Hoarseness (Dysphonia)

I. Introduction

Change in voice quality is termed “hoarseness”. A hoarse voice may sound raspy, breathy, strained, or show change in volume or pitch. It is both a symptom and sign of dysfunction of the phonatory apparatus (i.e., the larynx) that often impairs the patient’s ability to communicate and reduces voice related QOL (quality of life).

II. Causes of hoarseness

A. What is the differential diagnosis for this problem?

Causes of hoarseness are diverse. Acute (viral) laryngitis is by far the most common cause followed by functional dysphonia.

Differential diagnosis for hoarseness includes:

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Inflammation of the larynx
  • Post-procedure such as after endotracheal intubation (usually short lived and typically resolved within a few days)

  • Due to irritants such as allergens, alcohol, tobacco (Reinke’s edema in smokers), inhaled steroids.

  • Infection by upper respiratory viruses (less commonly bacterial).

  • Acute vocal strain. For example due to screaming or shouting, vocal fold hemorrhage.

  • Chronic conditions such as laryngopharyngeal reflux disorder (LPRD), chronic infection such as sinusitis, chronic voice misuse or strain

  • Benign vocal fold lesions such as polyps, cysts, nodules

  • Laryngeal papillomatosis

  • Malignancies such as squamous cell cancer of the larynx

Neuromuscular or psychogenic disorder
  • Vocal cord paralysis/paresis (unilateral or bilateral) due to recurrent laryngeal nerve injury (Iatrogenic during head and neck or thoracic surgery, cancer related or from other compressive lesions)

  • Multiple sclerosis

  • Parkinson’s disease

  • Myasthenia gravis

  • Cerebrovascular accident involving brainstem

  • Spasmodic Dysphonia (involuntary movements or spasms causing intermittent voice breaks or to voiceless phases during speech)

  • Muscle tension dysphonia/Hyperfunctional Dysphonia (chronic stressful overuse of the voice)

  • Conversion aphonia (acute, typically in periods of severe psychological stress/affects only communicative aspects/loud coughing and throat clearing is still possible)

Systemic disorder
  • Hypothyroidism

  • Acromegaly

  • Sarcoidosis

  • Amyloidosis

  • Rheumatologic Diseases – Rheumatoid Arthritis, Systemic Lupus Erythematosus, Vasculitides (Granulomatous Polyangiitis)

  • Lymphoma

Medications that may cause hoarseness

  • Inhaled steroids (dose dependent mucosal irritation)

  • Antipsychotics (laryngeal dystonia)

  • ACE inhibitors (cough)

  • Coumadin, thrombolytics, Phosphodiesterase-5 inhibitors (vocal fold hematoma)

  • Bisphosphonates (chemical laryngitis)

  • Antihistamines, diuretics, anticholinergics (drying effect on the mucosa)

B. Describe a diagnostic approach/method to the patient with this problem

All patients with hoarseness require a detailed history-taking and thorough physical exam, with special attention to:

a) Characterizing the hoarseness (acute vs chronic, intermittent vs progressive, exacerbating/relieving factors, social/professional impact of hoarseness)

b) Eliciting any history that may provide clues to the more benign causes of hoarseness i.e., acute laryngitis, functional dysphonia, symptomatic reflux disease, use of inhaled steroids, recent intubation, etc.)

c) Eliciting history of serious co-morbidities and risk factors that may signal a more serious pathology as detailed in the next section.

d) History suggesting voice abuse or professions presdisposing to chronic phonotrauma (e.g., singers/teachers/aerobics instructors/telemarketers/clergy, etc.)

A consult to the Ear Nose and Throat Specialist (ENT) should be considered if no obvious cause for hoarseness is identified on history and physical exam, hoarseness persists beyond 3 months after onset or if a serious underlying cause is suspected irrespective of duration of hoarseness.

1. Historical information important in the diagnosis of this problem.

The history-taking and exam should focus on eliciting serious co-morbidities and risk factors that require an urgent referral for laryngoscopic exam by an Ear Nose and Throat (ENT) specialist:

  • History of smoking and/or alcohol consumption

  • Association with hemoptysis, dysphagia, odynophagia, otalgia or dyspnea

  • Unexplained weight loss

  • Immunosuppression

  • Neurologic symptoms

  • Hoarseness following trauma

  • Hoarseness after an operative intervention (head and neck or thoracic surgery)

  • Possible bolus aspiration

  • Enlarged cervical lymph nodes

2. Physical Examination maneuvers that are likely to be useful in diagnosing the cause of this problem.

All patients with hoarseness should get their vital signs checked including respiratory pattern and rate. A general physical exam should be performed including assessment of vocal quality. Oropharyngeal exam using a tongue depressor specifically looking for uvular edema/inflammation may provide clues to the diagnosis of conditions such as gastroesophageal reflux disease (GERD). Examination of neck, looking for cervical lymph nodes or masses, is useful. The nose/sinuses should also be examined to look for signs of inflammation/infection. Otoscopic examination of ear can be helpful to diagnose concurrent ear infection. A thorough neurologic evaluation is indicated if neurologic causes are suspected.

3. Laboratory, radiographic and other tests that are likely to be useful in diagnosing the cause of this problem.

  • A complete blood count can reveal leukocytosis which can point to a possible infectious etiology. If the patient has an obvious exudate in the oropharynx, a culture may be taken.

  • A CT scan of neck can be helpful in diagnosing localized abscesses or masses leading to hoarseness if history or physical exam raise concerns about pathology in this area. Otherwise it should be obtained as supportive and advanced testing AFTER laryngoscopy.

  • A laryngoscopic exam for direct visualization of true and false vocal folds, epiglottis, piriform, sinus, and vallecula is the gold standard diagnostic test in cases of hoarseness, and helps reveal etiology in most cases. Abnormal findings may include vocal fold edema, polyp, nodule or mass or paralysis.

Stroboscopy is a special method used to visualize vocal cord vibration using a strobe light synchronized to the vibratory frequency of the vocal cords.

C. Criteria for Diagnosing Each Diagnosis in the Method Above.

See above.

D. Over-utilized or “wasted” diagnostic tests associated with the evaluation of this problem.

Computed tomography (CT) imaging usually not indicated unless localized abscess or mass is suspected based on history and physical exam findings.

III. Management while the Diagnostic Process is Proceeding

A. Management of hoarseness.

  • Hoarseness due to acute laryngitis can be treated with adequate hydration, humidification and voice rest.

  • Clinicians should NOT prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease (GERD). In a hoarse patient with signs of chronic laryngitis (seen on laryngoscopy), anti reflux medications may be prescribed (The AAOHNS, American Academy of Otolayngology and Head and Neck Surgery 2009 guidelines for management of hoarseness).

  • Clinicians should NOT routinely prescribe oral corticosteroids to treat hoarseness. (AAOHNS 2009 guidelines).

  • Clinicians should NOT routinely prescribe antibiotics to treat hoarseness (AAOHNS 2009 guidelines).

  • Hoarseness due to inhaled steroid use may be treated by reduction in dose or discontinuation of inhaled steroids in selected patients with asthma.

  • Hoarseness related to sino-nasal disease can be treated with anti-histamines and decongestants.

  • Hoarseness due to benign polyps or malignant laryngeal pathologies may require surgery.

  • Hoarseness due to neurological causes such as Parkinson’s disease, myasthenia and stroke can be addressed by voice therapy.

  • Hoarseness due to systemic conditions should be aimed at treating the underlying condition. For example, thyroid hormone supplementation in patients with hypothyroidism.

  • Good vocal hygiene (hydration, avoiding vocal strain, smoking & alcohol cessation) is beneficial in treating patients with non-organic dysphonia.

  • All active smokers should be counseled on smoking cessation.

B. Common Pitfalls and Side-Effects of Management of this Clinical Problem

It is important for hospitalists not to miss historical or physical exam clues that may point to laryngeal cancer or other serious pathology that may present with hoarseness. Hoarseness lasting for more than 3 months warrants an ENT referral for laryngoscopic examination. If a serious underlying cause is suspected, an immediate ENT referral should be made, irrespective of duration of hoarseness.

What's the Evidence?

“Clinical Practice Guideline: hoarseness (dysphonia)”. Otolaryngology. vol. 141. 2009 Sep. pp. S1-S31.

Reiter, R, Hoffman, TK, Pickhard, A, Brosch, S. “Hoarseness-causes and treatments”. Dtsch Arztbl Int. vol. 112. 2015. pp. 329-37.

“Evidence Based Practice: Management of hoarseness/dysphonia”. Otolaryngologic Clinics of North America. vol. 48. August 2015. pp. 547-564.

Sulica, L. “Hoarseness”. Archives of Otolaryngology – Head and Neck Surgery. vol. 137. 2011 Jun. pp. 616-619.

Feierabend, RH, Malik, SN. “Hoarseness in adults”. Am Fam Physician. vol. 80. 2009. pp. 363-70.

Syed, I, Daniels, E, Bleach, NR. “Hoarse voice in adults: an evidence-based approach to the 12 minute consultation”. Clin Otolaryngol. vol. 34. 2009. pp. 54-8.

Hopkins, C, Yousaf, U, Pedersen, M. “Acid reflux treatment for hoarseness”. Cochrane Database Syst Rev. vol. 1. 2006. pp. CD005054

Qadeer, MA, Phillips, CO, Lopez, AR. “Proton pump inhibitor therapy for suspected GERD-related chronic laryngitis: a meta-analysis of randomized controlled trials”. Am J Gastroenterol. vol. 101. 2006. pp. 2646-54.

Gallivan, GJ, Gallivan, KH, Gallivan, HK. “Inhaled corticosteroids: hazardous effects on voice – an update”. J Voice. vol. 21. 2007. pp. 101-11.