David P. Goldstein B.A., Meds 9T8 University of Toronto
Dysphonia is defined as an impairment of voice, and can be divided into
two categories; problems with projection of voice or problems with quality of
voice. Hoarseness is one form of dysphonia that is defined as a rough or noisy
quality of voice. However, hoarseness is often used interchangeably with
Importance: hoarseness is a symptom of both local laryngeal pathology and
systemic disease. It is not only a distressing symptom for patients, but is also
often the early presenting symptom of serious disease such as cancer of the
Mechanics of voice production
Anatomy: The vocal apparatus of the larynx (the glottis) consists of a
pair of true vocal cords that are lengthened, abducted and adducted by numerous
muscles, thereby changing the tension of the cords and the amount of space
between them. The musculature is innervated by 2 branches of the vagus nerve,
the superior laryngeal and the recurrent laryngeal nerves (dominant supply).
Voice production: During speech a column of air is passed through the
adducted vocal cords, causing them to vibrate and produce sound that is shaped
into articulated speech with the help of the oropharynx, tongue and lips. Any
changes in the vocal cord or controlling structures may result in abnormal voice
production by interfering with cord movement, approximation or vibration
(organic dysphonia). On the other hand dysphonia may still be present with
normal anatomy (functional dysphonia).
See Table 1 for the most common clinical
- acute viral laryngitis
- bacterial tracheitis/laryngitis
Non-infectious inflammatory (chronic irritation leading to vocal edema,
nodules, contact ulcers or chronic laryngitis)
- gastro-esophageal reflux disease (GERD)
- smoke irritation
- chronic cough
Trauma- external laryngeal trauma
- Cysts ( retention cysts, laryngoceles , ventricular prolapse)
- Tumors ( vocal cord polyps, papillomas, chondromas, lipomas,
- Malignant tumors (squamous cell carcinoma)
- endocrine ( hypothyroidism, virulization)
- rheumatoid arthritis, SLE, sarcoidosis, wegner's granulotomosis,
- Central lesions (CVA, Guillain barre, head injury, MS, neural tumors)
- Peripheral lesions
- Tumors: glomus jugulare, thyroid, bronchogenic, esophageal, neural
- Surgery: thyroid surgery, cardiovascular or thoracic/esophageal
- Cardiac : left atrial entargment, aneurysm of aortic arch
- Neuromuscular: myasthenia gravis, spastic dysphonia
Psychogenic aphonia ( hysterical aphonia)
History: take a full history keeping in mind the differential diagnosis to
guide your questions
° to GERD, with hoarseness worse in the am (lying supine).
Precipitating Factors and Past medical history: was the hoarseness
preceded by a viral URTI? Is there any history of trauma or recent screaming
or yelling? Has the patient had thyroid, esophageal or cardiothoracic surgery?
Does the patient have a history of hiatus hernia, GERD or hypothyroidism?
Associated symptoms: dysphagia, odynophagia, hemptoysis, stridor,
heartburn or symptoms of GERD, allergy symptoms, post-nasal drip, chronic
cough, symptoms of hypothyroidism or airway compromise.
Social History: smoking, alcohol use, vocal demands on the patient, their
environment (level of noise, smoke or irritant toxins, do they use their voice
Medication history: meds that dry the mucous membranes, cardiac meds
producing a cough or hormones?
- ascertain the nature, onset and duration (acute or chronic) of the voice
abnormality. Acute is usually considered to be less than 2 weeks.
- Are there times when the voice returns to normal? This would decrease the
suspicion of a fixed lesion as the cause of hoarseness.
- Does the voice fluctuate throughout the day? This often is seen in
patients with hoarseness 2
Do a complete ENT exam on the patient that presents with hoarseness.
one should always attempt to examine the larynx using either direct or
indirect laryngoscopy, especially in the patient presenting with chronic
indirect laryngoscopy involves examining the larynx with a mirror, whereas
direct laryngoscopy entails using a scope; either a rigid Hopkins scope or a
fibroptic flexible laryngoscope
on laryngoscopy try to examine the vallecula, epiglottis, pyriform
sinuses, false vocal cords, growths protruding from the ventricle, true vocal
cords and immediately subglottic.
Examine the aforementioned areas for the colour and character of the
mucosa, look for any lesions and their location, examine the vocal cords, and
their resting position, demonstrate normal and symmetric abduction and
Stroboscopy (commonly not seen in a primary care office) can help the
specialist increase detection of small undiagnosed lesions.
If you are unable to adequately view the larynx or its surrounding anatomy
in a patient with a history that is not suggestive of a benign cause or a
patient with chronic dysphonia, obtain an ENT consultation.
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Garrett C, Ossoff R. Hoarseness: Contemporary Diagnosis and Management.
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Meyerhoff W L, Rice DH. Otolaryngology- Head and Neck Surgery.
Philadelphia, Pa: W.B. Saunders; 1992.