Hoarseness is defined as roughness or breathiness of voice resulting from variations of periodicity and/or intensity of consecutive sound waves. For healthy voice production, vocal cords must approximate properly, maintain suitable size and stiffness, and vibrate regularly in response to air column. Conditions like vocal cord paralysis, tumours, oedema, or fibrosis can disturb these functions. Additionally, congestion, haemorrhages, nodules, or polyps may impair vibration, leading to hoarseness. Importantly, hoarseness signals underlying vocal cord or vocal tract disorders, and any hoarseness lasting longer than two weeks requires urgent laryngeal examination, especially in patients over 40 years, to rule out laryngeal cancer.
Physiology of voice
Voice is the sound produced when vocal cords vibrate as air moves through the vocal tract. Voice generation operates through four critical systems. The generator involves the airflow from the lungs. The vibrator refers to the vocal cord vibrations, driven by pressure differences above and below the glottis. The resonator shapes the voice through the oral cavity and pharynx. Finally, the central command system — the nervous system — controls and coordinates these processes.
While often used interchangeably with speech, voice specifically refers to the acoustic output created during vowel production. Phonation describes the physical and physiological mechanisms behind these vocal fold vibrations. When vocal fold vibration becomes abnormal, the condition is called dysphonia. Complete loss of voice, or whispery speech without vibration, is termed aphonia.
History and Evaluation
Hoarseness, characterised by a rough, breathy, or strained voice, is one of the most common complaints in ENT (Ear, Nose, and Throat) clinics. Patients typically report voice changes such as hoarseness or breathiness, and the onset, duration, and associated factors play a crucial role in diagnosis.
Additional symptoms like dysphagia (difficulty swallowing), coughing, choking, aspiration, stridor (noisy breathing), globus pharyngeus (sensation of a lump in the throat), sore throat, chronic throat clearing, odynophagia (painful swallowing), nasal discharge, and postnasal drip help clinicians narrow down potential causes. Occupational voice use, smoking, alcohol consumption, and reflux history must always be assessed. Asking about history specific to the suspected cause enhances diagnostic accuracy.
Causes of hoarseness
| Category | Subcategory | Specific Causes |
|---|---|---|
| Inflammatory | Acute Infections | Acute laryngitis (viral/bacterial/fungal), influenza, laryngotracheobronchitis, diphtheria |
| Chronic Specific | Tuberculosis, syphilis, scleroma, fungal infections | |
| Chronic Nonspecific | Chronic laryngitis, atrophic laryngitis, allergic rhinitis, GERD, smoking, alcohol/caffeine/ , environmental/occupational irritants | |
| Neoplastic | Benign Tumors | Papilloma, haemangioma, chondroma, fibroma, leucoplakia, vocal nodules, polyps, angiofibroma, amyloid tumour, contact ulcer, cyst, laryngocele |
| Malignant Tumors | Laryngeal carcinoma, thyroid cancer, oesophageal cancer | |
| Traumatic | Surgical Trauma | Skull base procedures, carotid endarterectomy, thyroidectomy, aortic aneurysm repair, cardiac surgery, laryngotracheoplasty, intubation trauma, arytenoid dislocation |
| Accidental Trauma | Submucosal haemorrhage, laryngeal trauma (blunt/sharp), foreign body, nerve paralysis, laryngeal fractures | |
| Neurologic | Nerve Paralysis | Recurrent laryngeal nerve palsy, superior laryngeal nerve palsy, combined paralysis |
| Neurologic Disorders | Parkinson's disease, muscular dystrophy, myasthenia gravis, ALS, spasmodic dysphonia, multiple sclerosis, cerebellar lesions, head injury, CVA | |
| Structural | Joint Fixation | Cricoarytenoid joint fixation (arthritis/trauma) |
| Congenital | Laryngeal web, laryngeal cyst, laryngocele | |
| Systemic | Endocrine/Metabolic | Hypothyroidism (myxoedema), diabetes, rheumatoid arthritis, acromegaly, testosterone deficiency, amyloidosis, sarcoidosis, gout |
| Pulmonary | COPD, asthma | |
| Drug-Induced | Medications | Antihistamines, tricyclic antidepressants, diuretics, antiparkinsonian drugs, vitamin C, cough suppressants, SSRIs, phenothiazines, inhaled steroids, bisphosphonates, ACE inhibitors |
| Functional | Psychogenic | Hysterical (psychogenic) aphonia, anxiety |
| Misuse | Dysphonia plica ventricularis, professional voice overuse |
Examination of Voice and Neck
The voice’s features provide critical diagnostic clues. Throughout history, clinicians should assess whether the voice sounds low or high, loud or soft, powerful or weak, clear or breathy, sharp or dull, sonorous or thin, resonant or falsetto, periodic or raw, and relaxed or tense. A systematic oral cavity, pharynx, and neck examination is essential following the voice assessment. Neck palpation helps identify masses, lymphadenopathy, or thyroid enlargement. However, to confirm the underlying cause, laryngoscopy remains the cornerstone of evaluation.
Laryngoscopy: Essential Tool for Voice Assessment
Several laryngoscopic techniques are available:
- Indirect Laryngoscopy (Mirror Exam): This quick, cost-effective outpatient procedure allows basic visualisation of the gross lesions in the larynx and vocal cord movements. However, it lacks magnification and can miss subtle vocal cord abnormalities and blind areas of the larynx. It’s often limited by patient gag reflex, epiglottic overhang, or young age.
- Flexible Laryngoscopy: Using a flexible fiberoptic scope through the nose, this technique provides excellent visualisation of vocal fold anatomy and its movements. It allows magnified views, photographic documentation, and dynamic assessment, making it a preferred choice for comprehensive laryngeal evaluation.
- Videostroboscopy: This gold standard technique uses strobe lighting to slow down high-speed vocal fold vibrations, offering detailed insights into mucosal waves, symmetry, amplitude, glottic closure, and periodicity. Stroboscopy does not physically slow the motion of the vocal folds but leverages optical synchronisation principles to create an apparent slow-motion visualisation, thereby facilitating precise, real-time assessment of vibratory laryngeal function.
Principle of stroboscopy – Vocal folds typically vibrate at high speed between 100 and 300 cycles per second (Hz) in adult speakers. However, the human eye can only see about 5–10 separate images each second, so it cannot directly see these rapid vibrations. To overcome this limitation, stroboscopy employs a flashing light (strobe light) that emits flashes at a frequency slightly above or below the fundamental frequency of the patient’s vocal fold vibration. Each flash catches a different part of the vibration cycle, creating a set of “frozen” images. When these snapshots are shown rapidly, they create an apparent slow-motion effect, known as aliasing. This allows clinicians to evaluate mucosal waves, closure patterns, symmetry, and periodicity—details invisible under regular light. - Direct Laryngoscopy/ surgical endoscopy with microlaryngoscopy: This surgical procedure under general anaesthesia is reserved for cases needing detailed examination, biopsies, or surgical manipulation. It enables tactile assessment, including palpation of the cricoarytenoid joint, which helps distinguish between vocal fold paralysis and fixation. Despite its diagnostic power, it carries risks like airway distress, dental trauma, oral cavity, oropharyngeal, and hypopharyngeal trauma and cardiovascular complications.
- High-Speed Digital Imaging: This advanced tool is used to analyze vibratory patterns in aperiodic voices or conditions like diplophonia, providing objective visual evidence of subtle vocal fold dysfunction.
Radiological Investigations
Accurate imaging studies are often required for comprehensive evaluation:
- Chest and Neck X-rays help assess structural abnormalities.
- CT Scans are essential in suspected laryngeal cancer, recurrent or persistent hoarseness, trauma cases, or when vocal cord paralysis is suspected. A contrast-enhanced CT from the skull base to the mediastinum is necessary to trace the recurrent laryngeal nerve.
- MRI Scans are preferred in suspected neurological causes of hoarseness or in cases with cranial nerve involvement, offering detailed brainstem and skull base evaluation.
Subjective voice assessment relies on perceptual evaluation by trained professionals. The most widely used tool is the GRBAS Scale, which grades five key voice aspects:
- Grade (G): Overall voice quality.
- Roughness (R): Frequency fluctuations.
- Breathiness (B): Air escape characteristics.
- Asthenia (A): Vocal power weakness.
- Strain (S): Excessive vocal effort.
Each parameter is rated from 0 (normal) to 3 (severely abnormal) based on recorded speech samples, often using standardised passages like the “Rainbow Passage.” The GRBAS scale has proven particularly valuable in evaluating head and neck cancer patients, post-surgical voice outcomes, and even laryngeal speech. Interestingly, clinician ratings using GRBAS don’t always align with patients’ own perceptions, emphasising the need for combined assessment approaches.
Objective Voice Assessment:
Objective voice evaluation uses specialised software like Dr. Speech or Vaughmi for quantitative assessment. This setup includes a high-sensitivity microphone and computer software to measure key acoustic parameters:
- Fundamental Frequency (F0): The number of vocal fold vibrations per second (85–180 Hz in males; 165–255 Hz in females).
- Jitter: Cycle-to-cycle variations in frequency.
- Shimmer: Variability in intensity/amplitude. Pathological voices have high jitter and shimmer values.
- Harmonic-to-Noise Ratio (HNR): Indicates the balance between harmonic (regular) signals and noise (irregularity), where low HNR correlates with breathiness and poor vocal quality.
Additional tests like Maximum Phonation Time (MPT) assess glottal competence by measuring how long a patient can sustain the vowel /a/ after maximal inhalation. An MPT under 10 seconds is typically abnormal.
Quality of Life Impact: Using the Voice Handicap Index
The Voice Handicap Index (VHI) is a widely validated questionnaire designed to capture the impact of voice disorders on a patient’s daily life. It evaluates functional, emotional, and physical components of vocal impairment, helping guide treatment priorities and monitor progress.
Specialised Neuromuscular Assessment: Laryngeal EMG
When neuromuscular dysfunction is suspected, laryngeal electromyography (EMG) provides vital information. Needle electrodes placed into laryngeal muscles assess electrical activity, distinguishing between:
- Myopathy: Normal firing frequency but reduced amplitude.
- Neuropathy: Reduced firing frequency, sometimes with reinnervation signals.
Such a detailed assessment is essential for diagnosing conditions like vocal fold paralysis, synkinesis, or cricoarytenoid joint disorders.
Medical Treatment
Hoarseness is a common voice problem, and managing it effectively requires understanding both medical and surgical options. Patients often ask: how do you treat hoarseness? Let’s break this down clearly.
Medical Therapy
- Antireflux Therapy. Patients with hoarseness often have underlying gastroesophageal reflux disease (GERD). If laryngoscopy shows signs like redness, swelling, or posterior commissure oedema, doctors usually start proton pump inhibitors (PPIs). These antireflux medications help reduce stomach acid, lowering irritation and improving vocal fold health.
- Corticosteroids. Corticosteroids are not routinely used in hoarseness. However, they play a vital role in cases like allergic laryngitis, croup in children, or laryngeal oedema. Because steroids carry risks of side effects, clinicians must limit their use to specific indications.
- Antimicrobials. Doctors generally avoid antibiotics for hoarseness unless the patient has bacterial laryngitis. Routine use of antibiotics is discouraged to prevent drug resistance and unnecessary side effects.
- Voice Therapy. Voice therapy is a key treatment for hoarseness caused by improper voice use. Professional voice users—such as singers, teachers, or speakers—benefit greatly. Voice therapy focuses on correcting harmful vocal habits and improving outcomes in both children (over age two) and adults.
Surgical Treatment
- Surgery. Surgery is necessary for patients with benign vocal cord lesions that don’t improve with voice therapy. Importantly, voice therapy should come first, as improving the phonatory mechanism is crucial. For suspicious malignant lesions, surgeons perform a biopsy. Other surgical indications include recurrent respiratory papilloma and vocal cord palsy, which may require medialization thyroplasty or injection laryngoplasty.
- Botulinum Injections. Botulinum toxin is the treatment of choice for hoarseness due to spasmodic dysphonia or arytenoid granulomas. These precise injections help relax overactive muscles, improving voice quality significantly.
Prevention: Voice Care Tips
Preventing hoarseness is always better than treating it.
- Avoid smoking and limit alcohol use.
- Stay well-hydrated with non-alcoholic fluids.
- Avoid throat clearing and harsh vocal behaviors.
- Get regular exercise, enough sleep, and maintain vocal warm-ups and cool-downs, especially if you sing or speak for long periods.
- Avoid chronic use of mouthwash, which can dry out the throat.
By following these tips, you can keep your voice healthy and reduce the risk of voice problems. Always seek medical advice if hoarseness persists beyond two weeks.
———— End of the chapter ————
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Reference Textbooks.
- Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
- Cummings, Otolaryngology-Head and Neck Surgery.
- Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
- Ballenger’s, Otorhinolaryngology Head And Neck Surgery
- Susan Standring, Gray’s Anatomy.
- Frank H. Netter, Atlas of Human Anatomy.
- B.D. Chaurasiya, Human Anatomy.
- P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
- Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
- Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
- Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
- Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
- Arnold, U. Ganzer, Textbook of Otorhinolaryngology, Head and Neck Surgery.
- Ganong’s Review of Medical Physiology.
- Guyton & Hall Textbook of Medical Physiology.
Author:
Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India
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- Please read. Juvenile Angiofibroma. https://www.entlecture.com/juvenile-angiofibroma/
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Keywords: Hoarseness Evaluation, Causes Of Hoarseness, Vocal Cord Examination, Laryngoscopy Techniques, Videostroboscopy Assessment, Vocal Fold Paralysis, Objective Voice Analysis, GRBAS Voice Rating, Voice Handicap Index, Laryngeal Electromyography, ENT Hoarseness Management, Hoarseness Causes, Treatment For Hoarseness, Voice Therapy Exercises, Vocal Cord Paralysis Treatment, Laryngoscopy Procedure, Vocal Fold Dysfunction, Spasmodic Dysphonia Treatment, Botulinum Toxin For Voice, GERD And Hoarseness, Laryngeal Cancer Signs, Vocal Cord Nodules Treatment, Voice Care Tips, How To Prevent Hoarseness, Stroboscopy In ENT, Flexible Laryngoscopy Exam, Hoarse Voice Remedies, Voice Disorder Evaluation, Vocal Fold Vibration Problems, Vocal Cord Biopsy Procedure, Voice Quality Assessment Tools