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Hoarseness in Adults
Hoarseness in Adults
Hoarseness in Adults
STEVEN A. HOUSE, MD, and ERIC L. FISHER, MD, University of Louisville School of Medicine, Louisville, Kentucky
Hoarseness is a common presentation in primary care practices. Combined with other voice-related changes, it
falls under the umbrella diagnosis of dysphonia. Hoarseness has a number of causes, ranging from simple inflam-
matory processes to less common psychiatric disorders to more serious systemic, neurologic, or cancerous condi-
tions. Medication-induced hoarseness is common and should be considered. The initial evaluation begins with a
targeted history and physical examination, while also looking for signs of potential systemic etiologies. Treatment
should begin with voice rest, especially avoidance of whispering, and conservative management directed toward a
presumptive cause. For example, proton pump inhibitors are appropriate for hoarseness due to reflux, and proper
vocal hygiene is recommended for vocal abuse–related indications. In the absence of a clear indication, antibiotics,
oral corticosteroids, and proton pump inhibitors should not be used for the empiric treatment of hoarseness. Direct
visualization of the larynx and vocal folds, commonly mislabeled as vocal cords, should be performed within three
months if an etiology has not been determined or if conservative management has been ineffective. Patients who
experience symptoms lasting longer than two weeks and who have risk factors for dysplasia (e.g., tobacco use, heavy
alcohol use, hemoptysis) may require earlier laryngoscopic evaluation. Voice therapy is effective for improving voice
quality in patients with dysphonia if conservative measures are unsuccessful, and it can also be helpful for prophy-
laxis in high-risk individuals (e.g., vocalists, public speakers). Surgical management is indicated for laryngeal or vocal
fold dysplasia or malignancy, airway obstruction, or benign pathology resistant to conservative treatment. (Am Fam
Physician. 2017;96(11):720-728. Copyright © 2017 American Academy of Family Physicians.)
H
CME This clinical content oarseness is a common symp- or strangled vocal quality. It includes any
conforms to AAFP criteria tom in adults, with a lifetime change in pitch, loudness, or vocal effort
for continuing medical
education (CME). See
prevalence of 30% and a point that impairs vocal function. The presence of
CME Quiz on page 705. prevalence of 7% for adults 65 hoarseness warrants investigation to deter-
Author disclosure: No rel- years and younger. Most never seek treat- mine an underlying cause.3
evant financial affiliations. ment, with only 6% of patients present-
ing to a health care professional.1 However, Laryngeal Anatomy and Function
hoarseness still constitutes a common out- The larynx functions in vocalization, deglu-
patient concern and can significantly impact tition, and respiration. It consists of an
patients’ voice-related quality of life and inner, mucosal-lined soft tissue framework
limit their productivity.2 protected by cartilaginous and bony struc-
The term hoarseness is commonly used tures (Figure 1).4 Extending from tongue
to describe any change in voice but more base to trachea, it can be divided into three
specifically refers to a coarse, rough, raspy, sections: supraglottic, glottic, and subglot-
tic. The supraglottis, protected by the hyoid
bone and thyroid cartilage, ranges from the
BEST PRACTICES IN OTOLARYNGOLOGY: RECOMMENDATIONS tongue base to just above the true vocal folds
FROM THE CHOOSING WISELY CAMPAIGN (commonly mislabeled as vocal cords), and
contains the epiglottis, false vocal folds, and
Recommendation Sponsoring organization
arytenoids. The glottis, protected by the thy-
Do not perform computed tomography or American Academy of roid cartilage, extends inferiorly 1 cm below
magnetic resonance imaging in patients Otolaryngology–Head and the true vocal folds. The subglottis extends
with a primary complaint of hoarseness Neck Surgery Foundation
before examining the larynx. from the inferior glottis to just below the cri-
coid cartilage.
Source: For more information on the Choosing Wisely Campaign, see http://www. The larynx contains extrinsic and intrin-
choosingwisely.org. For supporting citations and to search Choosing Wisely recom- sic muscles innervated by two nerves
mendations relevant to primary care, see http://www.aafp.org/afp/recommenda
tions/search.htm. branching from the vagus on each side: the
superior laryngeal nerve and the recurrent
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SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
Examination of the larynx by direct or indirect laryngoscopy should be performed on patients with hoarseness C 3
lasting longer than two weeks without an apparent benign etiology.
In the absence of signs and symptoms suggestive of an underlying cause, antibiotics, oral corticosteroids, and C 3
proton pump inhibitors should not be used for the empiric treatment of laryngitis/hoarseness.
If laryngopharyngeal or gastroesophageal reflux is suspected, consider a trial of a high-dose proton pump C 26
inhibitor for three to four months.
Voice therapy is effective for improving voice quality and vocal performance in patients with nonorganic A 20
dysphonia.
Voice therapy is effective for treating benign vocal fold nodules, polyps, cysts, and granulomas. B 29-31
Vocal hygiene education is effective for treating patients with hoarseness. B 29, 32
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented
evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.
Superior
laryngeal
nerve Thyroid cartilage
Vocal fold
Oblique
arytenoid
muscle
Transverse
arytenoid
muscle
Inferior
laryngeal Cricothyroid
nerve muscles
Posterior
cricoarytenoid
muscle ILLUSTRATION BY STEVE OH
Cricoid cartilage
Figure 1. Laryngeal anatomy. (Left) Posterior view of larynx, and (right) cross-section of larynx from above.
Reprinted with permission from Feierabend RH, Malik SN. Hoarseness in adults. Am Fam Physician. 2009;80(4):364.
(or inferior) laryngeal nerve. The internal upward around the aortic arch on the left
branch of the superior laryngeal nerve enters and the subclavian artery on the right to
the supraglottis between the hyoid and thy- ultimately enter the glottis through the cri-
roid cartilage, and the external branch enters cothyroid membrane. The extrinsic muscles
the glottis laterally through the cricothyroid elevate and lower the position of the lar-
membrane. The recurrent laryngeal nerves ynx in the neck. The intrinsic muscles pro-
ascend lateral to the trachea after recurring duce fine movements of the vocal folds for
phonation, and except for the cricothyroid to create a wide range of sound waves, and
muscles, are innervated by the recurrent the positioning of other speech organs such
laryngeal nerves. as the lips, tongue, and soft palate modifies
The larynx produces sounds by forcing these waves to increase the range of sounds.
air through partially closed vocal folds to
create vibrations of the folds. The intrinsic Causes of Hoarseness
muscles control the tension of the vocal folds Dysphonia (i.e., voice impairment) can result
from any pathology affecting these complex
mechanisms of vocalization, but hoarseness
primarily results from vocal fold changes.
Table 1. Common or Important Causes of Hoarseness Causes of hoarseness can be grouped into
four categories: irritant/inflammatory, neo-
Inflammatory or irritant Neuromuscular and psychiatric
plastic, neuromuscular/psychiatric, and
Allergies and irritants Age-related vocal atrophy
(alcohol, tobacco)
associated systemic disease. Common and
Multiple sclerosis
Direct trauma (intubation) important causes are listed in Table 1.4
Muscle tension dysphonia
Environmental irritants Myasthenia gravis INFLAMMATORY AND IRRITANT CAUSES
Infections (upper Nerve injury (vagus or recurrent laryngeal nerve)
respiratory infection,
Parkinson disease
The most common cause of hoarseness in
fungal laryngitis) adults is laryngitis, which is classified as
Psychogenic (including conversion aphonia)
Laryngopharyngeal or acute or chronic. Acute laryngitis is a com-
gastroesophageal reflux Spasmodic dysphonia (laryngeal dystonia)
Stroke mon, self-limited condition lasting less
Medications
Associated systemic diseases than three to four weeks. Common causes
Vocal abuse
Neoplasia or physical Acromegaly include acute vocal strain or upper respira-
lesions Amyloidosis tory infection. Short-term vocal abuse (e.g.,
Benign vocal fold lesions Hypothyroidism singing, screaming) or protracted coughing
Dysplasia Inflammatory arthritis can cause microtrauma and focal vocal fold
Laryngeal papillomatosis Lupus edema. Hoarseness is often part of a constel-
Squamous cell carcinoma Sarcoidosis lation of upper respiratory symptoms caused
by viruses and less commonly by bacterial or
Adapted with permission from Feierabend RH, Malik SN. Hoarseness in adults. Am fungal sources.5 Allergic rhinitis is another
Fam Physician. 2009;80(4):365.
common cause of acute laryngitis.
Chronic laryngitis is diagnosed when
symptoms persist for more than three to four
Table 2. Medications That May Cause Hoarseness weeks. Long-term inhalation of irritants
(usually through smoking), reflux, chronic
Medication Mechanism of impact on voice
vocal strain, and postnasal drip are com-
mon causes. Irritation of vocal fold mucosa
Angiotensin-converting enzyme inhibitors Cough by reflux can be caused by laryngopharyn-
Antihistamines, diuretics, anticholinergics Drying effect on mucosa geal reflux (LPR) or gastroesophageal reflux
Antipsychotics, including atypical Laryngeal dystonia disease (GERD). Medications are another
antipsychotics
common cause of chronic laryngitis,6-9 par-
Bisphosphonates Chemical laryngitis
ticularly those classes listed in Table 2.3
Danazol, testosterone Sex hormone production/
utilization alteration
NEOPLASIA AND PHYSICAL LESIONS
Inhaled corticosteroids Dose-dependent mucosal irritation,
candidal or fungal laryngitis Vocal fold lesions may be benign or malig-
Warfarin (Coumadin), thrombolytics, Vocal fold hematoma nant. More common benign lesions include
phosphodiesterase-5 inhibitors Reinke edema (also known as polypoid chor-
ditis), cysts, pseudocysts, polyps, and nod-
Adapted with permission from Schwartz SR, Cohen SM, Dailey SH, et al. Clinical
practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3 ules (also known as midfold masses).10 Some
suppl 2):S9. benign lesions have a higher prevalence based
on factors such as age and sex (Table 3).10-13
722 American Family Physician www.aafp.org/afp Volume 96, Number 11 ◆ December 1, 2017
Hoarseness in Adults
Premalignant or malignant vocal fold nerve injury during neck, thyroid, or car-
lesions include laryngeal leukoplakia, dys- diothoracic surgery, but many times it is
plasia, and squamous cell carcinoma. Smok- idiopathic.16 Unilateral paralysis can also be
ing, alcohol abuse, LPR, and GERD are risk associated with infiltrating thyroid or apical
factors for more serious underlying causes lung cancers.12,13 Bilateral vocal fold paralysis
such as malignant lesions.3 Hoarseness alone is typically associated with bilateral thyroid
or other related symptoms (e.g., dysphagia, surgery or neck trauma resulting in bilateral
odynophagia, otalgia, hemoptysis, unilateral recurrent laryngeal nerve injury. Prolonged
throat pain) may be the initial presentation or traumatic endotracheal intubation can
of these lesions, particularly in middle-aged cause vocal fold inflammation and paralysis.
or older persons who smoke.3,14,15 Presbylaryngis, or age-related vocal atro-
phy, is increasingly common with an aging
NEUROMUSCULAR AND PSYCHIATRIC CAUSES population, and can mimic fold paralysis
Vocal fold paralysis is a common neurologic as laryngeal muscles atrophy despite intact
cause of hoarseness. Unilateral paralysis innervation.17 Less common neurologic
is typically caused by recurrent laryngeal causes include myasthenia gravis, Parkinson
Bilateral midfold masses Subepithelial fibrous thickening at Female, 18 to 39 years of age Vocal abuse
(includes nodules) vocal fold midpoint
Contact lesion (ulceration Mucosal irregularity over vocal Male, unilateral or bilateral Direct trauma (intubation),
or granuloma) process of arytenoid cartilage inhaled corticosteroid use,
LPR, vocal abuse
Leukoplakia White-appearing epithelia of vocal Male, older age (60 years and older) Benign leukoplakia, carcinoma,
fold dysplasia
Pseudocyst Translucent lesion on vibratory Female, 18 to 39 years of age, Vocal abuse, vocal fold paresis
margin unilateral
Reactive lesion Focal mucosal thickening in vocal Unilateral, contralateral lesion Trauma by contralateral vocal
fold midpoint fold lesion
Reinke edema (polypoid Proliferation of superficial mucosa Female, middle-aged (40 to 59 years) GERD, LPR, tobacco and other
chorditis) over entire length of one or both or older age (60 years and older), irritants, vocal abuse
vocal folds bilateral more common
Unilateral midfold masses Subepithelial fibrous thickening at Male, less common than bilateral Vocal abuse
(includes nodules) vocal fold midpoint
disease, amyotrophic lateral sclerosis, and hoarseness. Sarcoidosis and laryngeal amy-
multiple sclerosis. loidosis are rare etiologies that strain voice
Spasmodic dysphonia (or laryngeal dys- quality from infiltration of the vocal folds
tonia) is the episodic, uncontrolled contrac- and supraglottic structures.21
tion of laryngeal intrinsic muscles to create
a halting, strangled voice. Once considered Evaluation of Hoarseness
psychogenic because of its relation to stress, HISTORY AND PHYSICAL EXAMINATION
the underlying neuromuscular etiology The first step in evaluating hoarseness should
remains unknown.18 Considered neuropsy- be assessing vocal quality, speech effort, or
chiatric in nature, muscle tension dysphonia signs of pain with speaking or swallowing,
results from excessive tension of the intrinsic followed by the history, including specific
or extrinsic muscles, and is associated with changes in vocal quality (Table 4).4 Tim-
lack of breath control and stress.19 Psychi- ing, onset, duration, and exacerbating or
atric or functional voice disorders include remitting factors can be key to determining
functional dysphonia, laryngeal conversion the etiology. The presence of any associated
disorder, paradoxical vocal fold motion, and symptoms, especially for GERD, LPR, or
malingering. Functional dysphonia occurs postnasal drip, should be elicited. Symp-
in patients with job-related chronic vocal toms of LPR include dysphagia, burning in
stress without organic cause. Conversion the throat, globus sensation, throat clearing,
disorder and paradoxical fold motion are or a sensation of postnasal drainage. GERD
psychogenic responses to stress.20 and LPR can occur together or separately. A
review of medications is imperative because
ASSOCIATED SYSTEMIC DISEASES multiple drug classes have been associated
Less commonly, hoarseness occurs sec- with dysphonia9 (Table 2 3). Acute onset is
ondary to systemic illnesses. Autoimmune more suggestive of infection, inflamma-
diseases, such as inflammatory arthritis tion, injury, or vocal abuse (e.g., singing or
and lupus, can affect the cricoarytenoid screaming at a sporting event or concert),
joints. Endocrine disorders, including whereas a chronic or progressive change in
hypothyroidism and acromegaly, can cause phonation can indicate more severe illness.
724 American Family Physician www.aafp.org/afp Volume 96, Number 11 ◆ December 1, 2017
Hoarseness in Adults
Hemoptysis Carcinoma
History of smoking or tobacco use Carcinoma, chronic laryngitis, leukoplakia, Reinke edema
Recent head, neck, or chest surgery Vagus or recurrent laryngeal nerve injury
Recent intubation or laryngeal procedure Direct trauma with vocal fold paralysis
GERD = gastroesophageal reflux disease; LPR = laryngopharyngeal reflux; URI = upper respiratory infection.
Adapted with permission from Feierabend RH, Malik SN. Hoarseness in adults. Am Fam Physician. 2009;80(4):367.
Findings Etiologies
reliable tests for diagnosing LPR. Videostro- as using a spacer, may be tried if dysphonia
boscopy, which uses strobe lighting during develops, and the corticosteroids can be dis-
laryngoscopy, can further visualize mucosal continued or given at a reduced dosage if the
vibration disorders (e.g., scar, sulcus) if con- hoarseness fails to resolve with these simple
ventional laryngoscopy is inconclusive.22,23 measures.9
Speech-language pathology offers percep- Voice therapy, or voice training, is strongly
tual, acoustic, and aerodynamic evaluations recommended for patients with hoarseness
if examination and imaging are insufficient who have significantly impaired vocal qual-
for making a diagnosis.24 ity of life, especially those with dysphonia
of nonorganic origins, benign vocal fold
Treatment lesions, or age-related vocal atrophy.3,20,24,29-32
Voice rest, especially the avoidance of whis- It can also be preventive in high-risk indi-
pering, is essential for the treatment of viduals such as vocalists and public speak-
hoarseness. Neither antibiotics nor corti- ers.12,29 Therapy regimens consist of vocal
costeroids should be routinely prescribed behavior modification to reduce laryngeal
empirically.3,25 A three- to four-month regi- trauma during weekly 30- to 60-minute ses-
men of high-dose proton pump inhibitors sions for eight to 10 weeks. Compliance with
should be prescribed only if the history indi- vocal hygiene (e.g., avoiding irritants and
cates GERD or LPR, or if signs of chronic alcohol, using a humidifier, controlling vocal
laryngitis are visualized.3,26,27 Inhaled cor- volume, limiting large or spicy meals), vocal
ticosteroids, notably fluticasone (Flovent), and physical exercises, and behavior change
budesonide (Rhinocort), and beclometha- are imperative.29,32
sone, can cause dysphonia in up to 58% of Surgical intervention is needed for dys-
persons, more so in women (3:2 ratio) and plastic or malignant lesions, airway obstruc-
individuals older than 65 years.9,28 Gargling, tion, or benign lesions (e.g., nodules, polyps,
rinsing the mouth, or drinking water, as well cysts) that do not respond to conservative
726 American Family Physician www.aafp.org/afp Volume 96, Number 11 ◆ December 1, 2017
Hoarseness in Adults
Initial Assessment and Management of Hoarseness
Hoarseness present > two weeks?
No Yes
History of recent vocal abuse or symptoms Risk factors for or symptoms of dysplasia
of upper respiratory infection or allergy? or carcinoma (e.g., smoking; heavy alcohol
use; long-standing gastroesophageal
reflux disease; dysphagia; hemoptysis)?
No Yes
No Yes
Current use of inhaled corticosteroids?
Laryngoscopy Continue proton pump
inhibitor; laryngoscopy if
any recurrent hoarseness No Yes
No Yes
therapies. Botulinum toxin can be used for clinical trials, reviews, and clinical practice guidelines.
the management of adductor spasmodic dys- Additionally, Essential Evidence Plus, the Cochrane
Database of Systematic Reviews, the DynaMed database,
phonia.33 Vocal fold paralysis can be treated and the National Institute for Health and Care Excellence
with laryngeal reinnervation or vocal fold guidelines were used. Search dates: November 30, 2015;
medialization procedures.34 March 25, 2016; and May 9, 2017.
of the University of Louisville/Glasgow (Ky.) Family Medi- 18. Persaud R, et al. An evidence-based review of botuli-
cine Residency Program. num toxin (Botox) applications in non-cosmetic head
and neck conditions. JRSM Short Rep. 2013;4 (2):10.
ERIC L. FISHER, MD, is an assistant professor in the Depart- 19. Altman KW, Atkinson C, Lazarus C. Current and emerg-
ment of Family and Geriatric Medicine at the University of ing concepts in muscle tension dysphonia:a 30-month
Louisville School of Medicine, and assistant medical direc- review. J Voice. 2005;19(2):261-267.
tor at the University of Louisville/Glasgow Family Medicine 20. Ruotsalainen J, Sellman J, Lehto L, Verbeek J. Systematic
Residency Program. review of the treatment of functional dysphonia and
Address correspondence to Steven A. House, MD, Uni- prevention of voice disorders. Otolaryngol Head Neck
Surg. 2008;138(5):557-565.
versity of Louisville/Glasgow Family Medicine Resi-
dency Program, 1325 North Race St., Glasgow, KY 42141 21. Bartels H, et al. Laryngeal amyloidosis:localized versus
(e-mail: shouse@tjsamson.org). Reprints are not avail- systemic disease and update on diagnosis and therapy.
able from the authors. Ann Otol Rhinol Laryngol. 2004;113(9):741-748.
22. Chang JI, Bevans SE, Schwartz SR. Otolaryngology clinic
of North America:evidence-based practice:manage-
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