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Doc, why is my voice so hoarse?

Frederic E. Levy, MD

Hoarseness is a term that describes abnormal voice changes. When hoarse, the voice may sound breathy, raspy, strained, or there may be changes in loudness or pitch (how high or low the voice is). The changes in sound are usually due to disorders related to the vocal cords that are the sound producing parts of the voice box (larynx). While breathing, the vocal cords remain apart. When speaking, singing, coughing or clearing the throat, they come together and as air leaves the lungs, then vibrate, producing sound. Swelling or lumps on the vocal cords prevent them from coming together properly and changes the way the cords vibrate. This changes the voice, altering quality, volume and pitch.

What are the causes?

Acute Laryngitis: There are many causes of hoarseness. Most are not serious and tend to go away in a short period of time. The most common cause is acute laryngitis, which usually occurs due to swelling from a common cold, upper respiratory tract viral infection, or irritation caused by excessive voice use such as screaming at a sporting event or rock concert.

Vocal Nodules: More prolonged hoarseness is usually due to using your voice either too much, too loudly, or improperly over extended periods of time. These habits can lead to vocal nodules (singers’ nodes), which are callous-like growths, or may lead to polyps of the vocal cords (more extensive swelling). Both of these conditions are benign. Vocal nodules are common in children and adults who raise their voice in work or play.

Gastroesophageal Reflux: 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 the voice do not have symptoms of heartburn. These people may have a sensation of a lump in their throat, mucus sticking in their throat or an excessive desire to clear their throat.

Smoking: Smoking is another cause of hoarseness. A long term smokers’ voice can deepen and sound rough. Since smoking is the major cause of throat cancer, if smokers are hoarse, they should see an otolaryngologist.

Other Causes: Many unusual causes for hoarseness include allergies, thyroid problems, neurological disorders, trauma to the voice box, and occasionally, the normal menstrual cycle.

Who can treat my hoarseness?

Hoarseness due to a cold or flu may be evaluated by family physicians, pediatricians, and internists. When hoarseness lasts longer than two weeks or has no obvious cause it should be evaluated by an otolaryngologist- head and neck surgeon (ear, nose and throat doctor). Problems with the voice are best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologist- head and neck surgeons, speech/ language pathologists, and teachers of singing, acting, or public speaking. Voice disorders have many different characteristics that may give professionals a clue to the cause.

How is hoarseness evaluated?

An otolaryngologist will obtain a thorough history of the hoarseness and your general health. Your doctor will usually look at the vocal cords with either a mirror placed in the back of your throat, or a very small, lighted flexible tube (fiberoptic scope) may be used in order to view your vocal cords. Videotaping the examination or using stroboscopy (slow motion assessment) may also help with the analysis.

These procedures are not uncomfortable and are well tolerated by most patients. In some cases, special tests (known as acoustic analysis) designed to evaluate the voice, may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in establishing a diagnosis and guiding treatment.

How are vocal disorders treated?

The treatment of hoarseness depends on the cause. Most hoarseness can be treated by simply resting the voice or modifying how it is used. The otolaryngologist may make some recommendations about voice use behavior, refer the patient to other speech pathologists, and in some instances recommend surgery if a lesion, such as a polyp, is identified. Avoidance of smoking or exposure to secondhand smoke (passive smoking) is recommended to all patients. Drinking fluids and possibly using medications for reflux or to thin the mucus are also helpful.

Speech pathologists or voice therapists are trained to assist patients in behavior modification that may help eliminate some voice disorders. Patients who have developed bad habits, such as smoking or overuse of their voice by yelling and screaming, benefit most from this conservative approach. The speech pathologist may teach patients to alter their method of speech production to improve the sound of the voice and to resolve the problems, such as vocal nodules. When a patients’ problem is specifically related to singing, a singing teacher may help improve the patients’ singing techniques.


*Adopted from literature originally created by the American Academy of Otolaryngology/ Head and Neck Surgery