Hoarseness

What is hoarseness?

Hoarseness is a general term that describes abnormal voice changes.  When hoarse, the voice may sound breathy, raspy, strained, or there may be changes in volume (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 or singing, they come together, and as air leaves the lungs, they vibrate, producing sound.  Swelling or lumps on the vocal cords prevent them from coming together properly and changes the way the cords vibrate, which makes a change in the voice, altering quality, volume, and pitch.

What are the causes of hoarseness?
Acute Laryngitis: There are many causes of hoarseness. Fortunately, 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.

Voice Misuse:

• Speaking in noisy situations
• Excessive use
• Telephone use with the handset cradled to the shoulder
• Using inappropriate pitch (too high or too low) when speaking
• Not using amplification when public speaking

Benign Vocal Cord Lesions: 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 voice do not have symptoms of heartburn.  Usually, the voice is worse in the morning and improves during the day. 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.

Laryngopharyngeal Reflux (LPRD): If the reflux makes it all the way up through the upper sphincter and into the back of the throat, it is called LPRD rather than GERD.  The structures in the throat (pharynx, larynx, and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of the reflux into this area can result in more damage.

Neurological Diseases or Disorders: Hoarseness can also appear in those who have neurological diseases such as Parkinson's or a stroke,  or may be a symptom of spasmodic dysphonia, a rare neurological disorder that usually affects only the voice,  but  sometimes affects breathing. A paralyzed vocal cord may be the cause of a weak, breathy voice. If the hoarseness persists for more than three months and other causes have been ruled out, a neurologist may be helpful for diagnosis.

Smoking: Smoking is another cause of hoarseness. Since smoking is the major cause of throat cancer, if smokers are hoarse, they should see an otolaryngologist.

Other Causes: These include allergies, thyroid problems, trauma to the voice box, and, occasionally, menstruation.  Very serious conditions such as laryngeal cancer can also cause hoarseness, which is why it is important to have chronic hoarseness evaluated by an otolaryngologist immediately.

When should you worry about hoarseness?

• If hoarseness lasts longer than two weeks, especially if you smoke
• If you do not have a cold or flu
• If you are coughing up blood
• If you have difficulty swallowing
• If you feel a lump in the neck
• If you observe loss or severe changes in voice lasting longer than a few days
• If you experience pain when speaking or swallowing
• If difficulty breathing accompanies your voice change

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 often best managed by a team of professionals who know and understand how the voice functions.  These professionals are otolaryngologists,  speech/language pathologists,  and teachers of singing,  acting,  and public speaking. Vocal nodules, polyps, and cysts are typically treated with a combination of microsurgery and voice therapy.

How is hoarseness or 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 voice team members, 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 to thin the mucus are also helpful.

What can I do to treat mild hoarseness? 
What can I do to prevent hoarseness?

Specialists in speech/language pathology (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/language pathologist may teach patients to alter their method of speech production to improve the sound of the voice and to resolve problems, such as vocal nodules. When a patients' problem is specifically related to singing,  a singing teacher may help improve the patients' singing techniques.

How is this diagnosed?
The evaluation of hoarseness involves assessment of the anatomic, physiologic, and behavioral factors that influence overall vocal production. Assessment begins with a description of the  voice, symptomatology,  and a medical and social history.  Laryngeal visualization is necessary to determine the status of the vocal folds.  In general, laryngeal examination should be  performed  whenever  hoarseness persists longer than 2 weeks. In select cases, more sophisticated diagnostic procedures may be indicated.

Services Offered at The Medical City
Rigid and Flexible Endoscopy: Endoscopy is a minimally invasive diagnostic medical procedure used to assess the interior surfaces of an organ by inserting a tube into the body.   The instrument may have a rigid or flexible tube and not only provide an image for visual inspection and photography, but also enable taking biopsies and retrieval of foreign objects.

Many endoscopic procedures are considered to be relatively painless and, at worst, associated with mild discomfort.  Most patients tolerate the procedure with only topical anaesthesia of the oropharynx using lidocaine spray

Laryngeal Videoendostroboscopy (LVES):  It provides useful information concerning the nature of vibration, an immediate image to detect the presence or absence of vocal pathology, and a permanent video record of the examination

Speaking Interventional Therapy. Strategies to regain voice that was lost due to vocal misuse or other medical conditions are carried out by speech language pathologists

Singing Interventional Therapy (Vocal Caching ).   Individuals who wish to improve or correct his/her   singing style may avail the services of our in-house trainer

Speech & Language Rehabilitation Program. Patients with communication problems as a result of stroke or other neurological conditions can improve their receptive language skills through this program

Laryngeal EMG.  EMG stands for “electromyography”.  It is a test performed to study muscle activities under various conditions. Laryngeal EMG studies activities of muscles in the larynx.

EMG guided injection for spastic dysphonia.  Patients suffering from focal dystonia of the larynx presents with a strained voice quality called spastic dysphonia.  This may be relieved with injection of Botox to the laryngeal muscle (thyroarytenoid)  to relax it.   A small needle is used to deliver this substance and is injected to the anterior neck area. It is attached to a portable EMG unit to allow proper placement of the needle into target muscle.

Microlaryngeal Surgery: Is a procedure that involves surgical removal of benign growths in the vocal cord ( eg. polyp, cyst, nodule ) using fine/microlaryngeal instruments.  It is performed under general anesthesia and requires an overnight stay in the hospital.

Thyroplasty: This laryngeal framework surgery is also called Isshiki Thryopasty type 1 or Medialization.  It   is performed under local anesthesia in the operating room and it involves placement of a small silastic block into the thyroid cartilage to move a paralyzed vocal cord into the midline and closing the glottal gap. It alleviates vocal
fatigue and improves voice quality. Candidates for this procedure are patients who have lost their voice due to thyroid, open heart surgery or neck trauma.

Arytenoidectomy: Airway compromise secondary to bilateral vocal cord paralysis (both vocal folds fail to open) from neck surgery or unknown etiology may benefit from this procedure.    It involves removal of one arytenoid and permits breathing. Surgery is done under general anesthesia.

How Can The Medical City Help You?
At The Medical City we have a complete roster of competent Otolaryngologists who may assess or treat people with hoarseness.  

References: Portions reprinted from a patient leaflet of the American Academy of Otolaryngology-
Head and Neck Surgery Foundation
TMC Department of ENT-HS  - CENTER FOR VOICE  AND SWALLOWING DISORDERS

Note:   This information is not intended to be used as a substitute for professional medical advise, diagnosis or treatment.   If you or someone you know have any of the symptoms mentioned above, it is advisable to seek professional help.

For further inquiries or if you want to seek consult, please call:

CENTER FOR VOICE AND SWALLOWING DISORDERS
Tel. No. (632) 988-1000 / (632) 988-7000 Ext. 6251

CENTER FOR PATIENT PARTNERSHIP
Tel. No. (632) 988-1000 / (632) 988-7000 Ext. 6444

Note:   This information is not intended to be used as a substitute for professional medical advise, diagnosis or treatment.   If you or someone you know have any of the symptoms mentioned above, it is advisable to seek professional help.