It's a common symptom but can signal serious pathology. ENT GPSI Dr Rakesh Chopra offers his hints
1 History is paramount.
Ask about upper respiratory tract infections, chest infections, heavy smoking, reflux, profession and age. Even hobbies – such as singing on Sundays at the church – will point you in the right direction. Laryngitis is common – a history or URTI with a sore throat or a cough with a concurrent chest infection will often be evident. But history can be confusing in the older patient who is a smoker, so refer if hoarseness persists (see tip 4).
2 Characterise the patient's voice.
Study the patient's ‘vocal personality type' – the amount and style of voice use, recent voice use (such as screaming at a football match) and vocal environment, such as needing to raise their voice in a noisy classroom. Vocal nodules (sometimes called teacher's, screamer's, preacher's or hawker's nodules) are often a result of vocal misuse and this may be especially relevant in a young, non-smoking patient. Speech therapy is the cornerstone of treatment of vocal nodules.
3 Remember acid can reach up to the vocal cords.
There is a long list of head and neck symptoms related to gastro-oesophagealreflux disease (GORD). ‘Acid' laryngitis, posterior laryngitis, spastic dysphonia, chronic cough and brochospasm have all been linked with reflux. If there is a clear-cut history, there are no red flags and no worrying historical pointers, it might be worth trying a course of PPIs.
4 Always suspect malignancy.
Any unexplained hoarseness persisting for more than three weeks must be referred urgently, as per national guidelines.1
Personally, I prefer to refer to the head and neck team under the two-week rule with a chest X-ray on the way, rather than wait for X-ray results. Hoarseness is far more likely to be laryngeal than secondary to an underlying pulmonary cause.
5 Always consider any inhaler use and technique.
Hoarseness is a well-known side-effect of poorly used inhalers so technique and inhaler hygiene are important to check. Sometimes a change of device will do the trick. Thrush affecting the vocal cords can be a possible cause in high-dose steroid inhaler users.
6 Consider spasmodic dysphonia.
You may see a patient with dysphonia rather than a hoarse voice, and this can be of two kinds:
• a strained, strangulated kind of voice
• a whisperer variant.
These may be symptoms of an important group of disorders called spasmodic dysphonia, which often goes unrecognised. This was initially considered to be a ‘functional' voice disorder but now has been reclassified as a neurological disorder in the US by the National Institute of Neurological Disorders and Stroke and the American Academy of Neurology.
For a demonstration watch the video below.
7 Vocal-cord paralysis may be a possibility.
The character of the hoarseness is an important clue. A weak, breathy, wasted voice, or being unable to speak loudly or project the voice are all clues, as are those patients who tend to aspirate or mention that liquids ‘go the wrong way down'. These should draw your attention to possible vocal-cord paralysis. There are various causes, but it can be idiopathic in up to 11% of cases. Examine for neurological dysfunction, such as Parkinson's disease or multiple sclerosis.
8 Consider lung or cardiac pathology.
Because the recurrent laryngeal nerve takes an excursion into the chest before returning towards the neck – hence ‘recurrent' – it can be affected by thoracic pathology. The left nerve loops around the arch of aorta and the right nerve around the subclavian artery. Ortner's syndrome is a clinical entity with hoarseness caused by a left recurrent laryngeal nerve palsy caused by cardiac disease.
9 Check for any recent surgery.
Any surgical procedure on the neck or the thorax can put the recurrent laryngeal nerves at risk. Also, intubation during general anaesthesia can be a possible cause of direct trauma to the larynx – so postoperative hoarseness could be related to this.
10 Hypothyroidism is a known cause of hoarseness.
There may be myxomatous change in the vocal cords giving rise to hoarseness, and as hypothyroidism is a very common condition, it is well worth remembering. There are various associations with hypothyroidism:
• deepened voice pitch
• voice fatigue and weakness
• dryness of the throat
• slow and hesitant speech.
Dr Rakesh Chopra is a GPSI in ENT in St Helen's, Merseyside
Competing interests None declared
Dr Chopra is running the NB Medical ENT in Primary Care Course on Thursday 24th June 2010 at the Brunei Gallery in London.
You can find out more about the course by clicking the link above or calling 0191 3853030.Swollen vocal cords (inverted V-shape on left) in patient with laryngitis Laryngitis Spasmodic dysphonia