Hoarseness

What hoarseness is

Your voice is made by the two vocal cords (vocal folds) in the voice box (larynx). As air passes, they vibrate hundreds of times a second. Anything that makes them swollen, stiff, uneven, or unable to meet in the middle changes the sound. Doctors call this dysphonia.

Hoarseness can sound:

• Rough or raspy: swelling or lesions on the cords
• Breathy: the cords not closing fully, as in paralysis
• Strained or strangled: excess muscle tension or spasmodic dysphonia
• Low or deep: swollen cords, as in smokers or hypothyroidism

Common causes

Acute laryngitis

The most common cause. A cold or other viral infection inflames the cords, often with sore throat and cough. It usually resolves within 1 to 2 weeks. See laryngitis.

Voice overuse

Shouting, singing, cheering or talking over noise for long periods causes temporary swelling. Teachers, singers, coaches and call center workers are at higher risk.

Reflux

Stomach acid reaching the larynx (laryngopharyngeal reflux) causes hoarseness, throat clearing, a lump feeling and chronic cough, often without heartburn.

Smoking and irritants

Smoking dries and inflames the cords and can cause chronic swelling (Reinke's edema) with a deep, husky voice. It is also the main risk factor for laryngeal cancer.

Other common causes

• Inhaled steroids for asthma, which can cause hoarseness and thrush in the throat. Rinsing after use and using a spacer helps
• Allergies and postnasal drip
• Dehydration and dry air
• Aging (presbyphonia), where the cords thin and the voice weakens

Can a vocal polyp cause hoarseness?

Yes. Vocal cord polyps are soft, fluid-filled or blood-filled growths, usually on one cord, that stop the cords meeting evenly and vibrating normally. They cause:

• rough, breathy or "double" hoarseness
• vocal fatigue and reduced range, especially for singers
• a feeling of something in the throat

They are usually caused by a single episode of vocal strain that bursts a small blood vessel, or by ongoing overuse, smoking and reflux. They are benign.

Treatment for a vocal polyp depends on size and type:

• Voice therapy with a speech-language pathologist to reduce strain. Small polyps sometimes shrink.
• Treating reflux and stopping smoking.
• Microlaryngeal surgery: removal under general anesthetic using a microscope, through the mouth, without external cuts. Most larger or blood-filled polyps need this.
• Voice rest for several days after surgery, followed by voice therapy to prevent recurrence.

See vocal cord polyp for more.

Polyps vs nodules vs cysts

See vocal cord nodules.

Serious causes

• Vocal cord paralysis: damage to the nerve controlling a cord, from thyroid, neck or chest surgery, a lung or thyroid tumor, viral infection or stroke. Causes a weak, breathy voice and coughing on liquids.
• Laryngeal cancer: persistent hoarseness is often the first symptom, especially in smokers and heavy drinkers. Early detection gives a high cure rate.
• Neurological conditions: Parkinson's disease (soft, monotone voice), spasmodic dysphonia, myasthenia gravis and ALS.
• Hypothyroidism: thickened cords and a deep, husky voice.
• Recurrent respiratory papillomatosis: HPV-related growths, in children and adults.

When to see a doctor for hoarseness

The American Academy of Otolaryngology guideline recommends a laryngoscopy (direct look at the vocal cords) if hoarseness does not improve within 4 weeks, or sooner if there is a serious concern such as:

• a history of smoking or heavy alcohol use
• recent neck, chest or thyroid surgery or intubation
• a neck lump, trouble swallowing, coughing blood or breathing problems
• a professional voice user with an urgent need

How hoarseness is diagnosed

An ear, nose and throat specialist (otolaryngologist) will ask about voice use, smoking, reflux, medicines, surgeries and how the voice has changed. They then examine the vocal cords with:

• Flexible laryngoscopy: a thin camera passed through the nose after numbing spray, done in the office in a few minutes
• Stroboscopy: a flashing light that shows the vibration of the cords in slow motion, useful for nodules, polyps, cysts and early cancer

Further tests may include CT of the neck and chest for vocal cord paralysis, biopsy of suspicious lesions, and thyroid blood tests.

Guidelines advise against routinely prescribing antibiotics, steroids or reflux medicines for hoarseness before the cords have been examined, unless there are clear signs of reflux.

Treatment and voice care

• Voice rest: speak less and softly, but do not whisper, which strains the cords
• Hydration: drink plenty of water and use a humidifier in dry air
• Avoid irritants: stop smoking and vaping, limit alcohol and caffeine
• Treat reflux: avoid late meals, raise the head of the bed, and use acid-reducing medicines if advised
• Voice therapy: the main treatment for nodules, muscle tension dysphonia and many other voice problems
• Surgery: for polyps, cysts, papillomas, some paralysis and cancer
• Botulinum toxin injections for spasmodic dysphonia

Frequently asked questions

Can a vocal polyp cause hoarseness and what is the treatment?

Yes. A polyp stops the vocal cords vibrating evenly, causing a rough, breathy or strained voice. Treatment includes voice therapy, stopping smoking and treating reflux. Many polyps, especially larger or blood-filled ones, are removed by microsurgery through the mouth, followed by voice rest and therapy.

How long is too long to be hoarse?

Most hoarseness from colds or overuse resolves within 2 weeks. Hoarseness lasting more than 4 weeks should be checked by an ear, nose and throat specialist with a laryngoscopy. Smokers and people with other red flags should be seen sooner.

Is hoarseness a sign of cancer?

It can be. Persistent hoarseness is often the earliest symptom of laryngeal cancer, especially in people who smoke or drink heavily. Most hoarseness has harmless causes, but any hoarseness lasting more than 4 weeks needs the vocal cords examined.

Can reflux cause hoarseness?

Yes. Acid and stomach contents reaching the voice box can inflame the cords, causing hoarseness, throat clearing, cough and a lump feeling, often without heartburn. Lifestyle changes and, when advised, acid-reducing medicine can help.

Should I whisper if I am hoarse?

No. Whispering can strain the vocal cords more than soft, normal speech. If your voice is hoarse, rest it by talking less, speaking gently at a comfortable volume, drinking water and avoiding shouting and throat clearing.