittently lost altogether.

Voice is produced when air from the lungs passes through the larynx (voice box) and causes the two vocal folds – paired bands of muscle and mucosal tissue – to vibrate. Any condition that alters the normal mass, tension, symmetry, or mobility of the vocal folds, or that disrupts the neural control of laryngeal muscles, can produce hoarseness.

Transient hoarseness accompanying a cold or upper respiratory tract infection is among the most common of all symptoms and is usually self-limiting. However, hoarseness that persists beyond two or three weeks without a clear benign explanation requires laryngoscopic examination to rule out underlying pathology, including malignancy.

Inflammatory and infectious causes

• Acute laryngitis: The most common cause of hoarseness overall; typically accompanies viral upper respiratory infection and resolves within one to three weeks.
• Chronic laryngitis: Persistent vocal fold inflammation due to tobacco smoke, alcohol, gastroesophageal or laryngopharyngeal reflux, post-nasal drip, or occupational irritant exposure.

Structural vocal fold lesions

• Vocal fold nodules: Bilateral callus-like thickenings from chronic vocal overuse; produce a rough, breathy voice
• Vocal fold polyps: Typically unilateral soft lesions often related to vocal trauma or irritant exposure, including Reinke’s edema (diffuse polypoid swelling strongly associated with smoking)
• Vocal fold cysts: Mucous retention cysts within the vocal fold substance
• Contact ulcers and granulomas: Erosions at the vocal fold process related to forceful voice use or acid reflux
• Laryngeal papillomatosis: HPV-related papillomas causing progressive hoarseness, particularly in children

Malignant and pre-malignant causes

• Laryngeal cancer: Hoarseness that persists without improvement is the cardinal early symptom of glottic (vocal cord) cancer; early evaluation is essential.
• Thyroid tumors: A large or invasive thyroid mass may compress or invade the recurrent laryngeal nerve.
• Lung or mediastinal malignancy: Tumors along the course of the left recurrent laryngeal nerve can cause unilateral vocal fold paralysis

There are other causes such as gastroesophageal / laryngopharyngeal reflux, hypothyroidism, aging, vocal overuse and misuse, allergy and post-nasal drip, and medications.

See a physician if:

• Hoarseness persists for more than two to three weeks without an identifiable benign cause such as a recent cold or viral illness
• Hoarseness occurs in a person with a history of tobacco use or heavy alcohol assumption
• Hoarseness is accompanied by difficulty or pain on swallowing
• A palpable lump is noted in the neck
• Hoarseness occurs after thyroid, neck, or thoracic surgery

Seek urgent or emergency evaluation if:

• Breathing becomes noisy or difficult – this may indicate significant airway obstruction
• Blood is coughed up (hemoptysis)
• Complete sudden loss of voice occurs after vocal exertion
• Hoarseness is accompanied by rapidly progressive neck swelling