What causes hoarseness of voice in individuals, considering age, occupation, and medical history?

Causes of Hoarseness of Voice

Hoarseness (dysphonia) results from a broad spectrum of etiologies that can be systematically categorized into structural, neurologic, inflammatory, iatrogenic, medication-induced, and functional causes, with the most critical imperative being early identification of laryngeal malignancy through timely laryngoscopy. 1

Malignancy and Life-Threatening Causes

• Head and neck cancer presents with dysphonia and requires immediate exclusion, as delayed laryngeal evaluation leads to higher staging, more aggressive treatment requirements, and reduced survival rates. 1
• Tobacco abuse increases laryngeal malignancy risk 2-3 fold and mandates immediate laryngoscopy. 2
• Laryngeal cancer accounts for 2.2-3% of hoarseness cases but carries the highest mortality risk. 3, 4

Neurologic Causes

• Vocal fold paralysis from recurrent laryngeal nerve injury is among the most common causes in elderly patients and results in breathy dysphonia with potential aspiration risk. 1, 5
• Parkinson's disease causes hypophonia (reduced speech volume) and is strongly associated with drooling due to impaired swallowing. 6
• Spasmodic dysphonia and other laryngeal dystonia almost universally manifest with dysphonia. 1
• Other neurologic conditions include essential tremor, amyotrophic lateral sclerosis, multiple sclerosis, and stroke affecting bulbar function. 1, 6

Inflammatory and Infectious Causes

• Acute laryngitis accounts for 42.1% of hoarseness cases and is typically self-limited. 3, 4
• Chronic laryngitis represents 9.7-10% of cases and may be associated with gastroesophageal reflux, eosinophilic esophagitis, or chronic irritant exposure. 1, 3, 4
• Fungal laryngitis (candidiasis) can occur, particularly in patients using inhaled corticosteroids. 1

Structural and Benign Lesions

• Benign vocal fold lesions (polyps, nodules, cysts) account for 10.7-31% of hoarseness cases. 3, 4
• Presbylarynx (age-related laryngeal changes) causes vocal fold bowing and atrophy, with prevalence substantially higher in adults >65 years (2.5% in those >70 years). 1
• Polypoid vocal fold lesions and masses can cause abnormally low pitch. 2

Functional and Musculoskeletal Causes

• Muscle tension dysphonia (MTD) constitutes 10-40% of voice center caseloads and is characterized by excessive laryngeal musculoskeletal tension with disrupted vocal fold vibration. 1
• Functional dysphonia from vocal overuse or abuse accounts for 30% of cases. 3, 4
• Psychogenic factors contribute to 2-2.2% of hoarseness cases. 3, 4

Iatrogenic Causes

• Vocal fold injury after intubation occurs in 2.3-84% of cases depending on patient age and injury definition. 1, 2
• Recurrent laryngeal nerve injury after thyroidectomy occurs in 0.85-8.5% of cases, and after anterior cervical spine surgery in 1.69-24.2% of cases. 1
• Cardiothoracic procedures represent another significant source of recurrent laryngeal nerve injury. 1

Medication-Induced Causes

• Inhaled corticosteroids cause fungal and nonspecific laryngitis. 1
• Drying agents (anticholinergics, antihistamines, decongestants, antihypertensives) are associated with 2.32-4.52 fold increased odds of dysphonia. 1
• Androgenic medications and testosterone exposure cause abnormally low pitch through hormonal effects. 2

Gastrointestinal Causes

• Gastroesophageal reflux disease and laryngopharyngeal reflux contribute to chronic laryngitis, though not all reflux patients develop dysphonia. 1
• Eosinophilic esophagitis can cause dysphonia through inflammatory mechanisms. 1

Rheumatologic and Autoimmune Causes

• Rheumatoid arthritis, Sjögren's syndrome, sarcoidosis, amyloidosis, and granulomatosis with polyangiitis all can cause dysphonia through laryngeal involvement. 1, 6

Age-Related Considerations

• Pediatric populations show 23.4% prevalence of dysphonia at some point, with higher rates in boys aged 8-14 years. 1
• Elderly patients (>65 years) have substantially higher prevalence, with vocal fold bowing and unilateral vocal fold paralysis being the most common causes, followed by benign lesions, voice tremor, and spasmodic dysphonia. 1, 5

Occupational Risk Factors

• High vocal demand occupations (singers, teachers, legal professionals, telemarketers, aerobics instructors, clergy, coaches) have increased dysphonia likelihood. 1
• Teachers specifically have 20% absenteeism rates due to dysphonia, with $2.5 billion annual economic impact in the United States. 1

Critical Pitfall to Avoid

Delaying laryngoscopy beyond 4 weeks in persistent dysphonia can change the diagnosis in 56% of cases initially labeled as "acute laryngitis," potentially missing vocal fold paralysis, benign lesions, or laryngeal cancer. 2, 7 Laryngoscopy should be performed within 4 weeks if symptoms persist, or immediately if red flags exist (tobacco use, neck mass, recent surgery, progressive dysphagia, stridor). 2, 7