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Hoarseness and Dysphonia

Essentials

  • The most common cause of hoarseness seen in primary care practice is acute laryngitis, and its most important treatment is voice rest.
  • Indirect laryngoscopy must always be performed if the hoarseness is not associated with a cold or flu, and in all patients with hoarseness lasting for 2-4 weeks. If visibility is not sufficient in indirect laryngoscopy the patient should be referred to a specialist (phoniatrician or ENT specialist).
  • If dysphonia restricting the patient's working capacity or functional ability is prolonged, it is also advisable to refer the patient to a specialist for diagnosis, treatment and rehabilitation.
  • When assessing the risk of malignant tumour in the larynx, taking a smoking history is essential. Remember to document the smoking history in the referral.
  • In prolonged dysphonia, the voice is not necessarily qualitatively hoarse or particularly abnormal. Symptoms may include fatigue of the voice or throat irritation symptoms.
  • Hoarseness in children is an indication for consulting a phoniatrician or an ENT specialist because indirect laryngoscopy is difficult to perform.

Structural causes of dysphonia

Acute laryngitis

  • The most common cause of hoarseness seen in primary care practice
  • There are typical symptoms of upper respiratory tract infection, sore throat, hoarseness, often also rhinitis, headache and mild fever.
  • The vocal chords are erythematous and swollen.
  • As the infection is usually viral, antimicrobial treatment is of no benefit Antibiotics for Acute Laryngitis in Adults. Antimicrobials may be indicated because of other infections, not because of laryngitis alone.
  • In viral laryngitis the most important treatment is voice rest and avoiding coughing, clearing the throat and whispering. Patients in professions with heavy vocal loading should have a sufficiently long sick leave of at least one week (unless other tasks can be arranged).-If hoarseness continues for 3-4 weeks and, particularly, if the vocal cords cannot be reliably examined, the patient should be referred to a phoniatrician or an ENT specialist.

Chronic laryngitis

  • Prolonged laryngitis may be due to, for example, the following:
    • smoking or other toxic irritation
    • prolonged respiratory tract infections
    • fungal or bacterial infection of the larynx
    • inhaled corticosteroids
    • mechanical irritation of the throat (severe cough or heavy vocal loading)
    • laryngeal reflux disease
    • possibly also allergic factors.
  • The vocal cords are erythematous, swollen, and sometimes dry or covered with crusts or mucus.
  • The treatment depends on the cause and should be based on the history as well as thorough laryngoscopy.
  • Therefore, if laryngitis is prolonged, an ENT specialist or phoniatrician should be consulted.
  • General guidance in vocal hygiene is important.
    • Smoking cessation
    • Avoidance of coughing and clearing of the throat
    • Avoidance of forceful use of the voice and whispering
    • Sufficient intake of water, steam inhalation (e.g. a steam inhalation pipe, picture 1)
    • Sufficient voice rest in connection with respiratory infections
    • A voice amplifier for patients in professions with heavy vocal loading

Vocal cord changes

  • Benign (e.g. nodules, polyp, cyst, granuloma, papilloma)
  • Malignant
  • Always refer the patient to an ENT specialist or phoniatrician.
  • Vocal cord changes may be associated with functional dysphonia, for which voice therapy is needed.

Neurological causes of dysphonia

Vocal cord paralysis

  • Damage to the recurrent laryngeal nerve (n. laryngeus recurrens) or external branch of the superior laryngeal nerve (n. laryngeus superior)

Damage to the recurrent laryngeal nerve

  • The vocal cord is paralysed or its motion limited.
  • The voice is at least initially hoarse, breathy and weak.
  • There may be mild swallowing problems and effort dyspnoea
  • Causes
    • A complication of surgery (thyroid, neck or thoracic cavity procedures)
    • Compression caused by a tumour anywhere along the nerve pathway (base of the skull, neck area, mediastinum)
    • Idiopathic causes (possibly neuritis)
    • Intubation
    • Certain neurological diseases
    • Certain heart diseases (left recurrent nerve compressed at the heart)
    • Idiopathic

Damage to the superior laryngeal nerve

  • Main symptom narrowed and lowered vocal range.
  • Examination using a mirror often reveals little about the patient's status

Treatment

  • Always refer the patient to a specialist (phoniatrician or ENT specialist) for further examinations and treatment.
  • Voice rest will not help.
  • Guidance provided by a speech therapist familiar with dysphonia is often helpful for the function of the voice even though voice training cannot cure a nerve.
  • Voice surgery in severe cases

Spasmodic dysphonia

  • A rare severe chronic voice disorder characterized by breaking and choking speech and tense and strained vocal quality. In another subtype the voice is whispery, weak and fades away at times.
  • A form of focal dystonia, where the motor disorder affects laryngeal muscles.
  • Botulinum treatment of the larynx is effective.
  • The patient should be referred to a phoniatrician.

Essential voice tremor

  • Laryngeal movement disorder similar to spasmodic dysphonia
  • Sometimes the tremor is only in the vocal muscles, sometimes there is also tremor in the head or hands.
  • Propranolol or botulinum toxin injections can be tried as treatment.

Dysphonia associated with neurological diseases

  • Many neurological diseases (e.g. Parkinson's disease, amyotrophic lateral sclerosis, MS) involve problems in voice production.
  • The voice is leaky and quiet. The loudness, pitch or rhythm may be altered.
  • Voice therapy and communication aids may be used for treatment.

Dysphonia in the elderly

  • Dysphonia becomes more prevalent by age and may cause significant impairment.
  • Careful examination of the larynx is important to rule out malignant causes and other diseases.
  • Often the aetiology is, however, benign, age-related vocal cord bowing (presbyphonia).
  • The treatment of presbyphonia consists of voice therapy and, sometimes in serious cases, intracordal injection.

Functional voice disorders

  • A group of voice disorders not explained by an organic cause
  • Organic causes should be excluded.
  • However, a functional voice disorder may occur simultaneously with an organic disorder; an organic voice disorder may cause a functional problem and vice versa.
  • The method of voice production may be uneconomic or the requirements for use of the voice excessive (e.g. often in professions with heavy vocal loading).
  • Typical symptoms include qualitative voice changes and voice fatigue, sometimes neck pain, a feeling of a lump in the throat and various throat irritation symptoms.
  • Underlying causes should be identified (excessive use of voice, a tense way of speaking, hobbies requiring use of the voice, bad acoustics in the working environment, such as background noise, high reverberation).
  • Treatment is based on voice therapy including, for example, voice ergonomics, voice and laryngeal care and vocal training. Voice therapy is provided by specialized speech therapists.

Dysphonia in children

  • Causes
    • Vocal nodules
    • Vocal cysts and other congenital structural defects
    • Vocal cord paralysis
    • Intubation damage
    • Functional disorders
    • Laryngitis
    • Vocal cord papilloma
    • Inhaled glucocorticoid
  • Hearing should be tested in loud children with a hoarse voice.
  • Unless hoarseness is associated with a cold or other clear cause, refer to a phoniatrician or an ENT specialist because indirect laryngoscopy is difficult to perform in children.

    References

    • Lyberg-Åhlander V, Rydell R, Fredlund P, et al. Prevalence of voice disorders in the general population, based on the Stockholm public health cohort. J Voice 2019;33(6):900-905. [PubMed]
    • Persaud R, Garas G, Silva S, et al. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Rep 2013;4(2):10. [PubMed]
    • Martins RH, Hidalgo Ribeiro CB, Fernandes de Mello BM, et al. Dysphonia in children. J Voice 2012;26(5):674.e17-20. [PubMed]
    • Ruotsalainen J, Sellman J, Lehto L, et al. Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Otolaryngol Head Neck Surg 2008;138(5):557-65. [PubMed]