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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 more than two 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.
Organic 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 dysphonia
- 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)
- 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 voice therapist is often helpful for the function of the voice even though voice training cannot cure nerve damage.
- 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 1.
- The patient should be referred to a phoniatrician.
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 functional 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, surgery.
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 2 including, for example, voice ergonomics, voice and laryngeal care and vocal training. Voice therapy is provided by specialized speech therapists.
Dysphonia in children
- Causes 3
- Vocal nodules
- Vocal cysts and other congenital structural defects
- Vocal cord paralysis
- Intubation damage
- Functional disorders
- Laryngitis
- Vocal cord papilloma
- Hearing should be tested in loud children with a hoarse voice.
- If hoarseness continues, refer to a phoniatrician or an ENT specialist because indirect laryngoscopy is difficult to perform in children.
References
- 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]
- 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]
- Martins RH, Hidalgo Ribeiro CB, Fernandes de Mello BM et al. Dysphonia in children. J Voice 2012;26(5):674.e17-20. [PubMed]
- 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]