Stanislaus County Health Services Agency
Hoarseness: May Be a Warning

Van is a high-pressure basketball coach who typically raises his voice early and keeps it that level throughout a practice session. He frequently complains of a sore throat and hoarseness.

Bill Clinton battled hoarseness through both of his campaigns for the presidency; in 1996 his voice was so weak that he was barely able to give his victory address.

Most Americans have suffered from laryngitis, usually as a result of a nasty cold or an afternoon of yelling at a football game. Politicians, lawyers, professors, ministers, singers and even workers who must shout over the noise of heavy machinery are also at risk of straining their vocal cords and suffering the consequences.

In most cases, the hoarse, raspy, croaky voice comes on quickly; with voice rest and plenty of fluids, it goes away equally quickly, usually in three to five days. If changes in the voice occur without an identifiable cause, however, or if they last two weeks or longer, it’s important to see a doctor. The hoarseness may be a symptom of a serious medical condition that requires early identification and treatment.

The larynx or voice box is a structure built of cartilage, muscle and mucus membrane located at the top end of the windpipe. Sound is created when air passes over the vocal cords inside, causing them to vibrate at varying wave lengths. The final speech product is then produced by the throat, the tongue and the lips.

When the vocal cords become inflamed and swollen, they are unable to vibrate as they normally would, and the result is hoarseness, a distortion of the voice or even temporary loss of voice.

Other symptoms of laryngitis include a raw or tickling feeling in the throat, a dry cough and a constant need to clear the throat.

Treat the Underlying Cause
When it’s caused by an upper respiratory infection, hoarseness is relieved by treating the underlying cause. For a viral infection, that means drinking plenty of fluids, using a humidifier to moisten the air in the environment, sucking cough lozenges and taking over-the-counter medications to reduce coughing. For bacterial infections, antibiotics may also be needed.

Vocal cord abuse is a more common cause. Under stress or trying to be heard above background noise, some individuals raise their vocal pitch, and when their voice starts to become gravelly, they raise the pitch even higher, setting the stage for chronic irritation. When an individual already bothered by a cold or allergy has to carry on with teaching or conducting a meeting, serious strain can occur.

Laryngitis can also result from smoking, allergies, chronic bronchitis or inhaling chemicals or other irritants. Heartburn, or gastroesophageal reflux disease (GERD) can cause regurgitation of acids that inflame the vocal cords. In many cases, the stomach acids irritate the throat during the night, and the person experiences hoarseness the next morning.
Whatever the cause, it’s important to rest a croaky voice–speaking as little as possible. Many people resort to whispering, but that’s no solution, since it creates an air flow pattern that’s just as hard on the vocal cords as loud speaking. There’s also a natural tendency to clear the throat, but this too can make swelling even worse and should be avoided.
Sucking throat lozenges and drinking plenty of fluids can speed recovery, but caffeine should be avoided since it constricts blood vessels and may cause acid regurgitation.

When the Frog Doesn’t Go Away
Chronic hoarseness can have some of the same causes and same remedies listed above. Nevertheless, it’s important to see a doctor for any voice change lasting two weeks or longer.

Chronic hoarseness is fairly common with aging. The vocal cords can lose some of their elasticity or nerves serving them can be damaged by a stroke or an injury. Ironically, a man’s voice tends to become higher, a woman’s, lower with aging. Sometimes contact ulcers or sores develop on the cartilage of the vocal cords in response to chronic irritation. If these are caused by the regurgitation of stomach acids, the first step is treatment of the stomach disorder. Voice retraining may also be necessary to reduce the irritation.
A polyp is a small swelling that occurs under the mucus membranes covering the vocal cords, often associated with smoking or voice abuse. Surgical removal of polyps is usually performed under general anesthesia. To prevent recurrence, smoking cessation and voice retraining are usually recommended.

Nodules are callus-like growths that develop in the mucus membranes. They often respond to several weeks’ rest; otherwise, they can be removed surgically, followed by voice therapy.

Any hoarseness that persists or gets progressively worse over two or three weeks raises concern about a possible malignancy–particularly if the hoarseness is accompanied by difficulty swallowing, coughing up blood or a lump on the neck or in the throat. In many cases of throat cancer, hoarseness may be the first or only symptom noticed.

About 7,000 cases of late-stage cancer requiring laryngectomy (complete removal of the larynx) occur every year. In one study of 73 patients undergoing laryngectomy, 75 percent reported that hoarseness or a change in the voice was an early symptom. Other symptoms included weight loss, sore throat and swallowing difficulties.

Smokers are at high risk, particularly if they are also heavy drinkers of alcoholic beverages. Four times as many men as women are diagnosed with vocal cord cancer, but the incidence among women has been increasing recently.

If the cancer is detected early enough, it can be treated with surgery, laser therapy and/or radiation with a cure rate of 90 to 95 percent. About 75 percent of patients, according to one doctor, regain a normal voice after laser treatment. Even when surgery is required, a partial laryngectomy can sometimes be performed, preserving some or all of voice function.
While not a disease itself, hoarseness should be taken as a sign that something has gone wrong with the mechanism that produces speech. Usually, the remedy involves simple common sense measures such as resting the voice and learning how to use it without straining the vocal cords. When in doubt about the cause of lingering hoarseness, don’t waste time. Seek a consultation with a medical specialist.

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“Hoarse Voice,” Mayo Clinic Health Letter, January, 1998.
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Tanveer A. Janjua and Clarence T. Sasaki, “Hoarseness: Just a Cold–Or Something More Serious?” Consultant, February, 1996.
“Laryngitis: Causes, Treatments Vary,” Mayo Clinic Health Letter, November, 2001.
Nicholas Mulcahy, “Unexplained Ear, Nose, and Throat Symptoms May Benefit from GERD Therapy,” Internal Medicine News, July 1, 2001.
Clark A. Rosen, Deborah Anderson and Thomas Murry, “Evaluating Hoarseness: Keeping Your Patient’s Voice Healthy,” American Family Physician, June, 1998.
“A Word of Warning to Our New President,” Medical Update, January, 1993.

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