Causes and Treatment for a Hoarse Voice

What Could It Mean if My Voice Sounds Hoarse?

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What does it mean if your voice sounds hoarse?. Jose Luis Pelaez/Iconica/Getty Images

In addition to interfering with speech, the symptom of hoarseness may have you concerned that something is wrong with your body. What exactly is a hoarse voice, what are some possible causes and when should you see your doctor?

Overview

Hoarseness is defined as an abnormal sound when you try to speak. This may be described as raspy, breathy, soft, tremulous and as changes in the volume of your voice.

The pitch of your voice may change as well, either lower or higher. You may also experience pain or a strained feeling when trying to speak normally.

A hoarse voice can be caused by anything that interferes with the normal vibration of the vocal cords, such as swelling and inflammation, polyps that get in the way of the vocal cords closing properly or conditions that result in one or both of the vocal cords becoming paralyzed. Hoarseness is also referred to by the medical term "dysphonia." 

Causes

Hoarseness is a common symptom that most people have experienced from time to time while fighting a cold or the flu. But it can also be a symptom of something more serious.

Hoarseness can be caused in different ways. Often it is due to a problem with the vocal folds (a part of the larynx). The problem can stem directly from problems with the larynx, or instead, be due to problems with the nerves that supply the vocal folds and direct them to do what our brains are telling them to do.

Some possible causes of hoarseness include:

  • Laryngitis - Laryngitis is the most common cause of hoarseness and can be caused by several things, ranging from the common cold to cheering a bit too loudly or long at a ball game, to singing your heart out at a concert.
  • Vocal cord cysts or polyps - Vocal cord cysts are essentially "lumps" on your vocal cords that interfere with their normal closing during speaking. They usually result from overuse of your voice. They can be seen as similar to the calluses people develop on their hands with overuse, such as after raking a yard in the fall. Singers, teachers and other professionals who use their voices a lot can get polyps.
  • Allergies - Both seasonal and year-round allergies can result in hoarseness.
  • Acid reflux/Heartburn - Gastroesophageal reflux (GERD), the reflux of acid from the stomach up to the vocal cords, is a fairly common cause of hoarseness, and many people are unaware of its presence because it's not always associated with heartburn. Hoarseness due to acid reflux is usually worse in the morning.
  • Thyroid conditions – Thyroid conditions, especially untreated hypothyroidism (low thyroid), can cause hoarseness.
  • Smoking - Secondhand smoke exposure may also result in a hoarse voice.
  • Exposure to other irritating substances - Irritants, ranging from air pollution to chemicals we use in our homes, can cause hoarseness.
  • Long-term use of inhaled corticosteroids - Inhaled corticosteroids, a category of inhalers used chronically for asthma or COPD can result in a hoarse voice. It appears that some inhaled corticosteroids are more likely than others to cause problems.
  • Cancer – Cancers of the larynx (the windpipe), the pharynx (the throat), the lungs, the thyroid, and lymphomas may all have hoarseness as a symptom. Sometimes hoarseness is the first symptom. Metastatic cancer (cancer that has spread) from the breast, lungs or other regions of the body to the mediastinum (the area between the lungs), can press on nerves leading to the voice box and cause hoarseness.
  • Neurological conditions - StrokesParkinson’s disease, and multiple sclerosis may all cause hoarseness due to their effects on the nerves supplying the vocal cords.
  • Trauma – Blunt trauma to the throat region, for example during a motor vehicle accident may damage the vocal cords. A more common cause of trauma occurs when the vocal cords are damaged by a tube that is placed down the throat during surgery (intubation) or during a bronchoscopy.
  • Spasmodic dysphonia - Spasmodic dysphonia is a local problem with the muscles of the larynx, resulting in hoarseness.
  • Laryngeal nerve paralysis - The nerves leading to the voice box may be damaged by any surgery in the region where a nerve travels, such as thyroid surgery, heart surgery, or head and neck surgeries.
  • Inhalation of a foreign body or caustic substance.

How Hoarseness Manifests

At rest, the vocal folds are open. When you decide to speak (or sing, or scream) there are several things that have to work together in order for an audible sound to be produced. 

First, the vocal folds have to come together. A problem with this step may occur in either the vocal folds or with the nerves which supply the vocal folds. An example may be if a cancer such as lung cancer or metastatic breast cancer pushes on the nerve that travels to the vocal folds in the chest. 

When the vocal folds are closed, the air then must travel past them and cause the folds to vibrate. Again, problems may occur due to the vocal folds themselves, or due to anything which keeps the folds from remaining closed (nerves) or anything which prohibits the normal flow of air past the folds.

Once air moves past the vocal folds, the sound then needs to "exit" the body, Anything which interferes with the flow of air out through the throat, mouth, and nose, may interfere with the sound. Sound passing to the outside world also resonates in the sinus cavities. This helps to explain the "nasal quality" of your voice if you have a condition affecting your sinus passageways.

The sound can vary from person to person depending on how it reverberates in the sinus passages and based on the size of the vocal folds.

Hoarseness can either involve both vocal folds or only one.

When to See a Doctor

It’s important to see your doctor if you are experiencing a hoarse voice that lasts beyond a few days. While most causes of hoarseness are benign and are due to transient causes such as a cold, it may also be a symptom of something more serious. If your symptom persists it’s important to make an appointment with your doctor—even if you think there's a reasonable cause. Doctors vary on what they call "persistent." In general, if your symptoms last more than two weeks, progressively worsen or are associated with other symptoms, you should make an appointment.

If you notice the sudden loss of voice or have other concerning symptoms, such as weakness in a part of your body, visual changes or lightheadedness, call your doctor or 911 immediately.

Questions Your Doctor May Ask

When you visit your doctor, she will first take a careful history. Some of the questions she may ask include:

  • When did your symptoms begin?
  • Is your hoarseness continuous or do you notice it on and off?
  • Have you had any symptoms of a "head cold," such as a runny nose, fever, or a cough, or have you had an illness such as tonsillitis or mononucleosis?
  • Have you strained your voice in any way, for example by cheering for your favorite football team or singing too long or too loudly?
  • Do you, or have you ever, smoked?
  • Do you drink alcohol?
  • Do you have allergies or eczema?
  • What other medical conditions do you have?
  • Have you experienced any heartburn, unexplained weight loss, persistent cough, coughing up blood, difficulty swallowing, weakness in any part of your body or felt a lump in your neck?
  • What medical conditions run in your family?

Tests Your Doctor May Order

If your symptoms are persisting and your doctor does not find an obvious cause after examining your ears, nose, and throat, she may order further tests. Some of these include:

  • Blood tests – To look for infection.
  • Laryngoscopy - A laryngoscopy is a test in which doctors use a flexible tube with a light attached to look down your nose at your vocal cords.A numbing medication is applied to the back of your throat before this is done, and people usually have little discomfort.
  • CT scan (or other imaging studies) - To look at your neck and chest. If you have a history of cancer, a PET scan may be recommended.
  • Other tests - Depending on your specific situation.

Treatment

Treating will depend on the underlying cause. Your doctor may recommend medications to soothe your throat. For most causes resting your body and voice for a few days will suffice.

If your voice is strained or if you develop vocal polyps, a longer period of voice rest may be recommended. Some of you have heard of your favorite singer needing to cancel his tour to take a break for a few months. This may be the case for amateur singers as well and overly enthusiastic sports fans.

If you smoke, it’s very important to quit—both to help with healing now and to prevent problems in the future.

For those whose problems persist, voice therapy can be very helpful to reduce damage while restoring your voice to health.

Sources:

Barry, D., and M. Vaezi. Laryngopharyngeal reflux: More questions than answersCleveland Clinic Journal of Medicine. 2010. 77(5):327-34.

Chang, J., Bevans, S., and S. Schwartz. Otolaryngology Clinic of North American: Evidence-Based Practice: Management of Hoarseness/DysphoniaOtolaryngology Clinics of North America. 2012. 45(5):1109-26.

Feierabend, R., and M. Shahram. Hoarseness in adultsAmerican Family Physician. 2009. 80(4):363-70.

Mau, T. Diagnostic evaluation and management of hoarsenessThe Medical Clinics of North America. 2010. 94(5):945-60.

Schwartz, S. et al. Clinical practice guideline: hoarseness (dysphonia)Otolaryngology – Head and Neck Surgery. 2009. 141(3Suppl 2):S1-S31.

Spantieas, N., Drosou, E., Bougea, A., and D. Assimakopoulos. Inhaled Corticosteroids and Voice Problems. What is New?Journal of Voice. 2016 Oct 11. (Epub ahead of print).

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