Evaluating hoarseness: keeping your patient's voice healthy

Author: Clark A. Rosen, Thomas Murry
Date: June, 1998

Hoarseness has many causes, ranging from a simple upper respiratory tract infection to a serious pathology such as head and neck cancer. This article discusses voice changes that may be described by patients as hoarseness and addresses the most important etiologies (Table 1). The physiology of voice production, diagnostic techniques for voice evaluation and recommendations for voice disorder prevention are outlined.

TABLE 1 Common Cause of HoarsenessFunctional dysphonia Abnormal use of the vocal mechanism despite normal anatomy. This condition can be related to stress, psychologic disturbance or habituation of compensatory techniques developed during an upper respiratory infection.Laryngeal papilloma Growths on the larynx caused by human papilloma viral infection.Muscle tension dysphonia A voice disorder resulting from excessive or unequal tension while speaking. This condition results from improper speaking technique and is commonly associated with reflux laryngitis.Reflux laryngitis Inflammation of the larynx caused by gastric acid irritation.Reinke's edema An accumulation of fluid in the vocal cords. This condition is associated with smoking and voice abuse. It may also occur with reflux laryngitis.Spasmodic dysphonia A condition resulting in irregular voice breaks and interruptions of phonation. This is a focal dystonia of the laryngeal muscles.Vocal cord paralysis Weakness or immobility of the vocal cord(s).Vocal nodules Fibrotic formations on the vocal cords. Commonly referred to as "nodes."


Dysphonia is defined as an abnormal voice quality. The patient's complaint of hoarseness frequently represents something entirely different from the way the physician defines hoarseness, so it is important that the physician consider the different descriptions of voice quality when evaluating a patient's complaint. Voice quality may be described as breathy, strained, rough, tremorous or weak. On questioning, the physician may discover that what the patient terms hoarseness is actually increased vocal effort or vocal fatigue. Other aspects of dysphonia to inquire about, particularly in patients who are singers, are changes in pitch and abnormal pitch range. These specific disturbances often help the physician focus on possible diagnoses (Table 2).

TABLE 2 Voice quality Differential diagnosisBreathy Vocal cord paralysis, abductor spasmodic dysphonia, functional dysphoniaHoarse Vocal cord lesion, muscle tension dysphonia, reflux laryngitisLow-pitched Reinke's edema, vocal abuse, reflux laryngitis, vocal cord paralysis, muscle tension dysphoniaStrained Adductor spasmodic dysphonia, muscle tension dysphonia, reflux laryngitisTremor Parkinson's disease, essential tremor of the head and neck, spasmodic dysphonia, muscle tension dysphoniaVocal fatigue Muscle tension dysphonia, vocal cord paralysis, reflux laryngitis, vocal abuse

Voice Production

The larynx consists of four basic anatomic components: a cartilaginous skeleton, intrinsic and extrinsic muscles, and a mucosal lining[1] (Figures 1 and 2). The cartilaginous skeleton, which houses the vocal cords (the thyroarytenoid muscles), is composed of the thyroid, cricoid and arytenoid cartilages. These cartilages are connected with other structures of the head and neck through the extrinsic muscles. The intrinsic muscles of the larynx alter the position, shape and tension of the vocal cords. An important consideration, therefore, is the innervation of these muscles and the characteristic features of lesions of these nerves.


The vagus nerve innervates the larynx through its branches, the superior laryngeal nerve and the recurrent laryngeal nerve (Figure 3). The superior laryngeal nerve supplies sensation to the epiglottis and false vocal cords, as well as motor function to the cricothyroid muscle (which serves to tense the vocal cord). A loss of the ability to sing high notes or to change pitch easily, or loss of sensation in the larynx and pharynx, therefore, may be caused by a lesion affecting the superior laryngeal nerve.


With the exception of the cricothyroid, all of the intrinsic muscles of the larynx are innervated by the recurrent laryngeal nerve. An important anatomic consideration is the location of the left and right branches of the recurrent laryngeal nerve; after leaving the vagus, the right recurrent laryngeal nerve loops around the subclavian artery, while the left recurrent laryngeal nerve loops around the arch of the aorta. Both branches travel cephalad into the neck in the tracheo-esophageal groove and then enter the larynx. A mass lesion anywhere along the course of the nerve may result in paralysis of the vocal cord. Diseases of the brain stem, the neck and the mediastinum must, therefore, be included in the evaluation of dysphonia resulting from vocal cord paralysis. Surgical injury or penetrating trauma to these areas may also cause vocal cord paralysis (Table 3).

TABLE 3 Surgical Procedures Associated with Risk of Injury to the Vagus and/or Recurrent Laryngeal Nerves

Carotid surgery MediastinoscopyNeck dissection for head and neck cancer EsophagectomyCardiac surgery Thyroid surgeryPatent ductus ligation Anterior cervical disc surgeryValve repair Tracheal surgeryCoronary artery bypass (rare) Tracheal reconstructionMediastinal surgery Tracheotomy (rare)Thymectomy

The larynx functions in deglutition, respiration and phonation. Voice production can be thought of in terms of three components: generation of airflow, vocal cord vibration that produces sound and shaping of the sound to produce various resonances.[2] The lips, tongue, teeth and palate provide the distinct sounds of speech. The lungs first supply adequate airflow to overcome the resistance of the adducted vocal cords. The vocal cords are finely tuned neuromuscular units that adjust pitch and tone by altering their position, length, tension and mass. Sound production occurs as a result of the vibration of the mucosa at the medial edge of each vocal cord. Thus, any structural, inflammatory or neoplastic lesion of the vocal cord affects voice production and quality. Final modification of speech occurs in the oropharynx and nasopharynx, where the tongue, palate, cheek and lips are involved in articulation. The integrated anatomy of voice production requires the physician to consider that a change in the anatomy or function of any of the structures involved in voice production, from the lungs to the nasopharynx, may result in dysphonia (Table 4).

TABLE 4 Differential Diagnosis of HoarsenessNeoplastic NeurologicVocal cord polyp Vocal cord paralysis (unilateral)Vocal cord nodules Spasmodic dysphoniaVocal cord granulomas Movement disorder (i.e., Parkinson'sVocal cord cyst disease)Laryngeal papilloma Essential tremorSquamous cell cancer of the Cerebrovascular accident larynxInflammatory MiscellaneousGastroesophageal reflux Vocal abuse laryngitisViral laryngitis Vocal cord atrophyBacterial laryngitis Vocal cord scarringTubercular or fungal Hypothyroidism (myxedematous laryngitis laryngitis)Allergic laryngitis Muscle tension dysphonia Reinke's edema Medications

Evaluation of Hoarseness


Examination revealed muscle tension in the patient's strap muscles. Laryngeal examination revealed abnormal medialization of the false vocal cords and a squeezing of the larynx in an anterior-posterior direction during phonation. Muscle tension dysphonia was diagnosed and, after six weeks of voice therapy in which she learned effective laryngeal relaxation techniques, the patient reported return of normal vocal quality and effort.

Discussion. Muscle tension dysphonia is a condition of muscle strain and misuse in the larynx and neck that usually occurs in patients who use their voices extensively as part of their work--teachers, attorneys and sales personnel, for example. The generalized increase in muscular tension has several interacting causes, including poor vocal technique, extraordinary voice-use demands and psychologic factors such as anxiety.[8] Vocal fatigue and discomfort are common presenting symptoms in patients with muscle tension dysphonia.

Illustrative Case 5

A 35-year-old man who smoked one pack per day and drank two to three beers per week reported a one-month history of hoarseness. He denied symptoms of airway compromise, dysphagia or throat pain.

On laryngeal examination he was found to have an irregular exophytic lesion of the mid-portion of his right true vocal cord (Figure 6). His vocal cords demonstrated normal mobility, and neck examination revealed no masses. The patient underwent direct laryngoscopy and biopsy, and a diagnosis of squamous cell carcinoma, stage T1, was made on the basis of those findings.


The patient underwent surgical excision of the lesion and has remained tumor-free after five years.

Discussion. Any adult patient with hoarseness and a history of tobacco use may have a laryngeal malignancy. Alcohol use increases the risk of head and neck malignancy in smokers. Glottic lesions are the most common laryngeal cancers and usually present early with hoarseness. Later presentations may include throat irritation, hemoptysis, dysphagia or referred otalgia. Surgery or radiation therapy are the primary treatment options, depending on the stage of the tumor at diagnosis.[9-11] Laryngeal cancer may have a 90 to 95 percent cure rate when detected early.

Prevention of Hoarseness

Vocal Hygiene

An integral aspect of the prevention of vocal pathology is the maintenance of good vocal hygiene. Patients should be advised to avoid straining their voices by shouting, whispering or attempting to talk over excessive background noise. The importance of hydration should be emphasized. Certain medications, such as antihistamines and drugs that dry the mucosa through anticholinergic side effects (such as tricyclic antidepressants), may also create unfavorable voice changes, and these drugs should be avoided if possible, Irritants such as tobacco, alcohol, marijuana and industrial chemicals should be avoided.

Table 5 outlines ways to avoid and ease vocal abuse. Patients with hoarseness lasting more than two weeks, pain occurring with speech or swallowing, or a foreign-body sensation in the throat should be examined.

TABLE 5 Methods of Easing Vocal Abuse

Things to do

Get plenty of rest Drink plenty of water--eight glasses per day

Things to avoid

Breathing foul air Using tobacco or marijuana Using drugs Drinking alcohol Shouting at sporting events Trying to be heard in noisy places like bars or airports Making sounds while yawning Clearing throat continually Trying to talk over a cold or laryngitis Whispering loudly or for very long Trying to change natural speaking voice

NOTE: Substances that can cause problems in the larynx include: cigarettes, marijuana, coffee (dehydration), antihistamines (drying effect), tricylic antidepressants (drying effect) and steroids.

Voice Therapy

Voice therapy includes four major components--vocal hygiene, vocal production, muscle relaxation and respiratory support--in addition to education about the vocal mechanism. Vocal hygiene includes the establishment of healthy attitudes about use and treatment of the voice mechanism, similar to a dental hygiene program. Vocal production includes the analysis and alteration of speaking pitch, loudness and voice quality, using listening and feeling techniques, and postures. Respiratory support and muscle relaxation involve posture, timing of respiration-phonation coordination and respiratory effort using relaxed upper thoracic muscles. Education helps the patient understand the goals of correcting the vocal mechanism.

Voice therapy is a behavior-based process in which maladaptive vocal habits and techniques are replaced with appropriate uses of the vocal mechanism. The treatment process incorporates auditory, visual and proprioceptive feedback channels to produce a healthy and efficient voice. Voice therapy is typically administered six to 14 times (in 30- to 40-minute sessions) over a six- to eight-week period. Following therapy, examination of the larynx and documentation of improvement are routine.


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[4.] Lancer JM, Syder D, Jones AS, LeBoutillier A. Vocal cord nodules: a review. Clin Otolaryngol 1988; 13:43-51.

[5.] Murry T, Woodson GE. A comparison of three methods for the management of vocal fold nodules. J Voice 1992;6:271-6.

[6.] Wanamaker JR, Netterville JL, Ossoff RH. Phonosurgery: silastic medialization for unilateral vocal fold paralysis. Operative techniques. Otolaryngol Head Neck Surg 1993;4(3):215.

[7.] Benninger MS, Crumley RL, Ford CN, Gould WJ, Hanson DG, Ossoff RH, et al. Evaluation and treatment of the unilateral paralyzed vocal fold. Otolaryngology Head Neck Surg 1994; 111:497-508.

[8.] Morrison MD, Rammage LA. Muscle misuse voice disorders: description and classification. Acta Otolaryngol [Stockh] 1993; 113:428-34.

[9.] Johnson JT. Review of early laryngeal carcinoma [Editorial]. Am J Otolaryngol 1994; 15(4):241.

[10.] DeSanto LW, Olsen KD. Early glottic cancer. Am J Otolaryngol 1994; 15:242-9.

[11.] Mendenhall WM, Parsons JT, Stringer SP, Cassisi NJ. Management of Tis, T1, and T2 squamous cell carcinoma of the glottic larynx. Am J Otolaryngol 1994; 15:250-7.

CLARK A. ROSEN, M.D., is director of the Voice Center in the Department of Otolaryngology at the University of Pittsburgh (Pa.) School of Medicine. He graduated from Rush Medical College of Rush University, Chicago, and completed a residency in otolaryngology/head and neck surgery at Oregon Health Sciences University School of Medicine, Portland, and a fellowship in laryngology and care of the professional voice at the University of Tennessee, Memphis, College of Medicine.

DEBORAH ANDERSON, M.D., is a resident in otolaryngology at the University of Texas. She graduated from the University of Pittsburgh School of Medicine.

THOMAS MURRY, PH.D., is associate director of the Voice Center in the Department of Otolaryngology at the University of Pittsburgh School of Medicine and director of the Center for Speech, Language, and Swallowing Disorders at the University of Pittsburgh Medical Center. He graduated from the University of Florida in the Communications Sciences Laboratory.

Address correspondence to Clark A. Rosen, M.D., 200 Lothrop St., Suite 500, Pittsburgh, PA 15213. Reprints are not available from the authors.

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