Hoarse Voice: Causes and When to Worry

What causes a hoarse voice

Your voice is produced when air from the lungs makes the two vocal cords vibrate hundreds of times a second. Anything that swells them, adds a bump to their surface, stiffens them or stops one from moving changes the sound.

Short-term (acute) hoarseness

• Viral laryngitis: the most common cause, with a cold, cough or sore throat. Usually clears within 1 to 2 weeks.
• Voice strain: shouting, cheering, singing or talking loudly for long periods.
• Coughing and throat clearing, which bang the vocal cords together.
• Inhaled steroid inhalers for asthma or COPD, which can irritate the cords or cause thrush. Rinsing after use helps.
• Croup in young children, with a barking cough.

Long-term (chronic) hoarseness

• Vocal cord nodules: callus-like bumps on both cords from repeated voice overuse. Common in singers, teachers, coaches and children who shout.
• Polyps and cysts: usually on one cord, sometimes after a single episode of strain.
• Reinke's edema: floppy swelling of the cords, almost always in smokers, producing a deep, gruff voice.
• Reflux: acid and stomach contents reaching the throat (laryngopharyngeal reflux) can irritate the larynx, with throat clearing and a lump-in-the-throat feeling. Heartburn is often absent.
• Muscle tension dysphonia: inefficient, strained use of the throat muscles, often after a cold or during stress.
• Smoking, vaping and heavy alcohol use.
• Allergies and postnasal drip.
• Aging: thinning of the vocal cords (presbyphonia) gives a weaker, breathier voice.
• Hypothyroidism, which can deepen and roughen the voice.

Nerve and neurological causes

• Vocal cord paralysis: damage to the recurrent laryngeal nerve, which controls the cords, causes a weak, breathy voice and sometimes choking on liquids. Causes include thyroid, neck, chest or heart surgery, lung or thyroid tumors, stroke and viral infections.
• Parkinson's disease: a softer, monotone voice.
• Spasmodic dysphonia: involuntary spasms causing a strained, broken voice.
• ALS and myasthenia gravis.

Growths and cancer

• Recurrent respiratory papillomatosis: wart-like growths from HPV.
• Laryngeal cancer: persistent hoarseness is often the first sign of cancer of the vocal cords, mainly in smokers and heavy drinkers over 50. Found early, it has a high cure rate.
• Cancers of the lung, thyroid or esophagus can affect the nerve to the vocal cords.

Clues to the cause

How hoarseness is diagnosed

US guidelines recommend that anyone hoarse for more than 4 weeks, or sooner if there is a serious concern, has their larynx examined. An ENT doctor will:

• ask about voice use, smoking, alcohol, reflux, surgery and other symptoms
• examine the head and neck for lumps
• look at the vocal cords with a thin, flexible camera passed through the nose (laryngoscopy), usually in the clinic with numbing spray
• use stroboscopy, a flashing light, to show how the cords vibrate

CT scans are used if a nerve problem or cancer is suspected. Guidelines advise against routine imaging or reflux medicines before the larynx has been looked at.

How to cure a hoarse voice at home

• Rest your voice: talk less and at a comfortable volume. Whispering strains the cords more than soft speaking, so avoid it.
• Drink plenty of water to keep the vocal cords moist.
• Breathe moist air: steam from a shower or a humidifier.
• Avoid smoke, alcohol and excess caffeine.
• Do not clear your throat repeatedly; sip water or swallow instead.
• Treat the cold: throat lozenges and pain relief such as acetaminophen (paracetamol) or ibuprofen, following the label dose.
• For possible reflux: avoid eating within 3 hours of bed, and limit fatty and spicy food.

Medical treatment

• Voice therapy with a speech-language pathologist is the main treatment for nodules, muscle tension dysphonia and many other voice problems.
• Surgery for polyps, cysts, papillomas, Reinke's edema and cancer, using fine instruments or lasers through the mouth.
• Injection or surgery to move a paralyzed vocal cord inward so the cords can meet.
• Botulinum toxin injections for spasmodic dysphonia.
• Stopping smoking, which is essential for Reinke's edema and reduces cancer risk.
• Reflux treatment if reflux is confirmed or strongly suspected.

Frequently asked questions

What causes a hoarse voice without a sore throat?

Hoarseness without pain is common with voice overuse, vocal cord nodules or polyps, reflux, smoking, allergies, aging, thyroid problems and vocal cord paralysis. Painless hoarseness lasting more than 4 weeks, especially in smokers, should be examined by an ENT doctor to rule out cancer.

How long does a hoarse voice last?

Hoarseness from a cold or shouting usually improves within a few days and clears within 2 weeks. If it lasts longer than 4 weeks, or you smoke and it lasts more than 2 to 3 weeks, see a doctor to have your vocal cords examined.

How can I get my voice back quickly?

Rest your voice by speaking softly and less, but do not whisper. Drink plenty of water, breathe steam, avoid smoke and alcohol, and stop throat clearing. There is no instant cure, but these steps help the swollen vocal cords recover within days.

Is a hoarse voice a sign of cancer?

Rarely, but it can be. Persistent hoarseness is often the first sign of cancer of the larynx, particularly in people over 50 who smoke or drink heavily. Most hoarseness has a harmless cause, but any hoarseness lasting more than 4 weeks should be checked.

Can acid reflux cause hoarseness?

Yes. Acid and stomach contents rising into the throat can irritate the larynx, causing hoarseness, throat clearing, a sensation of a lump and chronic cough, often without heartburn. Doctors usually examine the larynx before treating for reflux.