CHAPTER 19 Hoarseness

Hoarseness is a disturbance of the normal voice pitch by an abnormal vibration of the vocal cords. It is a term used to describe an unnaturally rough, harsh, or deep voice. Voice is the sound produced when the vocal folds are approximated and expired airflow between the cords causes them to vibrate. The sound produced by the larynx is amplified by the pharynx, oral cavity, sinuses, and nasal cavity and is modified by movements of the tongue, uvula, and soft palate. Hoarseness may be an early sign of local disease or a manifestation of a systemic illness. Hoarseness is a cardinal symptom for laryngeal disease.

The larynx is a musculocartilaginous structure lined with a mucous membrane connected to the superior part of the trachea and to the pharynx inferior to the tongue and hyoid bone. It is the sphincter that guards the entrance into the trachea and functions secondarily as the organ of voice. Nine cartilages connected by ligaments and eight muscles form the larynx. The lower portion of the thyroarytenoid muscle forms the true vocal fold, or folds, which are highly elastic and account for the extraordinary versatility of the voice and the wide range of pitch, volume, and quality. The glottis is the triangular opening between the true vocal cords. The supraglottic area includes the ventricular folds (false vocal cords), aryepiglottic folds, and the epiglottis (Figure 19-1). The epiglottis is the lidlike cartilaginous structure that overhangs the entrance to the larynx and serves to prevent food from entering the larynx and trachea while swallowing.

FIGURE 19-1 Laryngoscopic view of the interior of the larynx.

(Modified from Greene MCL, Mathieson L: The voice and its disorders, ed 5, London, 1989, Wiley. Copyright John Wiley & Sons Limited. Reproduced with permission.)

Many benign conditions cause hoarseness, such as functional disorders from voice overuse. Functional causes are unrelated to organic disease and may have a psychosocial component, such as restraint in expressing anger, or crying, or a history of psychological trauma.

However, persistent hoarseness for more than 2 weeks in an adult and 1 week in a child may indicate secondary changes to the vocal cords. These changes may be caused by structural changes resulting from palsies, polyps, or cysts; laryngeal neoplasm; or congenital disorders of the larynx. Hoarseness may also be a symptom of systemic disease, such as hypothyroidism, or a symptom of inflammation caused by a variety of processes. Many forms of laryngitis that appear alike on physical examination have very different causes; critical clues to the specific etiology of laryngitis depend on a careful history.

Diagnostic reasoning: focused history

Is the hoarseness acute or chronic?

Key questions

How long has the symptom been present?

Has this happened before? Is it recurrent?

Is it getting better or worse?

Duration

Symptoms of less than 2 weeks’ duration are considered to be acute; the most likely cause is a viral upper respiratory tract infection. Inflammations secondary to acute viral infection or voice overuse are the most common causes of acute laryngitis. Chronic symptoms suggest structural change in the larynx or hoarseness secondary to disorders, such as gastroesophageal reflux disease (GERD) or systemic disease. If the duration of hoarseness is longer than 2 weeks, referral to an ear, nose, and throat specialist is indicated to evaluate for neoplasm, most often squamous cell carcinoma, because chronic laryngitis is rarely of an infectious etiology.

Recurrence

Recurrent episodes of hoarseness may indicate allergies or sinusitis with postnasal drip.

Progression

Progressive hoarseness usually indicates a lesion, such as a laryngeal or hypopharyngeal cyst.

What does the onset of hoarseness tell me?

Key questions

How did the hoarseness develop?

Is there any history of trauma to the throat?

Have you had any recent surgery around the throat or neck?

Onset

Acute onset of hoarseness is usually the result of infection or trauma. The trauma can be from direct injury (foreign body, accidents) or overuse from screaming. The overuse can be gradual, resulting in progressive hoarseness and vocal cord changes. This hoarseness is worse in the afternoon or evening.

Hoarseness from birth may indicate a congenital problem, such as laryngeal web, cyst, palsy, or angioma. Newborns with aphonia or a hoarse cry that does not resolve may have a congenital anomaly, papilloma, or vocal cord paralysis.

Trauma

External trauma to the throat is a rare cause of hoarseness but can result in hematoma formation in the laryngeal soft tissues. There can also be mucosal lacerations, arytenoid cartilage dislocation, or fracture of the laryngeal cartilage. Internal trauma can occur with intubation associated with surgery, as occurs when an endotracheal tube catches on laryngeal structures and is pushed against resistance.

Surgical history

Tonsillectomy, thyroidectomy, or rhinoplasty can alter the quality of the voice secondary to structural change and scarring. Cardiac surgery has also been cited as a cause of injury when the vagus nerve (cranial nerve [CN] X) is damaged in its course around the aorta.

Does the presence of risk factors help narrow the diagnosis?

Key questions

Have you had a recent cold or upper respiratory tract infection?

Do you have allergies or asthma?

Do you smoke? How long have you been a smoker?

How much alcohol do you drink?

Can you describe your voice habits, such as singing, talking, and shouting?

Are you frequently exposed to dust, fumes, or loud noise?

Are your immunizations up to date?

Upper respiratory infection

Acute laryngitis, epiglottitis, and acute laryngotracheobronchitis (croup) are sequelae from a viral upper respiratory infection (URI) that can result in vocal cord inflammation. Postnasal discharge that is thick and purulent may pool around the larynx and cause chronic secondary edema. Nasal congestion that leads to mouth breathing produces laryngeal dryness, with resultant hoarseness on arising in the morning.

Children who have epiglottitis are not hoarse, but, as the epiglottis swells, the voice becomes muffled and drooling is observed.

Allergies and asthma

Poorly controlled or undiagnosed asthma can result in a chronic cough with subsequent hoarseness. Allergies can cause chronic or recurrent irritation and swelling of both the upper and lower airways. Children who have a history of asthma and or allergies can develop vocal cord edema, inflammation, and hoarseness.

Smoking

Cigarette smoking is the most significant risk factor for laryngeal cancer. Smoking is also a risk factor for acute or chronic laryngitis because smoke irritates all mucous membranes and impairs ciliary function, causing pooling of secretions around the larynx.

Alcohol consumption

Chronic consumption of hard liquor is a direct irritant to the throat and is associated with laryngeal cancer.

Voice habits

Voice misuse occurs when the true vocal cords are forced to vibrate under undue stress and tension. Voice abuse is exuberant overuse and can lead to inflammation of the larynx and edema, hemorrhage, or vocal cord polyps. A gradual progression of hoarseness may go unnoticed by the patient. Often a precipitating incident (such as shouting, excessive speaking, or singing) produces acute laryngitis. Specific questions may need to be asked to make the patient aware of conditions that lead to voice abuse, such as the following:

Have others noticed a change in the quality of your voice?

Do you talk frequently to persons who are hard of hearing?

Do you yell at children?

Do you work in an environment that is noisy or contains dust or fumes?

Have you attended a recent sporting event?

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