Hoarseness is a rough, harsh, or raspy change in voice quality. It can result from infections, inflammatory lesions, or exudates of the larynx, laryngeal edema, compression or injury of the vocal cords, or recurrent laryngeal nerve dysfunction. Systemic disorders, such as rheumatoid arthritis, thoracic aortic aneurysm, and age-related atrophy of laryngeal muscles, may also cause hoarseness. Worsening factors include excessive alcohol intake, smoking, inhalation of noxious fumes, prolonged talking, and shouting.

Hoarseness can be acute or chronic:

• Acute hoarseness is often caused by infections or sudden vocal cord injury.

• Chronic hoarseness may result from vocal cord polyps, nodules, gastroesophageal reflux, or progressive laryngeal muscle atrophy.

History and physical examination

History

• Age and sex (laryngeal cancer most common in men 50–70 years)

• Onset and duration of hoarseness

• Voice overuse, recent fire exposure, inhalation injury

• Symptoms: sore throat, cough, dry mouth, dyspnea, dysphagia

• History of smoking, alcohol use, cancer, rheumatoid arthritis, or aortic aneurysm

Physical Examination

• Inspect oral cavity, pharynx, neck, cervical lymph nodes, and thyroid

• Assess tracheal position, tongue mobility, eye signs (Sjögren’s syndrome)

• Examine jugular and chest veins for distention (possible aortic aneurysm)

• Vital signs: fever, bradycardia

• Observe for respiratory distress: nasal flaring, stridor, intercostal retractions

• Auscultate lungs for crackles, rhonchi, wheezing; percuss for dullness

Medical causes

Other causes

• Inhalation injury: Burns, soot in sputum, cough, hoarseness, respiratory distress

• Surgical trauma or intubation: Temporary or permanent vocal cord paralysis

Special considerations

• Monitor for stridor, indicating possible bilateral vocal cord paralysis

• Hoarseness >2 weeks warrants indirect or fiber-optic laryngoscopy

• Evaluate for underlying systemic or airway pathology

Patient counseling

• Rest the voice; teach alternative communication methods

• Avoid alcohol, smoking, and secondhand smoke

• Gradually resume vocal activity under guidance

Pediatric considerations

• Congenital causes: Laryngocele, dysphonia plicae ventricularis

• Juvenile papillomatosis: Prepubescent boys

• Croup (laryngotracheobronchitis): Infants/young children; may cause partial/total airway obstruction

• Other causes: aspiration of liquids, foreign bodies, diphtheria (rare)

• Supportive care: voice rest, comfort, quiet environment, humidification

References

• Holtzman, M. J. (2012). Asthma as a chronic disease of the innate and adaptive immune systems responding to viruses and allergens. Journal of Clinical Investigation, 122, 2741–2748.

• Sato, S., & Kiyono, H. (2012). The mucosal immune system of the respiratory tract. Current Opinion in Virology, 2, 225–232.