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Hoarse voice

Hoarseness or change in the voice: What is laryngitis?

by Professor David Howard

The word hoarseness is usually used to describe a change in our voice. The change may be very different from one patient to another. The voice may have altered in its volume (loudness) and become weaker. It may have changed in quality becoming higher or lower (pitch). It may have become more strained, requiring more effort to speak, and may have altered in character. Different descriptions are used by patients to describe these changes in their voice which may have become more 'rough','raspy',”creaky','squeaky“, 'breathy', etc.

What causes hoarseness?         

There are many causes of hoarseness but most of them are not serious problems and get better quickly with some simple advice. Hoarseness is due to something altering the vocal folds (often called vocal cords) in our larynx (voice box), so that they are not working properly. The larynx lies in our neck at the top of the windpipe (trachea) from our lungs.

Normally, when we talk or sing our vocal folds come together and vibrate as we are breathing out. The vibration of the vocal folds produces sound which we turn into speech by using the rest of our throat, tongue, teeth and lips (all together known as the vocal tract). So, although hoarseness caused by a problem with our vocal folds is common, change in other structures, such as the tongue, can also alter our voice. If we have serious problems with our breathing this can affect the voice because we require normal expiration (breathing out from our lungs) to power the vocal fold vibration to produce sound.


Voice change is natural in children as they grow older, particularly in boys during puberty (usually between 10 and 15 years of age) as their larynx and its vocal folds increase in size.

The elderly

In our older age, beyond 70 years and more, our speaking and singing voices may naturally become changed and weaker but this happens gradually. A sudden change requires a visit to the doctor in most circumstances.

Causes: What is laryngitis?

Although there are many causes of hoarseness, the most common is a simple viral infection of our nose, throat, larynx and windpipe (all these areas together are called the upper respiratory tract). The commonest viruses are those which cause what we call a 'cold'. There are many types of these cold viruses and others too (like influenza and mumps) which can all infect our upper respiratory tract. When they produce swelling of the vocal folds in the larynx it alters our voice and this is laryngitis.

Overuse of the voice, shouting, or repeated throat clearing may cause swelling of the vocal folds and produce hoarseness. This swelling is more common in people who also smoke and drink. The swelling may become localised to certain areas of the vocal folds in the larynx, producing either nodules, polyps or Reinke’s oedema. These swellings can cause longstanding and more serious hoarseness requiring referral to hospital and assessment and treatment by speech and language therapists and laryngologists.

Reflux of acid from the stomach, often called gastro-oesophageal or laryngo-pharyngeal reflux, is thought to be an important factor in causing irritation of the vocal folds and larynx, producing hoarseness (particularly in overweight patients who are more prone to reflux).

Benign tumours (growths) and more serious malignant tumours (cancer) usually cause progressive worsening of the voice. Cancer of the larynx (voice box) occurs almost entirely in smokers and must be treated as early as possible. Early treatment gives excellent results. Delayed treatment is much more difficult and less successful. It is yet another major life-threatening cancer which can be almost (more than 95%) avoided by simply not smoking, or stopping as soon as possible (before 30 years of age). Anyone with a problem with hoarseness lasting longer than three weeks MUST see the family doctor. This is absolutely necessary for all smokers.

There are other rare causes of hoarseness such as paralysis of the important nerves which supply the larynx from the brain. These require investigation in hospital and may involve seeing a specialist other than an ENT specialist, such as a neurologist. Hoarseness may be part of a neurological disease such as Parkinson disease, motor neurone disease or stroke.

Direct damage to the neck and larynx - such as may occur sometimes in a serious road traffic or industrial accidents - may produce hoarseness and permanent voice change.

The medical term dysphonia means a change in the voice, including hoarseness, and the similar term aphonia means complete loss of voice (usually reduction to a tiny whisper).

How is hoarseness understood and evaluated by the doctor?

Your family doctor (GP) will listen to the story of your hoarseness and any other symptoms you have and will often know your family and medical history. The doctor may ask you a number of questions and examine your head and neck and other areas such as your chest, if it seems relevant. However it is important to remember that most cases of hoarseness are due to viral infections (which do NOT require antibiotics) or overuse of the voice . The problem will get better over a few days and your doctor may advise you to:

  • rest your voice and use it gently and sparingly
  • drink plenty of liquids, particularly water, and avoid alcohol, tea and coffee
  • stop smoking (preferably forever!)
  • take simple painkillers regularly if necessary (paracetamol or soluble aspirin), and/or
  • start or increase antacid medication if acid reflux is thought to be a factor in your case.

Why would a doctor refer me to an ENT/laryngologist?

Most patients with hoarseness do NOT have some damage or disease of the larynx, but instead have problems with the way they are using and often abusing their voice. They are often straining their voice in some way and may additionally be subjecting their larynx to the effects of cigarettes, alcohol, and/or caffeine.

Your family doctor may be concerned by your history, the length of time of your symptoms and possible causes for your hoarseness which do not fit in with a simple cause which will quickly get better. The doctor will refer you to the hospital so that you can have amore detailed assessment and any special examination and tests required. Your doctor will be more inclined to do this if you are a smoker, if you drink excessively or if you rely on your voice for your job (for example if you are a teacher, actor, singer, salesperson, or in a similar job).

Important factors for referral to hospital are:

  • if you have not had a viral infection (e.g. cold or influenza)
  • if you smoke or drink
  • if hoarseness lasts more than three weeks
  • if you have difficulty or pain on swallowing, any lumps in your neck, or have difficuly breathing or are coughing up blood.

What will happen if I need to go to the hospital to see a specialist? 

Usually you will be referred to an ENT clinic where an ENT surgeon who may specialise in throat problems (a laryngologist) will assess you. In many ENT departments in the UK nowadays the laryngologist works with a speech and language therapist and they will see you together in a specialist voice clinic . Here, they will have all the expertise and equipment required to examine your throat and larynx (voice box) and usually make an accurate diagnosis at this first visit. They can also decide immediately in most cases what is the best treatment for your problem.

If your hospital does not have a specialist voice clinic the ENT surgeon may see you and make a diagnosis before sending you either to a specialist centre or to a speech therapy department, if that is the treatment you require.

What does the examination of my larynx (voice box) require?

With you comfortably seated, the surgeon or speech therapist will pass a small narrow, highly flexible telescope (fibreoptic endoscope) through your nose and into the back of your throat. This gives us the most detailed view of your throat and larynx with its vocal folds. For almost every patient, an instant and accurate diagnosis is made. This examination also allows the speech therapist and surgeon to ask you to talk/sing/swallow so that they can see your larynx working. This examination in the clinic minimises the need for people to be admitted to hospital (as was necessary in the past) and most people only require a small amount of local anaesthetic to be placed in the nose. The examination is NOT painful and even children and the most nervous adults are not distressed under examination. 

After a diagnosis is made, what treatments are used for hoarseness?

Depending on the cause of your hoarseness or voice change, the following treatments may be necessary and these will be explained to you by your specialists. The majority of patients attending a voice clinic require treatment by a speech therapist, and surgery is only occasionally required and is often undertaken after, or in combination with, speech therapy.

Speech therapy

Speech and language therapists in the UK have detailed university and scientific training in all the complex aspects of the human voice. The therapy is aimed to restore the best possible voice for the patient. This begins with educating a patient in how to care for their voice (vocal hygiene) and helping the patient to understand the lifestyle factors and any stresses which have led to the hoarseness. Reduction or removal of these factors is often essential in restoring a good voice and the therapist is able to continuously monitor and measure the patients progress, while providing therapy.

Voice therapy may involve additional advice about posture and body position as well as breathing exercises. Voice exercises may be given that are specific to each patient, depending on the problem. Occasionally direct massage to the muscles of the neck around the larynx (manual therapy) is used to relax excessive tension in this area.

To be successful, this therapy requires the patient's understanding and cooperation, particularly for those patients who have had problems for many months or years and where factors such as smoking or alcohol abuse are in evidence.

Microlaryngoscopy (examination and operations on the larynx)

If the ENT or voice clinic examination shows a swelling or tumour in the larynx, usually on one or both of the vocal folds, then an examination and operation under a general anaesthetic may be required. This is called a microlaryngoscopy. This examination and any surgery are best undertaken once the patient has been assessed and advised what to do both before and after the surgery, includiing the immediate period after the operation and the long-term.

Microlaryngoscopy is done while the patient is comfortably asleep under full general anaesthesia. (This is explained to the patient upon admittance to the hospital.) While the general anaesthetic is being administered, the laryngologist passes special telescopes and laryngoscopes through the mouth and down the patient's throat into the larynx. The use of these finely-tuned instruments allows a clear view of the larynx; this view can be considerably magnified by additional used of a special operating microscope, which is the reason for the name: microlaryngoscopy. This procedure also enables the laryngologist to accurately assess any swellings and disease and in many cases to completely remove these with further specialised instruments or by means of a laser. The following are some of the swellings and diseases that require may require microlaryngoscopy:

  • Vocal Nodules. These common and relatively simple swellings of the vocal folds are usually diagnosed at the examination in the outpatient clinic. They do NOT usually need an operation. They will get better and disappear if the patient follows the instructions and advice of the Speech and Language Therapist. The patient should proceed to surgery on the advice of the therapist if conservative measures have not resolved the nodules, or there is any doubt as to whether they are the correct diagnosis.
  • Vocal polyps: Once a polyp has formed on a vocal fold it is rare that for it to resolve itself, even if the patient follows the speech and language therapist's advice. For this reason, polyps require removal by the laryngologist during the microlaryngoscopy. A polyp,a nd indeed any other tissue removed during microlaryngoscopy, is sent to the hospital histopathology laboratory so that it can be accurately examined by a specialist pathologist to be certain of the correct diagnosis.
  • Benign cysts, papillomas, and tumours: Cysts and benign tumours are both rare (there are different types which occur in both children and adults) but usually require removal for pathology examination and to treat the hoarseness successfully.
  • Malignant tumour (cancer) of the larynx: At microlaryngoscopy, the laryngologist can take a small portion of any cancer to send it to the histopathology laboratory for exact diagnosis.This is known as a biopsy. If the cancer is small enough (usually because the patient went early to their doctor when they became hoarse) iit may be possible to remove it all at this operation.

Unfortunately if the cancer is larger it may require treatment by radiotherapy (often 4-6 weeks of treatment) or an open operation through the skin of the neck to remove part (partial laryngectomy) or all (total laryngectomy) of the larynx. It cannot be emphasised enough that patients with hoarseness for more than 3 weeks must see their doctor urgently.

Summary: How can I prevent hoarseness?

  • Do not use your voice for too long or too loud. Do not scream and shout, particularly against background noise
  • Use a microphone when possible if you need to project your voice so that many people can hear you, particularly if you are a professional voice user such as a teacher, lecturer, singer, actor, or in a similar profession
  • Seek professional voice training
  • Do not continue straining your voice when it is hoarse or injured
  • If you smoke – STOP!!
  • Avoid things that dehydrate you such as caffeine (excessive amounts of tea/coffee) or alcohol. Drink plenty of water (particularly if you are using your voice for  long periods as, for example, a teacher, singer, actor, salesperson)
  • Avoid secondhand smoke
  • Humidify your home in a dry climate