Hoarseness — Ankara

What is hoarseness?

The voice is produced when two vocal cords in the larynx vibrate in the airstream. Anything that disturbs that vibration changes the voice: swelling of the cords, a lesion on them, one cord failing to move, or the cords not closing fully.

In medicine this is called dysphonia. What people call hoarseness covers a wide range: a deeper voice, a voice that tires quickly, a breathy voice, or loss of voice altogether.

Hoarseness is a symptom rather than a disease. The cause can be as simple as an infection or as significant as involvement of the nerve supplying the vocal cords.

The commonest causes

Causes fall broadly into three groups: inflammatory, structural and neurological.

• Acute laryngitis — temporary swelling accompanying an upper respiratory infection. The commonest cause; it usually settles within a week or two.
• Voice misuse — shouting, prolonged loud speaking, singing with poor technique. Nodules or polyps can develop on the cords.
• Reflux — stomach contents reaching the larynx can irritate the cords. The diagnosis should not be made before the cords are seen.
• Vocal cord paralysis — one cord stops moving. Surgery in the neck or chest, thyroid surgery, or a mass in that region can affect the nerve.
• Smoking and alcohol — both cause lasting change in the cords and raise the risk of malignant disease.
• Age-related change — thinning of the cords can make the voice weaker and quicker to tire.

The treatments for these causes are entirely different from one another. The only way to tell them apart is to look at the vocal cords; it cannot be done by listening or by taking a history alone.

When not to wait

The 2018 updated guideline of the American Academy of Otolaryngology–Head and Neck Surgery sets two thresholds.

• Four weeks — if hoarseness has not resolved within that time, the vocal cords should be examined endoscopically. In the guideline's own terms, no patient should wait longer than four weeks before the larynx is examined.
• Regardless of duration — if a serious underlying cause is suspected, waiting is not appropriate. Features raising that suspicion include smoking and alcohol use, a neck mass, coughing blood, difficulty or pain on swallowing, weight loss, recent neck or chest surgery, recent intubation, and previous radiotherapy to the area.
• Professional voice users — teachers, lawyers, performers, call-centre staff. Assessment happens earlier in this group, because a delayed diagnosis also means loss of livelihood.

These points are not a diagnosis; they set the priority for examination.

The guideline's three clearest points

The same guideline is unusually direct about what should not be done. Three recommendations target the commonest mistakes in practice:

• No antibiotics before the cords are seen. Antibiotics have no role in isolated hoarseness.
• No corticosteroids before the cords are seen. They can mask the symptom temporarily and delay the diagnosis.
• No anti-reflux medication before the cords are seen. Reflux is a common cause, but treating on assumption can conceal another condition underneath.

The guideline applies the same order to imaging: in a patient whose primary complaint is hoarseness, CT or MRI should not be requested before the larynx has been visualised.

The shared reasoning fits in one sentence: treating on assumption carries needless risk of side effects and delays the correct diagnosis.

How is laryngoscopy done?

Laryngoscopy is how the vocal cords are seen. It is done in the clinic, either with a thin endoscope passed through the nose or with a mirror-optic through the mouth. It needs no general anaesthesia and takes a few minutes.

A local anaesthetic spray may be applied to the nose or throat beforehand. During the examination you will be asked to make a few sounds; cord movement can only be assessed while the voice is being used.

Findings are usually discussed at the same visit. If a suspicious lesion is seen, further assessment and any tissue sampling are planned separately.