It may come as a surprise to you the variety of medical conditions that can lead to voice problems. The most common causes of hoarseness and vocal difficulties are outlined below. If you become hoarse frequently or notice voice change for an extended period of time, please see your otolaryngologist (ear, nose and throat doctor) for an evaluation.
Acute laryngitis is the most common cause of hoarseness and voice loss that starts suddenly. Most cases of acute laryngitis are caused by a viral infection that leads to swelling of the vocal cords. When the vocal cords swell, they vibrate differently, leading to hoarseness. The best treatment for this condition is to stay well hydrated and to rest or reduce your voice use. Serious injury to the vocal cords can result from strenuous voice use during an episode of acute laryngitis. Since most acute laryngitis is caused by a virus, antibiotics are not effective. Bacterial infections of the larynx are much rarer and often are associated with difficulty breathing. Any problems breathing during an illness warrants emergency evaluation.
Chronic laryngitis is a non-specific term and an underlying cause should be identified. Chronic laryngitis can be caused by acid reflux disease, by exposure to irritating substances such as smoke, and by low grade infections such as yeast infections of the vocal cords in people using inhalers for asthma. Chemotherapy patients or others whose immune system is not working well can get these infections too.
Laryngopharyngeal Reflux Disease (LPRD)
Reflux of stomach juice into the throat can cause a variety of symptoms in the esophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), swallowing problems, a lump in the throat sensation or throat pain are common symptoms of stomach acid irritation of the throat. Please be aware that LPRD can occur without any symptoms of frank heartburn and regurgitation that traditionally accompany gastro esophageal reflux disease (GERD).
Voice Misuse and Overuse
Speaking is a physical task that requires coordination of breathing with the use of several muscle groups. It should come as no surprise that, just like in any other physical task, there are efficient and inefficient ways of using your voice. Excessively loud, prolonged and/or inefficient voice use can lead to vocal difficulties, just like improper lifting can lead to back injuries. Excessive tension in the neck and laryngeal muscles, along with poor breathing technique during speech leads to vocal fatigue, increased vocal effort and hoarseness. Voice misuse and overuse puts you at risk for developing benign vocal cord lesions (see below) or a vocal cord hemorrhage.
Common situations that are associated with voice misuse:
- Speaking in noisy situations
- Excessive cellular phone use
- Telephone use with the handset cradled to the shoulder
- Using inappropriate pitch (too high or too low) when speaking
- Not using amplification when publicly speaking
Benign Vocal Cord Lesions
Benign non-cancerous growths on the vocal cords are most often caused by voice misuse or overuse, which causes trauma to the vocal cords. These lesions (or bumps) on the vocal cord(s) alter vocal cord vibration and lead to hoarseness. The most common vocal cord lesions are nodules, polyps and cysts. Vocal nodules (also known as nodes or singer’s nodes) are similar to calluses of the vocal cords. They occur on both vocal cords opposite each other at the point of maximal wear and tear, and are usually treated with voice therapy to eliminate the vocal trauma that is causing them. Contrary to common myth, vocal nodules are highly treatable and intervention leads to improvement in most cases. Vocal cord polyps and cysts are the other common benign lesions. These are sometimes related to voice misuse or overuse, but can also occur in people who don’t use their voice improperly. These types of problems typically require microsurgical treatment for cure, with voice therapy employed in a combined treatment approach in some cases.
Vocal Cord Hemorrhage
If you experience sudden loss of voice following yelling, shouting or other strenuous vocal tasks, you may have developed a vocal cord hemorrhage. Vocal cord hemorrhage results when one of the blood vessels on the surface of the vocal cord ruptures and the soft tissues of the vocal cord fill with blood. It is considered a vocal emergency and is treated with absolute voice rest until the hemorrhage resolves. If you lose your voice after strenuous voice use, see your otolaryngologist as soon as possible.
Vocal Cord Paralysis and Paresis
Hoarseness and other problems can occur related to problems between the nerves and muscles within the voice box or larynx. The most common neurological condition that affects the larynx is a paralysis or weakness of one or both vocal cords. Involvement of both vocal cords is rare and is usually manifested by noisy breathing or difficulty getting enough air while breathing or talking. When one vocal cord is paralyzed or weak, voice is usually the problem rather than breathing. One vocal cord can become paralyzed or weakened (paresis) from a viral infection of the throat, after surgery in the neck or chest, from a tumor or growth along the laryngeal nerves or for unknown reasons. Vocal cord paralysis typically presents with a soft and breathy voice. Many cases of vocal cord paralysis will recover within several months. In some cases, however, the paralysis will be permanent, and may require active treatment to improve the voice. Treatment choice depends on the nature of the vocal cord paralysis, the degree of vocal impairment and the patient’s vocal needs. While we are not able to make paralyzed vocal cords move again, there are good treatment options for improving the voice. One option includes surgery for unilateral vocal cord paralysis that repositions the vocal cord to improve contact and vibration of the paralyzed vocal cord with the non-paralyzed vocal cord. There are a variety of surgical techniques used to accomplish this. Voice therapy may be used before or after surgical treatment of the paralyzed vocal cords, or it can also be used as the sole treatment.
Throat cancer is a very serious condition requiring immediate medical attention. Chronic hoarseness warrants evaluation by an otolaryngologist to rule out laryngeal cancer. It is important to remember that prompt attention to changes in the voice facilitate early diagnosis. Remember to listen to your voice because it might be telling you something. Laryngeal cancer is highly curable if diagnosed in its early stages.