Hoarseness can be defined in many ways. It usually means that your voice sounds different. It could be breathy, raspy, strained, softer in volume, or lower or higher in pitch. Hoarseness usually accompanies some type of irritation or inflammation of the voice box or larynx. The most common reasons we have hoarseness could be due to an upper or lower respiratory infection, allergies, exposure to toxic chemicals or gasses, or voice abuse. In this article, we will discuss what long term or chronic hoarseness signals.

Many ENT doctors may have a strong suspicion of what is causing your hoarseness even before you are examined.

How do I speak?

Our voices are a coordinated effort from the sound and resonance produced by our vocal cords, the structures in our mouth and throat and nose, and our conscious efforts to control what the sounds we produce. We can mouth words, but without some type of sound production, nothing comes out.

People who are choking on food are an illustration of how we speak.

They can mouth the words, even try to push air through their vocal cords, but although they are trying to say something, in this case cry for help, they cannot speak.

Another example are patients who have had cancer in their voice box. In many instances, the air that they breathe is diverted away from their vocal cords, if they even have the use of them anymore. One solution to get them to speak again is to offer them an artificial sound box to make sounds so they can craft speech.

The importance of the voicebox is to create sounds. The creation of speech is up to us and how we use our mouth, nose, and throat to make the sounds into something others can understand.

Sound modulation or the quality of your voice includes pitch, volume and tone may have a lot to do with the size and shape of your vocal cords, how they are moving or not moving, and the resonating cavities such as your nose, nasal cavity, and your sinuses.

What should I do if my voice stays hoarse?

If your voice still sounds different after about three weeks, particularly if you are recovering from a recent respiratory illness, you should see your doctor.

Another important consideration is that if you have hoarseness that is accompanied by difficulty swallowing, a lump in your neck or throat, pain with swallowing or speaking, it may be that the hoarseness is a signal for something else going on.

What makes my voice sound different?

Your vocal cords are finely tuned instruments, and they are uniquely specific to you. Long term or chronic hoarseness or laryngitis means there is some type of alteration of the voicebox itself. Many times, it is an irreversible change in the lining overlying the vocal cord or vocalis muscles.

The patterns of changes to the vocal cords can vary. Reactive or reparative processes can happen depending on the causes, which may include:

  • Inflammation.
  • Edema (swelling).
  • Hyperemia (redness).
  • Infiltration and proliferation of the mucosal lining depending on the response.

The inflammatory process can damage the fine lining of the voicebox, particularly the back or posterior wall. This is where the opening is to our esophagus. The technical term for this area is the cricopharyngeal area and muscles control it.

Gastroesophageal reflux, for example, can affect this region.

The posterior area of the voice box also plays the role of moving mucous out of the tracheobronchial tree. There are fine hair-like cells or cilia that move in waves or beat. If the cilia become impaired, the resultant mucus stays on the back wall of the voicebox, and it can provoke a cough.

Mucus that stays on the vocal cords can also cause them to freeze or stop working. This is called laryngospasm and it can be life-threatening. Choking on food as described previously or a response to a noxious chemical are good examples of laryngospasm.

What will my doctor use to figure out why I am hoarse?

If your doctor has treated you for an upper or lower respiratory illness and you still remain hoarse or you have another problem such as a neck mass, it is likely that you need to see an ENT specialist.

Laboratory studies will be obtained, including:

  • Complete blood count.
  • Sputum cultures and sensitivities for bacteria, viruses, and fungi.
  • Culture and sensitivities of a swab of your nose or throat.
  • Serologic markers for autoimmune disorders.
  • Studies to rule out tuberculosis and syphilis, if indicated.

Imaging studies may be helpful, including:

  • Lateral plain neck Xray.
  • Chest Xray.
  • CT and MRI scans.
  • Barium swallow studies to evaluate the esophagus and stomach.

The single most valuable tool that your ENT doctor will use is direct laryngoscopy. It is performed either with a simple dental mirror and an intense light or by using more updated technology known as a flexible fiberoptic nasopharyngolaryngoscopy. This is a long, complicated word that means a thin tube with a light and usually a camera is used to examine the back of the throat and voice box.

In some cases, it is important for the patient to be anesthetized so that a direct laryngoscopy with a rigid laryngoscope for a more detailed examination may be performed which may include biopsy, cultures, and smears for identification of possible causative agents. Also, this is when other abnormalities such as vocal cord polyps or nodules can be assessed.

Another method of examining the voice box is using a videostrobe. This is used if a tumor or other abnormalities have been excluded from the diagnosis. This procedure can provide significant information regarding the characteristics of the vocal cord vibration and movement.

Key takeaways

Persistent hoarseness may signal many things, therefore it should not be ignored.

Supportive therapy such as hydration, steam inhalation, humidification, avoidance of pollutants or irritative substances such as those in the environment can be a first step.

Most importantly, a close look at the voicebox will lend clues as to the cause of the hoarseness. Some solutions may require minor surgery in addition to medications. In many cases, speech therapy and the way in which we use our voice can be vital as well.

References

Cleveland Clinic. Hoarseness.

Johns Hopkins. Hoarseness.

University of Pittsburgh. Hoarseness.

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