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Dysphonia or Hoarseness

Don't you like medical terms? Dysphonia is the medical term for "hoarseness" that can further be termed a voice change that is characterized as raspy, coarse, and/or soft. Everyone knows hoarseness and probably you have diagnosed it in your own voice, as well as others with whom you converse. So the question is, what does it mean?

The Marvelous Anatomy of the Larynx

Our larynx is a marvelous part of the human anatomy. Often referred to as the "voice box," there are a number of structures that must work in a coordinated fashion so that we can eat, drink, breathe, and talk. This is all something we usually take for granted - until we can't eat, drink, breathe, or talk normally. When eating and drinking, the structures in the larynx keep food and liquids from entering the trachea or wind pipe. When breathing, the opening to the trachea opens and air goes in and out. Vocal folds known as "vocal cords" keep the trachea (for air to pass to and from the lungs) separate from the esophagus (for food and liquids to pass to the stomach and digestive track). When we talk, or phonate, the vocal cords open and vibrate with the air that passes through them making the sounds we have learned to use as words in language. All this is more or less automatic, meaning we really don't think about all the muscles, nerves, and other structures that must work so well together.

Incidence of Hoarseness

Hoarseness is a symptom of something gone amiss with this marvelous laryngeal system. As we age, the incidence of persistent hoarseness increases from around one percent of the population under 70 to 2.5 percent for those over 70. The vocal cords do not vibrate normally and produce hoarseness. Hoarseness is a symptom of some underlying problem (see section below). The problem usually is an infection (viral or bacterial) that inflames the larynx and its structures thus interfering with the vocal cords. There are other causes such as smoking, gastric reflux, trauma (for example, an endotracheal tube during surgery), neoplasm (benign or malignant), thyroid disease, amyloidosis, and certain neurological diseases. A common functional cause is shouting or talking for prolonged periods.

The irritated laryngeal tissues react to the irritant and edema, ulcers, and granulomas may form. The normal function of the throat clearing cilia can be damaged and the result is a feeling of needing to clear the throat. The repeated throat clearing and/or coughing can further injure the delicate tissues of the larynx.

There are a lot of causes of hoarseness, and if it persists for more than a few weeks, it is time to see a physician. Either your primary care physician or an ear, nose, and throat (ENT) specialist is the person to see to find out the cause of the persisting (chronic) hoarseness.

Causes of Acute & Chronic Hoarseness

Inflammation:

  • Allergies
  • Viral or bacterial
  • Acid reflux
  • Smoking

Neurological:

  • Multiple sclerosis
  • Myasthenia gravis
  • Parkinson's Disease
  • Nerve injury

Systemic disease:

  • Thyroid
  • Amyloidosis
  • Sarcoidosis
  • Acromegaly

Neoplastic:

  • Vocal cord dysplasia
  • Cysts
  • Polyps
  • Nodules
  • Cancer

Functional:

  • Overuse of voice
  • Shouting/yelling/cheering
  • Stress Psychogenic

Diagnosis

Chronic hoarseness is generally caused by chronic laryngitis, which is an inflammation of the larynx that causes the vocal cords to vibrate abnormally. With chronic buildup of edematous tissue in the larynx, approximation and vibratory movement of the cords can be impaired. The diagnosis is made by taking a detailed history including asking about associated symptoms that usually involve frequent clearing of the throat, coughing, and "strange" sensations when swallowing. A sore throat and tickle in the throat are other symptoms. The pitch of the voice is abnormal and talking elicits this. The physical exam involves inspection of the larynx with direct vision and an ENT physician will usually use an endoscope that makes a video recording of the cords when you are asked to say the letter "e."

The diagnosis is straightforward in most cases; but to treat the underlying cause of the inflammation of the larynx, more needs to be done. A swallowing study is used to see if one's swallowing is normal and if fluid leaks into the trachea. A pH study is sometimes done to document if stomach acid during the night comes up to irritate or burn the larynx.

Treatment

Acute laryngitis and associated dysphonia will disappear with the passing of the infection or cold. However, chronic laryngitis treatment is aimed at reversing a process that has several different causes, as indicated in the list in the sidebar. Stop smoking if you smoke. If there is an underlying disease (including cancer), this needs to be diagnosed and treated appropriately.

A most common cause of chronic laryngitis is gastric acid reflux. Half of these cases will respond to several preventive steps:

  • Do not eat or drink for three hours before bed.
  • Avoid chocolate, peppermint, and alcohol before bed.
  • Sleep with the head (larynx) elevated above the stomach - on two or three pillows.

Your physician may prescribe a drug that reduces the amount of acid secreted in the stomach if the conservative steps do not work. Medicine and the preventive steps are usually effective in most people to successfully treat the laryngitis, but it returns when medicine is stopped.

The Bottom Line

Hoarseness is common and is usually not a serious problem. However, if it persists for over a month it is time to go see a physician to diagnose the problem and treat it.