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Hoarseness is a difficult term to define because what may be considered hoarseness in one person may be normal in another. Singers and professional voice users generally have a heightened sensitivity to changes in the voice. Thus, hoarseness may be considered a change in voice quality.

The following "red flags" may indicate a need for visualization of the larynx and otolaryngologic consultation:

1. Hoarseness that persists.

2. Hoarseness that is associated with shortness of breath {this condition requires immediate evaluation).

3. Hoarseness associated with symptoms of aspiration or dysphagia.

4. Hoarseness in a patient with a history of tobacco.

5. Hoarseness associated with a neck mass.

Causes of hoarseness may be broadly classified into inflammatory, neoplastic, neurologic, endocrinologic, traumatic or congenital. The following cases illustrate some of the more common causes of hoarseness.

Vocal Cord Nodules. Vocal cord nodules are callus-like lesions on the anterior portion of the vocal cords caused by vocal abuse, such as that which occurs with yelling, screaming or excessive talking. Such nodules are common.

Laryngitis. Laryngitis is swelling and inflammation of the larynx. Acute episodes of laryngitis are usually secondary to viral or bacterial infection or recent voice abuse. Laryngitis is often associated with sore throat, cough.

Vocal Cord Polyps. Vocal cord polyps are benign overgrowths of the outer lining of the vocal cords. Although these polyps most commonly develop in persons who smoke, those who habitually abuse their voice and patients.

Vocal Cord Granulomas. Vocal cord granulomas are benign lesions on the posterior aspect of the vocal cords. They are most often caused by gastroesophageal reflux disease. They usually resolve after treatment.

Papillomas. Papillomas of the larynx are typically benign lesions caused by human papillomavirus that can cause symptoms ranging from hoarseness to complete airway obstruction. Treatment consists of laser ablation.

Malignancies. Premalignant and malignant lesions of the vocal cords and larynx are most often seen in persons who smoke and drink alcohol. The most common presenting symptoms include hoarseness, dysphagia for solid foods, odynophagia, otalgia (referred pain), dyspnea, neck mass and aspiration. Biopsy of the lesion is performed.

Additional Considerations. Other neu-rologic disorders that affect laryngeal function include stroke, Parkinson's disease, familial tremor and dystonias. Treatment depends on the severity of impairment and begins with speech and swallowing therapy. Dystonias (including spasmodic dysphonia) are often best treated with botulinum toxin injections.

It should also be noted that it is important for the physician to be alert for voice abnormalities in children. Hoarseness is common in this patient population and, as discussed earlier, is usually related to vocal abuse or vocal cord nodules. A child with chronic hoarseness should have the larynx visualized to rule out such disorders as papillomas, laryngeal cysts, webs and vocal cord paralysis. Appropriate evaluation for other disorders, such as velopalatal insufficiency, is crucial. Management with speech therapy and prosthodontics can be very effective.