Hoarseness

What is Hoarseness?

Hoarseness or Dysphonia means a change in the sound of someone’s voice.

People suffering from hoarseness can experience a strained, husky or breathy voice.

They may also notice a difference in loudness and/or changes in how high or low their voice sounds (Pitch).

Changes in voice pitch are common in young children as they grow through puberty (voice “breaking”).

A complete loss of voice, resulting in only a whisper, is called Aphonia.

What Causes Hoarseness?

Normally when we talk/sing the vocal cords come together and vibrate. This creates a sound which we know as the voice. Hoarseness results from the vocal cords in the voice box (Larynx) not working properly. There are several causes of hoarseness, fortunately most are not serious and tend to go away after a short period of time. Common causes are:

  • A viral upper respiratory tract infection, causing the voice box lining to swell (Laryngitis)
  • Stomach acid/enzymes irritating the throat (Laryngopharyngeal Reflux)
  • A build-up of soft tissue (polyps) or thickenings (nodules) on the vocal cords. These can develop when the voice is used too much or too loudly for long periods of time (Singer’s Nodules). Vocal cord polyps are often related to smoking.
  • Problems with the strength of the lungs can also lead to a change in voice
  • Rarely a growth or tumour develops on the vocal cords and or voice box. These may be non-cancerous (benign) or cancerous (malignant).
  • Problems with movement of the vocal cords (paralysed vocal cords). One or both of the vocal cords may be paralysed if it’s nerve is affected by infection or tumour.

How is Hoarseness Treated?

A key question here is whether the hoarseness is constant or getting worse or does it come and go with periods of “normal” voice in between.

Intermittent mild episodes of hoarseness: In most cases this will settle by itself. To help relieve the symptoms one can:

  • rest the voice (but don’t resort to whispering which can make matters worse).
  • drink plenty of fluids (avoid too many fizzy drinks).
  • avoid alcohol.
  • avoid cigarette smoke.
  • take Antacids e.g Gaviscon if you get a build-up of acid in the throat.

Persistent and / or worsening hoarseness: People suffering from the following symptoms should seek urgent medical advice

  • prolonged hoarseness for more than two weeks
  • repeated spells of hoarseness without reason
  • prolonged sore throat or difficulty swallowing for more than two weeks

It is particularly important to see an ENT doctor especially if you are a smoker or drink more than the recommended amount of alcohol.

What will the ENT surgeon do?

The surgeon will examine the throat to help identify the cause of the hoarseness. This is done by passing a flexible telescope through the nose (Fibreoptic Endoscope). This examination is done at the time of your out-patient visit.

Depending on the clinical findings, the following treatments may be recommended:

Simple advice: As described above for intermittent mild hoarseness.

Voice therapy (Speech and Language Therapist): The majority of patients will have no structural abnormality identified. The problem with their voice will be related to the way they are using their voice i.e. they are ‘straining’ it in some way. In this case a voice therapist will be able to give advice or suggest exercises that might help the quality of the voice. Voice therapy may require more than one visit to the therapist.

Microlaryngoscopy: An operation to remove nodules, polyps and non cancerous (benign) tumours may be recommended if these are identified at the outpatients visit. This type of operation is usually done under general anaesthetic using a rigid telescope (Endoscope) and a microscope (to provide magnification). It can remove the problem in the case of polyps, nodules or cysts and will provide a piece of tissue for laboratory analysis (abiopsy). If a malignant (cancerous) tumour of the larynx is diagnosed by biopsy then further treatment will be planned at a multidisciplinary head & neck team meeting and discussed with the patient.

Possible treatment options for cancer are:

Radiotherapy: High energy X-rays are used to kill cancerous tumours on the vocal cords and voice box. Radiotherapy is usually provided by a clinical oncologist and usually involves daily treatments, 5 days of the week for approximately 6 weeks. Radiotherapy can cause a number of side effects which the surgeon/ oncologist will explain.

Surgery: This may involve removal of part (Partial Laryngectomy) or all of the voice box (Total Laryngectomy). This major surgery involves operating through the skin of the neck and may result in an opening for the windpipe in the front of the neck (Tracheostomy).

Alternatively, for some tumours surgery can be performed using a telescope (Endoscope) through the mouth, removing the tumour using a laser. This avoids the need for surgery through the neck. There is ongoing debate regarding the value of different forms of surgery and the surgeon will discuss what is best for the patient.

If surgery to remove all of the voice box is required (Total Laryngectomy) then there are several ways of allowing a patient to regain their speech. The commonest form is the use of a “speaking valve” inserted through the tracheostomy opening. The surgeon and the voice therapist will discuss this in detail and training will be given to help.

 

Summary

Hoarseness is very common and usually due to simple problems that get better quickly with simple pain killers, drinking water and rest.

Very occasionally however it can be a warning symptom that something more serious is wrong with the throat or voice box. This is especially important to remember in people who smoke and drink excess alcohol.