Hoarseness and voice change

Hoarseness is an abnormal change in the voice characterised by alterations in pitch, volume, or vocal quality. It is a symptom, not a diagnosis, and may reflect benign self-limiting causes (e.g. laryngitis) or serious disease (e.g. laryngeal cancer). Any hoarseness lasting longer than 3 weeks, especially in smokers or adults over 40, should prompt urgent ENT referral. Careful history, examination, and laryngoscopy are essential to identify the underlying cause.

🧬 Pathophysiology of Voice and Hoarseness

• Normal phonation: Air from the lungs passes through the glottis, causing the vocal cords to vibrate. Sound is then modified by resonance in the pharynx, mouth, and nose.
• Mechanisms of hoarseness:
  • Mucosal/structural disruption: Oedema, nodules, polyps, inflammation, malignancy alter vibration.
  • Neurological impairment: Recurrent laryngeal nerve injury → incomplete closure → breathy/weak voice.
  • Mechanical interference: Extrinsic compression from thyroid or mediastinal masses.
  • Chemical irritation: Acid reflux, smoking, alcohol → chronic laryngeal inflammation.
  • Functional misuse: Excessive/professional voice use → nodules and muscle tension dysphonia.
• Result: Any disruption in cord vibration, glottic closure, or respiratory support leads to altered voice quality (hoarse, breathy, strained, weak).

📋 History Taking

• Duration: Acute (days–weeks) vs chronic (>3 weeks, red flag).
• Associated symptoms: Dysphagia, odynophagia, cough, hemoptysis.
• Voice use: Occupational/recreational use (singers, teachers at higher risk).
• Smoking & alcohol: Strong risk factors for malignancy.
• Reflux symptoms: Heartburn, regurgitation.
• Recent URTI: Suggests laryngitis.
• Neurological symptoms: Weakness, dysarthria, swallow difficulty (cord palsy, Parkinson’s, ALS).
• Thyroid disease: Neck swelling, weight change, family history.

🩺 Physical Examination

• Head & neck: Masses, thyroid nodules, lymphadenopathy.
• Oral cavity & pharynx: Lesions, infection, obstruction.
• Laryngeal exam: Flexible laryngoscopy for nodules, polyps, cord palsy, cancer.
• Neurological exam: Cranial nerves, focal deficits, Parkinsonian signs.

🔎 Investigations

• Laryngoscopy: Gold standard for cord visualisation.
• Imaging: CT/MRI for tumours, mediastinal disease, or neurological causes. CXR if suspect lung malignancy.
• pH monitoring: For suspected reflux-related laryngitis.
• Thyroid function tests & ultrasound: If thyroid disease suspected.
• Biopsy: For persistent or suspicious lesions.

🚩 Red Flags

• Hoarseness lasting >3 weeks (especially in smokers/age >40).
• Unexplained weight loss.
• Dysphagia or odynophagia.
• Hemoptysis.
• Neck mass or rapidly enlarging thyroid.
• Unilateral vocal cord paralysis.
• Neurological symptoms (weakness, dysarthria, progressive speech change).

🛠️ Management Principles

• Voice rest & speech therapy: For overuse syndromes, nodules, muscle tension dysphonia.
• Medical therapy: PPIs for reflux, antibiotics for bacterial laryngitis, steroids short-term for inflammation.
• Surgical intervention: Excision of nodules/polyps, medialisation procedures for cord palsy, oncological surgery for cancer.
• Multidisciplinary approach: ENT, speech therapy, oncology, neurology, endocrinology as appropriate.

📊 Summary Table of Causes, Tests, Management & Red Flags

📝 Summary

Hoarseness is a common presentation with a broad differential. Understanding the pathophysiology of phonation helps link causes to symptoms. The priority is to identify red flags that suggest malignancy or serious disease. Management ranges from reassurance and voice therapy to surgery and oncology input. Persistent hoarseness (>3 weeks) always warrants ENT referral and laryngoscopy.