Hoarseness & Laryngitis

Why Am I Hoarse? 

Hoarseness is necessarily a symptom of your voice box or larynx.  It may be native to the vocal cords or secondary to problems such as allergies that indirectly affect them.   While most cases of hoarseness are unrelated to cancer, that is often our patient’s worst fear.  So let’s address this first.

Laryngeal cancer is a very serious condition that can cause hoarseness but left untreated can also cause a dangerous blockage of air from reaching your lungs.  Chronic hoarseness always warrants evaluation by an otolaryngologist to rule out laryngeal cancer. It is important to remember that prompt attention to changes in the voice lasting more than four weeks facilitate early diagnosis. Laryngeal cancer is highly curable if diagnosed in its early stages. Usually an otolaryngologist can see a cancer in your voice box by looking with an endoscope at the time of your visit.

Fortunately, most causes of hoarseness are not due to cancer.  The term laryngitis is often used interchangeably with hoarseness. Acute laryngitis is the most common cause of hoarseness and voice loss that starts suddenly. Most cases of acute laryngitis are caused by a viral infection that leads to swelling of the vocal cords. When the vocal cords swell, they vibrate differently, leading to hoarseness. The best treatment for this condition is to stay well hydrated and to rest or reduce your voice use. Rarely, serious injury to the vocal cords can result from strenuous voice use during an episode of acute laryngitis. Since most acute laryngitis is caused by a virus, antibiotics are not effective. Bacterial infections of the larynx are much rarer and often are associated with difficulty breathing. Any problems breathing during an illness warrants emergency evaluation.  Chronic laryngitis, on the other hand, refers to a problem that is ongoing, usually for more than three months.  Acid reflux disease, exposure to irritants such as smoke, and low grade infections or inflammations from a variety of sources can lead to swelling in the voice box.

More specific causes include of hoarseness include vocal cord growths, vocal cord paralysis or movement disorders of the vocal cords, vocal cord hemorrhage (bleeding into the substance of the vocal cords) and other problems that lead to swelling or interfere with proper closure of the vocal cords.

Growths on the vocal cords may be benign (non-cancerous) or malignant (cancerous).  Nodules, cysts, polyps, and general swelling are all considered benign and interfere with proper vibration and closure of the vocal cords.  They are often associated with poor voice habits and/or irritants including smoke.  Voice therapy and breathing techniques alone may help but is also important as a part of surgical treatment to assure proper healing.  Smoking cessation is strongly advised to accelerate healing and prevent recurrence.

Speaking is a physical task that requires coordination of breathing with the use of several muscle groups. It should come as no surprise that, just like in any other physical task, there are efficient and inefficient ways of using your voice. Excessively loud, prolonged, and/or inefficient voice use can lead to vocal difficulties, just like improper lifting can lead to back injuries. Excessive tension in the neck and laryngeal muscles, along with poor breathing technique during speech leads to vocal fatigue, increased vocal effort, and hoarseness. Voice misuse and overuse puts you at risk for developing benign vocal cord lesions or a vocal cord hemorrhage.  Avoiding whispering or speaking at overly loud levels (especially yelling or screaming) are extremely important.  Maintaining proper hydration and lubrication of your vocal cords is also helpful.  Lemon in tea or water is particularly good at helping with lubrication.

Yelling, shouting, or other stress on the vocal cords can lead to bleeding from small vessels within the vocal cords.  This often presents with sudden loss of voice associated with the behavior.  Most of the time this will resolve more rapidly with strict voice rest.  If left untreated, especially if there is continued stress on the vocal cords, this can lead to problems that are more difficult to correct.

Warm up your voice before heavy use. Most people know that singers warm up their voices before a performance, yet many don’t realize the need to warm up the speaking voice before heavy use, such as teaching a class, preaching, or giving a speech. Warm-ups can be simple, such as gently gliding from low to high tones on different vowel sounds, doing lip trills (like the motorboat sound that kids make), or tongue trills.

Don’t smoke. In addition to being a potent risk factor for laryngeal (voice box) cancer, smoking also causes inflammation and polyps of the vocal cords that can make the voice very husky, hoarse, and weak. Use good breath support. Breath flow is the power for voice. Take time to fill your lungs before starting to talk, and don’t wait until you are almost out of air before taking another breath to power your voice. Use a microphone. When giving a speech or presentation, consider using a microphone to lessen the strain on your voice.

Minimize throat clearing: Clearing your throat can be compared to slapping or slamming the vocal cords together. Consequently, excessive throat clearing can cause vocal cord injury and subsequent hoarseness. An alternative to voice clearing is taking a small sip of water or simply swallowing to clear the secretions from the throat and alleviate the need for throat clearing or coughing. The most common reason for excessive throat clearing is an unrecognized medical condition causing one to clear their throat too much. Common causes of chronic throat clearing include gastroesophageal reflux, laryngopharyngeal reflux disease, sinus and/or allergic disease.

Hoarseness and other problems can also occur due to problems between the nerves and muscles within the voice box or larynx. The most common neurological condition that affects the larynx is a paralysis or weakness of one or both vocal cords. Involvement of both vocal cords is rare and is usually manifested by noisy breathing or difficulty getting enough air while breathing, walking, or talking. When one vocal cord is paralyzed or weak, voice is usually the problem rather than breathing. One vocal cord can become paralyzed or weakened (paresis) from a viral infection of the throat, after surgery in the neck or chest, from a tumor or growth along the laryngeal nerves, or for unknown reasons. Vocal cord paralysis typically presents with a soft and breathy voice. Many cases of vocal cord paralysis will recover within several months. In some cases, however, the paralysis will be permanent, and may require active treatment to improve the voice. Treatment choice depends on the nature of the vocal cord paralysis, the degree of vocal impairment, and the patient’s vocal needs. One option includes surgery for unilateral vocal cord paralysis that repositions the vocal cord to improve contact and vibration of the paralyzed vocal cord with the non-paralyzed vocal cord. There are a variety of surgical techniques used to accomplish this. Voice therapy may be used before or after surgical treatment of the paralyzed vocal cords, or it can also be used as the sole treatment.