Causes and Treatment for a Hoarse Voice

A hoarse voice may be a barely noticeable change in the volume of your speech or it may be pronounced, with a raspy sound that is hardly audible.

A hoarse voice can be caused by anything that interferes with the normal vibration of the vocal cords, such as swelling and inflammation, polyps that get in the way of the vocal cords closing properly, nodules, or conditions that result in one or both of the vocal cords becoming paralyzed.

Some causes are primarily a nuisance, such as shouting too loud at a football game. Others can be very serious, alerting people to underlying conditions such as cancer or a stroke.

Most of the time, causes such as a cold, allergies, or inhaled irritants are the culprit, but hoarseness should never be dismissed without talking to your healthcare provider, especially if it persists.

Diagnostic tests will depend on your history but could include a laryngoscopy, blood tests, a computerized tomography (CT) scan of your chest, and more. The treatment will depend on the specific cause, but no matter the diagnosis, quitting if you smoke is important. Hoarseness is also referred to by the medical term "dysphonia."

Hoarseness Symptoms

Hoarseness is an abnormal sound when you try to speak. This may be described as raspy, breathy, soft, tremulous, and/or as changes in the volume of your voice. The pitch of your voice may change as well, becoming either lower or higher.

You may also experience pain or a strained feeling when trying to speak normally. Symptoms may come on suddenly or be so gradual you barely notice. They may be subtle, or instead, obvious.

In addition to asking about the quality of and duration of your hoarse voice, your healthcare provider will want to know about any other symptoms you are experiencing as these can give important clues as to the causes. Some of these include:

Causes

Hoarseness is a common symptom that most people have experienced from time to time while fighting a cold or the flu. But it can also be a symptom of something more serious.

Hoarseness can be caused in different ways. Often it is due to a problem with the vocal folds (a part of the larynx). The problem can stem directly from problems with the larynx, or instead, be due to problems with the nerves that supply the vocal folds and direct them to do what our brains are telling them to do.

Some possible causes of hoarseness include:

• Laryngitis: Laryngitis is the most common cause of hoarseness and can be caused by several things, ranging from the common cold to cheering a bit too loudly or long at a ball game, to singing your heart out at a concert.
• Vocal cord nodules: Vocal cord nodules are "lumps" on your vocal cords that interfere with their normal closing during speaking. They usually result from overuse of your voice, much like skin calluses develop. Singers, teachers, and other professionals who use their voices a lot can get polyps.
• Allergies: Both seasonal and year-round allergies can result in hoarseness.
• Acid reflux/heartburn: Gastroesophageal reflux (GERD) is a fairly common cause of hoarseness as stomach acid affects the vocal cords. Hoarseness is usually worse in the morning and may be accompanied by chronic symptoms such as throat clearing, cough, sore throat, and postnasal drip. When reflux affects the vocal folds it is called laryngopharyngeal reflux or silent reflux.
• Thyroid conditions: Thyroid conditions, especially untreated hypothyroidism (low thyroid), can cause hoarseness.
• Smoking: Smoking and secondhand smoke exposure may result in a hoarse voice.
• Exposure to other irritating substances: Irritants, ranging from air pollution to chemicals used in the home, can cause hoarseness. Thyroid cancer can also cause hoarseness.
• Recurrent respiratory papillomavirus: Papillomas on the larynx are fairly common and may result in slowly worsening hoarseness. It is seen most often in children and usually caused by the human papillomavirus (HPV). Most are caused by HPV types 6 and 11, strains that are included in HPV vaccinations.
• Long-term use of inhaled corticosteroids: Inhaled corticosteroids, a category of inhalers used chronically for asthma or COPD can result in a hoarse voice. It appears that some inhaled corticosteroids are more likely than others to cause problems.
• Cancer: Cancers of the voicebox (laryngeal cancer), throat, lungs, thyroid, and lymphomas may have hoarseness as a symptom, sometimes as the first symptom. Metastatic cancer spreading to the mediastinum (the area between the lungs), can press on the recurrent laryngeal nerves leading to the voice box and cause hoarseness.
• Neurological conditions: Strokes, Parkinson’s disease, and multiple sclerosis may all cause hoarseness due to their effects on the nerves supplying the vocal cords.
• Trauma: Blunt trauma to the throat region, for example during a motor vehicle accident may damage the vocal cords. A common cause of trauma occurs when the vocal cords are damaged by a tube that is placed down the throat during surgery (endotracheal tube) or during a bronchoscopy.
• Spasmodic dysphonia: Spasmodic dysphonia is a local problem with the muscles of the larynx, resulting in hoarseness.
• Laryngeal nerve paralysis: The nerves leading to the voice box may be damaged by any surgery in the region where a nerve travels, such as thyroid surgery, heart surgery, or head and neck surgeries.
• Inhalation of a foreign body or caustic substance

How Hoarseness Manifests

At rest, the vocal folds are open. When you decide to speak (or sing, or scream) there are several things that have to work together in order for an audible sound to be produced. Hoarseness may result from conditions that affect any of these steps:

Step 1: The vocal folds come together. A problem with this step may occur in either the vocal folds or with the nerves which supply the vocal folds. An example may be if cancer such as lung cancer or metastatic breast cancer pushes on the nerve that travels to the vocal folds in the chest. 

Step 2: Passing air causes the vocal folds to vibrate. When the vocal folds are closed, the air then must travel past them and cause the folds to vibrate. Again, problems may occur due to the vocal folds themselves, due to anything which keeps the folds from remaining closed (nerves), or anything that prohibits the normal flow of air past the folds.

Step 3: The sound needs to exit the body. Once air moves past the vocal folds, the sound then needs to "exit" the body, Anything which interferes with the flow of air out through the throat, mouth, and nose, may interfere with the sound.

Sound passing to the outside world also resonates in the sinus cavities. This helps to explain the "nasal quality" of your voice if you have a condition affecting your sinus passageways. The sound can vary from person to person depending on how it reverberates in the sinus passages and based on the size of the vocal folds.

Diagnosis

If you are coping with a hoarse voice, your healthcare provider will first perform a careful history, focusing on some of the questions listed below. They will then perform a physical exam, carefully evaluating your head and neck as well as chest and lungs.

Questions Your Healthcare Provider May Ask

When you visit your healthcare provider, she will first take a careful history. Some of the questions they may ask include:

• When did your symptoms begin?
• Is your hoarseness continuous or do you notice it on and off?
• Have you had any symptoms of a "head cold," such as a runny nose, fever, or a cough, or have you had an illness such as tonsillitis or mononucleosis?
• Have you strained your voice in any way, for example by cheering for your favorite football team or singing too long or too loudly?
• Do you, or have you ever, smoked?
• Do you drink alcohol?
• Do you have allergies or eczema?
• What other medical conditions do you have?
• Have you experienced any heartburn, unexplained weight loss, persistent cough, coughing up blood, difficulty swallowing, shortness of breath, weakness in any part of your body or felt a lump in your neck?
• Do you or any family members have a history of thyroid problems? Have you experienced any weight gain, constipation, or fatigue?
• What medical conditions run in your family?

Tests and Procedures

If your symptoms are persisting and your healthcare provider does not find an obvious cause after examining your ears, nose, and throat, she may order further tests. Some of these include:

Laryngoscopy: According to 2018 practice guidelines, people who have hoarseness that fails to go away after four weeks should have a laryngoscopy performed. This is true no matter how long the condition has been going on and even if a serious underlying cause of the hoarseness is suspected.

Videostroboscopy: Videostroboscopy is a procedure in which a strobe light is used to create a series of images that show slow motion vibration of the vocal folds.

Imaging studies: Tests such as a computerized tomography (CT) scan of the chest or neck, magnetic resonance imagine (MRI), etc. may be needed, but it's recommended that these be performed after a laryngoscopy is first done. If you have a history of cancer, a positron emission tomography (PET) scan may be recommended.

Other testing: A number of other tests may be done based on history and symptoms, For example, blood tests may be done if an infection is suspected, and upper GI endoscopy may be done if acid reflux is suspected, and so forth.

When to Call Your Healthcare Provider

It’s important to see your healthcare provider if you are experiencing a hoarse voice that lasts beyond a few days. While most causes of hoarseness are benign and are due to transient causes such as a cold, it may also be a symptom of something more serious.

If your symptom persists, it’s important to make an appointment with your healthcare provider—even if you think there's a reasonable cause. Healthcare providers vary on what they call "persistent." In general, if your symptoms last more than two weeks, progressively worsen, or are associated with other symptoms, you should make an appointment.

Treatment

Treating will depend on the underlying cause. Your healthcare provider may recommend medications to soothe your throat. For most causes resting your body and voice for a few days will suffice.

If your voice is strained or if you develop vocal polyps, a longer period of voice rest may be recommended. Some of you have heard of your favorite singer needing to cancel his tour to take a break for a few months. This may be the case for amateur singers as well (and overly enthusiastic sports fans).

For spasmodic dysphonia, botulinum toxin injections may be helpful. If you smoke, it’s very important to quit—both to help with healing now and to prevent problems in the future.

For those whose problems persist, voice therapy can be very helpful in reducing damage while restoring your voice to health. That said, it is now recommended that anyone with hoarseness have a larygnoscopy before voice therapy is prescribed.

A Word From Verywell

There are many potential causes of hoarseness that range from primarily a nuisance to very serious. The important thing to keep in mind is that hoarseness is a symptom that something isn't working right in your body.

Not only is it important to make a diagnosis (especially since many of the possible causes are more treatable when caught early) to figure out the best treatment, but living with a hoarse voice can seriously reduce your quality of life.