What causes a hoarse voice?

Causes of Hoarse Voice

Hoarseness is most commonly caused by acute viral laryngitis, but persistent hoarseness beyond three months requires laryngoscopy to rule out serious underlying conditions like laryngeal malignancy, benign vocal fold lesions, or glottic insufficiency. 1

Common Causes of Hoarseness

Inflammatory Causes (Most Common)

• Acute laryngitis (42.1% of cases) 2

  • Primarily viral in origin (parainfluenza, rhinovirus, influenza, adenovirus) 1
  • Self-limited, typically resolves in 7-10 days 1
  • Antibiotics are ineffective for viral laryngitis 1

• Chronic laryngitis (9.7% of cases) 2

  • Often associated with:
    • Laryngopharyngeal reflux
    • Inhaled irritants (tobacco smoke, chemicals)
    • Inhaled corticosteroid use 1

Functional Voice Disorders (30% of cases) 2

• Vocal overuse/abuse
• Muscle tension dysphonia
• Common in teachers, singers, clergy, and others with high vocal demands 1

Structural Lesions

• Benign vocal fold lesions (10.7-31% of cases) 2

  • Vocal nodules (especially in children - 77% of hoarse children) 1
  • Polyps
  • Cysts (epidermal inclusion and mucous retention)
  • Reinke's edema (polypoid degeneration)
  • Vocal process granulomas

• Malignant tumors (2.2-3% of cases) 2

  • More common in patients over 60 years 1
  • Higher risk in smokers and alcohol users 1

Neurological Causes

• Vocal fold paralysis/paresis (2.8-8% of cases) 2

  • May result from:
    • Surgical injury (thyroid surgery, anterior cervical spine surgery, cardiac surgery) 1
    • Intubation trauma
    • Neurological disorders (stroke, Parkinson's disease, multiple sclerosis) 1
    • Compression of recurrent laryngeal nerve (tumors, aortic aneurysm)

• Laryngeal dystonia (spasmodic dysphonia) 1

Other Causes

• Age-related vocal changes (2% of cases) - vocal fold atrophy 2, 1
• Psychogenic factors (2-2.2% of cases) 2
• Post-intubation trauma - especially after prolonged intubation 1
• Congenital abnormalities in infants and children 1

Red Flags Requiring Immediate Laryngoscopy

Regardless of duration, immediate laryngoscopy is warranted when hoarseness is accompanied by: 1

• History of tobacco or alcohol use
• Concomitant neck mass
• Hemoptysis
• Dysphagia or odynophagia
• Otalgia
• Airway compromise
• Neurologic symptoms
• Unexplained weight loss
• Worsening hoarseness
• Immunocompromised status
• Possible foreign body aspiration
• Hoarseness in a neonate
• Unresolving hoarseness after surgery (intubation or neck surgery)

Diagnostic Approach

1. Laryngoscopy is the primary diagnostic tool for persistent hoarseness 1

   • Should be performed when hoarseness persists beyond 3 months
   • May be performed earlier if serious underlying cause is suspected
   • Must be performed before voice therapy is initiated 1

2. Imaging may be indicated after laryngoscopy in select cases 3

   • CT with contrast is the imaging of choice for laryngeal tumors and vocal cord paralysis
   • Should cover from skull base to aorticopulmonary window (especially for left vocal cord paralysis)

Treatment Considerations

Treatment depends on the specific cause:

1. For acute viral laryngitis:

   • Voice rest
   • Adequate hydration
   • Avoid antibiotics (ineffective for viral causes) 1, 4
   • Avoid decongestants (limited evidence for benefit) 4

2. For benign vocal fold lesions and functional disorders:

   • Voice therapy is first-line treatment 1, 2
   • Surgery may be indicated for certain lesions that don't respond to conservative management

3. For glottic insufficiency:

   • Surgical options include injection laryngoplasty or laryngeal framework surgery 1

4. For malignancy:

   • Surgical biopsy for diagnosis
   • Treatment based on staging and location

Important Clinical Pearls

• Hoarseness lasting more than 3 months requires visualization of the larynx 1
• Antibiotics should not be routinely prescribed for hoarseness 1
• Voice therapy should only be prescribed after laryngoscopy has been performed 1
• Smokers with hoarseness require prompt evaluation due to increased risk of malignancy 1
• Professional voice users (singers, teachers, clergy) may require earlier intervention due to occupational impact 1
• Elderly patients with hoarseness often have vocal fold atrophy or neurologic causes 1
• Children with chronic hoarseness most commonly have vocal nodules 1

Remember that early diagnosis of serious conditions like laryngeal cancer significantly improves outcomes, making timely laryngoscopy crucial for persistent hoarseness 1.