Hoarseness

Aka: Hoarseness, Laryngitis

1. Epidemiology
   1. Hoarseness is common, with a point Prevalence as high as 7% for those <65 years old
2. Pathophysiology
   1. Abnormal voice production (change in pitch, loudness or effort)
      1. Breathiness
      2. Harsh, rough or raspy voice
   2. Lack of smooth vocal cord approximation
      1. Laryngeal pathology
      2. Abnormal vocal cord mobility
   3. Usually caused by organic disorder (not functional)
3. Causes
   1. See Hoarseness Causes
4. Symptoms
   1. Abnormal voice quality (e.g. Breathy, Strained, Raspy, Weak)
5. History
   1. See Hoarseness History
6. Evaluation: Laryngoscopy Indications (see Laryngeal Examination)
   1. More than 4 weeks of Hoarseness despite specific management trials (see below)
   2. More than 2 weeks of symptoms and risk factors for Laryngeal Cancer
      1. Tobacco abuse
      2. Alcohol Abuse
      3. Gastroesophageal Reflux disease (esp. if longstanding or with Dysphagia)
      4. Hemoptysis
7. Management: Suspect benign causes (esp. in first 2 weeks of symptoms)
   1. See Acute Laryngitis
   2. See Chronic Laryngitis
   3. Consider Laryngoscopy if Hoarseness persists despite empiric management
   4. General measures: Vocal Hygiene
      1. Voice rest (do not whisper!)
      2. Avoid Tobacco, Alcohol and other irritants
      3. Consider humidifier
      4. Avoid raising voice volume
   5. Upper Respiratory Infection, allergy, or Voice Abuse
      1. Voice rest and symptomatic treatment
   6. Gastroesophageal Reflux symptoms (suggests Reflux Laryngitis)
      1. Trial on Proton Pump Inhibitor (expect improvement by 4 weeks)
   7. Inhaled Corticosteroid use
      1. Use spacer with Inhaler
      2. Gargle and rinse mouth (or drink water after)
      3. If using Fluticasone, Budesonide or Beclomethasone, consider substituting other Inhaled Corticosteroid
      4. Consider reducing or trialing off Inhaled Corticosteroid (expect improvement in 4 weeks)
   8. Underlying systemic or neuromuscular condition (e.g. Hypothyroidism, Parkinsonism)
      1. Treat the underlying cause
   9. Voice therapy indications (Behavior Modification training in 30-60 min weekly sessions for 8-10 weeks)
      1. Significantly vocal dysfunction
         1. Nonorganic Dysphonia
         2. Benign Vocal Fold Lesions
         3. Age-related vocal atrophy
      2. Preventive
         1. Vocalist, singer or public speaker
8. Management: Temporary voice restoration prior to performance
   1. Indications
      1. Professional singer or speaker and
      2. Vocal fold edema present by Nasolaryngoscopy
   2. Contraindications
      1. Vocal fold Hemorrhage, abrasion by Nasolaryngoscopy
   3. Preparations (not FDA approved)
      1. Voice rest is preferred
         1. Results in faster healing time
      2. Prednisone 40 mg PO given 4 hours prior to event
         1. Corticosteroids do not decrease healing time
         2. Not generally recommended
      3. Afrin sprayed directly on Larynx
   4. References
      1. Woodson in Rakel (2003) Conn's Therapy, p. 210
      2. Postma in Cummings (1998) Otolaryngology, p. 2064
9. References
   1. Dworkin (2008) Otolaryngol Clin North Am 41(2):419-36 [PubMed]
   2. Feierabend (2009) Am Fam Physician 80(4): 363-70 [PubMed]
   3. House (2017) Am Fam Physician 96(11): 720-8 [PubMed]