Voice Changes: Causes and When to Worry

How the voice works

Your voice is made by two vocal folds (vocal cords) in the voice box (larynx). Air from the lungs makes them vibrate hundreds of times a second. Anything that changes their shape, stiffness, closure or nerve control changes the voice. Swelling makes the voice deeper and rough. A growth stops the folds meeting, making it breathy. A weak nerve can leave one fold not moving at all.

Types of voice change

Common causes of voice changes

Acute laryngitis

Laryngitis is swelling of the vocal folds, usually from a viral cold or from shouting, singing or talking loudly. It causes hoarseness or temporary voice loss, often with a sore throat and cough, and settles within 1 to 2 weeks.

Voice overuse and vocal fold lesions

• Vocal cord nodules: callus-like bumps on both folds from repeated strain, common in singers, teachers, coaches and children who shout. The voice is hoarse and tires quickly
• Vocal cord polyps and cysts: usually on one side, sometimes after a single episode of shouting
• Vocal fold hemorrhage: sudden voice loss from a burst blood vessel during forceful voice use; it needs voice rest and prompt assessment

Reflux

Acid and enzymes from the stomach can irritate the larynx (laryngopharyngeal reflux), causing hoarseness worse in the morning, throat clearing, a lump-in-the-throat feeling and chronic cough, often without heartburn.

Smoking, irritants and dryness

Smoking causes chronic swelling (Reinke's edema), deepening the voice, and is the main risk factor for laryngeal cancer. Inhaled steroid medicines for asthma, dry air, dehydration, alcohol and allergies also affect the voice.

Muscle tension dysphonia

Muscle tension dysphonia is a voice that sounds strained or tight because the throat muscles are overworking, often after a cold or during stress. The vocal folds look normal. Voice therapy is very effective.

Aging voice

With age, the vocal folds can thin and lose bulk (presbyphonia), producing a weaker, breathier, higher voice in men and lower voice in women.

Hormonal changes

Voice deepening in boys at puberty is normal. Hypothyroidism, menopause, testosterone therapy and anabolic steroids can also lower the voice.

Serious causes not to miss

• Vocal cord paralysis: damage to the recurrent laryngeal nerve, from thyroid, neck or heart surgery, intubation, a viral infection, or a tumor in the neck or chest (including lung and thyroid cancer). The voice becomes breathy and weak, and drinking may cause coughing
• Laryngeal cancer: persistent hoarseness in a smoker or heavy drinker, sometimes with a sore throat, ear pain, swallowing difficulty or a neck lump. Caught early, cure rates are high
• Neurological conditions: Parkinson's disease (soft, monotone voice), stroke, ALS, multiple sclerosis, myasthenia gravis (voice weakens as you talk) and spasmodic dysphonia (strangled, breaking voice)
• Recurrent respiratory papillomatosis: wart-like growths on the vocal folds caused by HPV

When to worry about a voice change

Guidelines recommend having the larynx examined if hoarseness lasts more than 4 weeks, or sooner if you:

• smoke or drink heavily
• recently had neck or chest surgery or a breathing tube
• have trouble swallowing or breathing, cough up blood, or have a neck lump or ear pain
• depend on your voice for work

How a voice change is diagnosed

An ENT (ear, nose and throat) specialist will ask about the voice change, voice use, smoking, reflux, surgery and other symptoms, then look at the vocal folds with laryngoscopy: a thin camera passed through the nose or mouth, done in the clinic. Stroboscopy uses flashing light to show vocal fold vibration in slow motion. Depending on findings, you may need a biopsy, CT scan of the neck and chest, thyroid tests or neurological assessment.

Treatment for voice changes

Home care for short-term hoarseness

• Rest your voice, but avoid whispering, which strains the folds more than soft speech
• Drink plenty of water and breathe humidified air or steam
• Avoid smoking, smoky rooms and alcohol
• Treat a cough and throat clearing, which bang the folds together
• Use lozenges for throat comfort

Medical treatment

• Voice therapy with a speech-language pathologist: first-line for nodules, muscle tension dysphonia and many other problems
• Reflux treatment: lifestyle changes and sometimes acid-reducing medicine
• Surgery: microsurgery for polyps, cysts and nodules that persist despite therapy, and for papillomas
• Injection or surgery to move a paralyzed vocal fold toward the middle and improve voice
• Botulinum toxin injections for spasmodic dysphonia
• Cancer treatment: radiotherapy or surgery, depending on stage
• Treating the underlying condition, such as hypothyroidism or Parkinson's disease

Frequently asked questions

What causes a sudden change in voice?

The commonest causes are viral laryngitis and shouting or singing. A sudden complete voice loss after forceful voice use may be a vocal fold bleed. Sudden voice change with facial droop or arm weakness can be a stroke and is an emergency.

When should I worry about hoarseness?

See a doctor if hoarseness lasts more than 4 weeks, or 2 to 3 weeks if you smoke, or straight away if it comes with difficulty breathing or swallowing, coughing up blood, a neck lump or follows neck surgery. These can signal vocal cord paralysis or cancer.

Can acid reflux change your voice?

Yes. Stomach contents reaching the larynx cause swelling that makes the voice hoarse, especially in the morning, with throat clearing and a lump-in-the-throat feeling. Many people have no heartburn. Lifestyle changes and sometimes medicine help.

How long does it take to get your voice back?

After a cold or overuse, most people recover their voice within 1 to 2 weeks with voice rest and hydration. Nodules and muscle tension problems improve over weeks to months of voice therapy. Hoarseness lasting more than 4 weeks needs examination.

Is whispering better than talking when you lose your voice?

No. Whispering can strain the vocal folds more than gentle, soft speech. Speak softly and briefly, or rest your voice, drink water and avoid throat clearing.