Posted by dkwinter

Source: AFP 2009 (Hoarseness in Adults)

     See Figure 1 for good anatomical image

See also:

     Croup vs Epiglottitis


Hoarseness: Abnormal vocal quality (breathy, strained, rough, raspy, high or low pitched)


Important history

  • Voice use/overuse
  • URI sx
  • Alcohol use
  • Tobacco use (incl. secondhand smoke)


Common or Important Causes of Hoarseness

  • Inflammatory or irritant
    • Allergies and irritants (e.g., alcohol, tobacco)
      • May be seen along with rhinitis and sinusitis
    • Direct trauma (intubation)
    • Environmental irritants
    • Infections (upper respiratory infection, including viral laryngitis)  TWO MOST COMMON
    • Inhaled corticosteroids (Fluticasone is particularly causative)
    • Laryngopharyngeal reflux
    • Vocal abuse TWO MOST COMMON
  • Neoplastic
    • Dysplasia
    • Laryngeal papillomatosis
    • Squamous cell carcinoma
  • Neuromuscular and psychiatric (Hoarseness is rarely the sole presenting symptom of degenerative neurologic conditions)
    • Multiple sclerosis
    • Muscle tension dysphonia
    • Myasthenia gravis
    • Nerve injury (vagus or recurrent laryngeal nerve)
    • Parkinson disease
    • Psychogenic (including conversion aphonia)
    • Spasmodic dysphonia (laryngeal dystonia)
  • Associated systemic diseases
    • Acromegaly
    • Amyloidosis
    • Hypothyroidism
    • Inflammatory arthritis (cricoarytenoid joint involvement)
    • Sarcoidosis


Findings and associated/suggested diagnoses

Finding Suggested diagnoses
Cough Allergy, tobacco and other inhaled irritants, URI
Dysphagia Carcinoma, inflammatory arthritis, laryngopharyngeal reflux
Heart burn Carcinoma, laryngopharyngeal reflux
Hemoptysis Carcinoma
History of heavy alcohol use Carcinoma, laryngopharyngeal reflux
History of smoking or tobacco use Carcinoma, chronic laryngitis, leukoplakia, Reinke edema
Odynophagia Carcinoma, inflammatory arthritis, URI
Palpable lymph nodes Carcinoma, URI
Professional voice user or untrained singer Vocal abuse
Recent head, neck, or chest surgery Vagus or recurrent laryngeal nerve injury
Recent intubation or laryngeal procedure Direct trauma
Rhinorrhea, sneezing, watering eyes Allergy, URI
Sensitivity to heat, spicy foods, other irritants Leukoplakia
Stridor, symptoms of airway obstruction Carcinoma, laryngeal papillomatosis
Throat clearing Allergy, inhaled corticosteroids, laryngopharyngeal reflux
Weight loss Carcinoma
Wheezing, other signs of asthma Allergy, inhaled corticosteroids



  • Conservative approach (acute, duration less than 2 weeks in duration, apparent benign cause)
    • If symptoms of GERD: may give short course of high dose PPI to see if hoarseness improves
    • Vocal hygiene
      • Air humidification
      • Avoidance of dust, smoke
      • Avoidance of shouting, speaking loudly for prolonged periods
    • Voice therapy
      • Refer to speech language pathologist patients whose occupation depends on singing or talking loudly for long periods
    • Dietary changes
      • Increase fluid intake
      • Avoidance of large meals
      • Excessive caffeine and alcohol use
      • Avoid spicy foods
  • Direct evaluation by Laryngoscopy (duration longer than 2 weeks; no apparent benign cause; suggestion of laryngeal cancer prompts laryngoscopy)
    • In absence of risk factor for laryngeal cancer, laryngoscopy may be deferred in some cases:
      • If patient taking inhaled corticosteroids, may consider drug holiday first.
      • If patient has poorly controlled hypothyroidism, may optimize treatment first.
    • If patient has poorly controlled GERD, should optimize regimen/do additional workup during/after laryngoscopy