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, vocal cords move towards each other and, as air leaves the lungs, they vibrate, which then produces sound. Swelling or growths on the vocal cords prevent vibration, can cause changes in voice quality, volume, and pitch.
“Hoarseness” is an abnormal voice change which may sound breathy, raspy, strained, or lead to volume or pitch adjustments.
Causes of Hoarseness
The most common cause of hoarseness is acute laryngitis—swelling of the vocal cords that occurs during a common cold, upper respiratory tract viral infection, or from voice strain. Serious injury to the vocal cords can result from strenuous voice use during an episode of acute laryngitis.
- Speaking in noisy situations
- Excessive use
- Telephone use with the handset cradled to the shoulder
- Speaking in a pitch that is either too high or too low
- Not using amplification when public speaking
Extended hoarseness can result as a consequence of routinely straining your voice. These habits can lead to nodules, polyps, and cysts. Vocal nodules are thick, rough growths that appear on the vocal cords. Vocal cord cysts and polyps are prevalent findings in those who misuse their voice; however, these growths can also occur for other reasons.
If you experience a sudden loss of voice following a yell or loud scream, this could be indicative of a vocal cord hemorrhage. Vocal cord hemorrhages occur if blood vessels located on the vocal cords rupture which then causes surrounding soft tissues to fill with blood. It is considered a vocal emergency and should be treated with absolute voice rest and examination by an otolaryngologist (ear, nose, and throat doctor).
A common cause of hoarseness is gastro-esophageal reflux, when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal cords. The voice is often worse in the morning then improves as the day progresses. These people may have a sensation of a lump or mucus in their throat and have an excessive desire to clear it.
If the reflux makes it all the way up through the upper sphincter and into the back of the throat, it is called LPR rather than GERD. The structures in the throat (pharynx, larynx, and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of the reflux into this area can result in more damage.
Smoking is another cause of hoarseness. Because smoking is the major cause of throat cancer, if smokers become hoarse, they should see an otolaryngologist.
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. If a vocal cord becomes paralyzed, it usually results in a weak, breathy voice. Seek treatment from a neurologist if concerns persist.
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.
Preventing Hoarseness
- If you smoke, quit
- Avoid alcohol and caffeine which dehydrate the body
- Avoid secondhand smoke
- Stay hydrated—drink plenty of water
- Humidify your home
- Watch your diet – avoid spicy foods
- Try not to use your voice too long or too loudly
- Use a microphone if possible in situations where you need to project your voice
- Seek professional voice training
- Avoid speaking or singing when your voice is injured or hoarse
Evaluating the Throat
If you are dealing with hoarseness and notice the following, please seek medical evaluation:
- If hoarseness lasts longer than two weeks
- If you have a history of smoking
- If you do not have a cold or flu
- If you are coughing up blood
- If you have difficulty swallowing
- If you feel a lump in the neck
- If you observe loss or severe changes in voice lasting longer than a few days
- If you experience pain when speaking or swallowing
- If difficulty breathing accompanies your voice change
Otolaryngologists will obtain a thorough history regarding your hoarseness and general health. They will then evaluate your 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. These procedures are well tolerated by most patients. In some cases, special tests designed to evaluate the voice may be recommended which can measure vocal irregularities, degree of airflow, and other characteristics that are helpful in guiding treatment.
Treating Hoarseness
The treatment of hoarseness depends on the cause. Many causes of hoarseness can be treated simply by resting the voice or modifying how it is used. 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.