Hoarseness and Voice Change

Introduction

Hoarseness, or dysphonia, is an altered voice quality - typically described as breathy, rough, strained or reduced in volume or range - and reflects a disturbance somewhere along the pathway from the vocal cords themselves to the nerves that control them.¹ It is extremely common as a short-lived symptom of a viral URTI, but persistent hoarseness is a different clinical problem entirely.

The single most important rule in this topic is that hoarseness lasting more than 3 weeks needs the vocal cords to be directly visualised, because among the many benign causes sits laryngeal cancer, for which hoarseness is very often the first and, for a time, only symptom.

Aetiology

Causes are usefully split by duration. Acute hoarseness (under 3 weeks) is overwhelmingly due to viral laryngitis accompanying an upper respiratory tract infection, or vocal strain/overuse (shouting, singing, prolonged speaking).¹

Chronic or persistent hoarseness has a wider differential, and this is the group that needs specialist assessment:

Vocal cord palsy: a nerve with a long course

Vocal cord palsy deserves particular attention because the recurrent laryngeal nerve's anatomy directly shapes the differential. On the left, the nerve loops under the aortic arch before ascending to the larynx; on the right, it loops under the subclavian artery - both courses take the nerve through the neck and upper chest, meaning pathology anywhere from the skull base to the aortic arch can cause a palsy.^1,2

• Thyroid disease: malignancy, or iatrogenic injury during thyroid or parathyroid surgery - one of the most common identifiable causes
• Lung cancer: particularly an apical (Pancoast) tumour or mediastinal lymphadenopathy compressing the nerve
• Oesophageal cancer
• Thoracic aortic aneurysm, stretching the left recurrent laryngeal nerve
• Cardiothoracic or neck surgery, including cardiac and oesophageal procedures
• Idiopathic, presumed viral, in a significant proportion of cases once other causes are excluded

A unilateral palsy typically causes a breathy, weak voice as the affected cord cannot meet the midline, while bilateral palsy is rarer but far more dangerous, as both cords may sit close to the midline and compromise the airway, sometimes presenting with stridor rather than a voice change.

Clinical features and history

Establish duration (the pivotal question), whether onset was sudden or gradual, occupational voice demands, smoking and alcohol history, and reflux symptoms (heartburn, regurgitation, a sour taste, or excessive throat clearing).¹ Ask specifically about associated dysphagia, odynophagia, referred otalgia, unintentional weight loss, and haemoptysis, and examine for a neck lump - all of these reframe the case towards malignancy.

Examination and investigations

Flexible nasendoscopy, performed by ENT, is the key investigation for any hoarseness persisting beyond 3 weeks, allowing direct visualisation of the vocal cords to identify nodules, polyps, a mass lesion, or reduced/absent cord movement consistent with a palsy.¹ Stroboscopy provides more detailed assessment of the vibratory pattern of the vocal cords where subtle pathology is suspected.

Examine the neck for a mass or lymphadenopathy, and perform a full cranial nerve examination. If a vocal cord palsy is found, imaging must cover the nerve's entire course: CT or MRI from the skull base to the aortic arch, alongside a chest X-ray, to look for a causative lesion. Thyroid function tests are checked if hypothyroidism is a plausible contributor.

Differential diagnosis summary

Beyond the causes above, consider neurological causes of voice change (Parkinson's disease, myasthenia gravis - look for fatigability), and functional/psychogenic dysphonia, a diagnosis of exclusion once organic pathology has been ruled out by laryngoscopy.

Management

Acute viral laryngitis is managed with voice rest, adequate hydration, and simple analgesia, and resolves within 1-2 weeks without specific treatment. Smoking cessation advice should be offered at every opportunity, since smoking underlies several chronic causes.¹

Vocal cord nodules and polyps are managed first line with speech and language therapy (voice therapy), which addresses the vocal overuse or technique driving the lesion; surgical removal is reserved for those that persist despite an adequate trial of therapy. Laryngopharyngeal reflux is managed with a trial of a proton pump inhibitor alongside lifestyle measures (weight loss, avoiding late meals, reducing caffeine and alcohol).

Vocal cord palsy management addresses the underlying cause where one is found and identifiable. For a persistent unilateral palsy causing a poor voice or aspiration, speech and language therapy and, if needed, surgical medialisation (injection medialisation or thyroplasty) bring the paralysed cord closer to the midline to improve voice and swallowing. Bilateral palsy is a different problem, potentially threatening the airway, and is managed as described in the airway compromise article.

Reinke's oedema requires smoking cessation as the essential first step, with surgery (cordectomy/stripping) considered for severe or persistent cases. Laryngeal cancer management is covered in detail in the head and neck cancer article.

Complications

• Aspiration, particularly with bilateral vocal cord palsy or significant glottic incompetence
• Airway compromise with bilateral vocal cord palsy
• Occupational and social impact of a persistent voice disorder, particularly for professional voice users
• Delayed diagnosis of laryngeal or other malignancy if the 3-week rule is not applied

Red flags

Prognosis

Acute viral laryngitis resolves fully within 1-2 weeks in almost all cases. Vocal cord nodules respond well to voice therapy in the majority of patients, avoiding the need for surgery. Vocal cord palsy prognosis depends on the underlying cause and whether it is treatable or reversible, with idiopathic palsies having a reasonable chance of spontaneous recovery over several months.¹

Laryngeal cancer detected early, while confined to the vocal cord (early glottic cancer), has an excellent prognosis with high cure rates - which is precisely why hoarseness lasting more than 3 weeks should never be dismissed without a laryngoscope having looked at the cords.