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Hoarseness

What is Hoarseness?
Vocal Cord Granuloma
Vocal Cord Paralysis
Vocal Cord Nodules
Vocal Cord Polyps
Laryngopharyngeal Reflux (LPR)

What is Hoarseness? 

Hoarseness is defined as an abnormal voice caused by interruption of vocal cord closure and vibration. Most commonly hoarseness develops from benign causes such as upper respiratory infections, vocal abuse, gastroesophageal reflux disease and advancing age. Vocal cord nodules, polyps, granulomas, paralysis, and cancer are less common causes. 
Symptoms and Types: 
Unexplained hoarseness lasting more than three weeks should usually prompt an evaluation as to its cause. An ear, nose and throat specialist will first obtain a history of the complaint, including the quality of the hoarseness, its severity, the length of time the hoarseness has been present, and any factors that either aggravate or alleviate it. 
Diagnosis and Tests: 
After obtaining the history, the physician reviews any pertinent medication history and social history that may affect the voice, including the use of tobacco and alcohol.
 
A thorough head and neck examination, including inspection for neck masses or surgical scars, the state of oral hydration, or the presence of any nasal or postnasal drainage, is then performed.
 
Finally, the physician examines the larynx, or voice box, to determine whether any visible pathology exists. This is usually accomplished using fiberoptic laryngoscopy. A simple procedure performed in the office, usually requiring only a few minutes.
 
Based on the specific findings on this examination, the specialist can present a diagnosis and treatment plan to the patient. 
Treatment and Care: 
To prevent and treat mild hoarseness:
  • Do not smoke, avoid noxious fumes and secondary smoke
  • Hydrate
    • 8 glasses of water a day
    • Chew gum, suck on hard candies
    • Keep environment humid
  • Avoid caffeine and alcohol – these cause the body to lose water
  • Treat Gastroespohageal Reflux Disease (GERD) if present
  • Avoid loud or prolonged voice use
  • Do not clear throat
  • Get plenty of sleep
  • Avoid over the counter antihistamines that cause dryness
  • Avoid menthol throat lozenges that dry the throat
  • “Warm up” vocal muscles prior to prolonged use
  • Rest your voice after vigorous use
  • Use a microphone where you need to project your voice

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Vocal Cord Granuloma

What is a vocal cord granuloma?

A vocal cord granuloma is an inflammatory lesion of the vocal cords, usually occurring on the posterior 1/3 of the cord.

What are the symptoms of a granuloma?

 The most common symptom of a granuloma is hoarseness. Some granulomas can cause pain. If a granuloma is large enough, it can lead to noisy breathing (stridor) and even difficulty breathing.

What causes a vocal cord granuloma?

Granulomas arise as a response to irritation or trauma. This can occur due to trauma from an endotracheal (breathing) tube, to irritation from acid reflux (GERD), or to trauma from improper voice use. Often granulomas are a response to a combination of these factors.

How are vocal cord granulomas diagnosed?

 After taking a thorough history, the physician visualizes the vocal cords using laryngoscopy. This is usually performed with a flexible fiberoptic endoscope. If there is doubt regarding the diagnosis, a biopsy of the lesion may be performed.

How are vocal cord granulomas treated?

Initial treatment consists of trying to eliminate the irritating agent. This includes removal of an endotracheal tube if possible, treatment of reflux disease, and sometimes voice therapy. Microsurgical removal, with or without use of a laser, is reserved for those patients who do not respond to conservative treatment.

By Ronald Newman, MD

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Vocal Cord Paralysis

What causes vocal cord paralysis?
The right and left recurrent laryngeal nerves control the motion of the vocal cords. Damage to one or both of these nerves leads to vocal cord paralysis. Causes of injury to the nerve include inadvertent damage from neck surgery such as thyroidectomy, carotid endarterectomy or others, complications from having an edotrachela (breathing) tube, trauma to the neck or chest, tumors involving the base of the skull, neck, or chest, and viral infections.
What are the symptoms of vocal cord paralysis?
Paralysis leads to a breathy voice because the paralyzed cord is unable to vibrate against the opposite cord. Choking while swallowing liquids is common, since the paralyzed cord is unable to seal off the airway from the swallowing portion of the throat. Frequently, individuals complain of shortness of breath, since air is wasted during speaking, requiring the individual to take frequent breaths in order to complete a sentence. In the unusual case of injury to both nerves, the voice may be relatively normal, but difficulty breathing may be more intense.
How is vocal cord paralysis diagnosed?
After taking a thorough history, the physician visualizes the vocal cords using a technique called laryngoscopy. This is usually performed with a flexible fiberoptic endoscope. If the cause of the paralysis is not obvious, the physician will frequently order studies to try to rule out more serious causes, such as tumors.
How is vocal cord paralysis treated?
If the cause of the paralysis is not apparent, observation, sometimes with speech therapy, may be recommended for up to a year to allow for spontaneous resolution of the paralysis and compensation from the opposite side. Surgical intervention is appropriate if the paralysis is deemed to be irreversible and the symptoms of hoarseness and/or choking are causing significant problems. This can take the form of injecting the paralyzed vocal cord with temporary or permanent fillers to bulk up the cord (vocal cord injection), or repositioning the vocal cord with an implant (thyroplasty). A tracheotomy may be indicated if there are serious breathing problems.

By Ronald Newman, MD

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Vocal Cord Nodules

What are vocal cord nodules?

Vocal cord nodules, also known as singer’s nodules or screamer’s nodules, are tiny calluses that form on both vocal cords simultaneously, usually 1/3 of the way back from the anterior-most aspect of the vocal cords.

What are the symptoms of vocal cord nodules?

Nodules lead to hoarseness, with a “raspy” sounding voice. The nodules prevent smooth closure of the cords, which creates the hoarseness. The degree of hoarseness may fluctuate depending on the degree of thickening of the nodules and the amount of recent vocal activity.

What causes vocal cord nodules?

Vocal cord nodules arise from misuse or overuse of the voice. This leads to friction between the vocal cords and the development of thickened skin, like a callus. Contributing factors to nodules include using incorrect pitch, development of neck muscle tension, and excessive screaming, cheering, or shouting. Nodules are common in children (more in boys), adolescent females, extroverts with loud voices, and with certain activities and professions, such as cheerleading, teaching, public speaking and singing. Irritants, including cigarette smoke and stomach acid from gastroesophageal reflux disease (GERD), may increase the chances of developing nodules.

How are vocal cord nodules diagnosed?

After taking a thorough history, the physician visualizes the vocal cords using a technique called laryngoscopy. This is usually performed with a flexible fiberoptic endoscope. 

How are vocal cord nodules treated?

Like calluses, nodules will usually resolve by removing the cause. Vocal therapy is indicated to decrease vocal cord friction and irritation. This may consist of self-treatment (see Treatment of Mild Hoarseness), or may benefit from professional speech therapy consultation. Microsurgical removal of the nodules is rarely necessary, but may be considered after failure of maximal attempts at voice therapy.

By Ronald Newman, MD

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Vocal Cord Polyps

What are vocal cord polyps?

Vocal cord polyps are benign growths originating from one or both vocal cords. Polyps differ from vocal cord nodules in that they are usually larger and more likely to be unilateral. They are usually filled with a jelly-like material that makes them unlikely to resolve spontaneously.

What are the symptoms of vocal cord polyps?

Polyps lead to hoarseness, with a “raspy” sounding voice. A polyp prevents smooth closure of the cords, which creates the hoarseness.

What causes vocal cord polyps?

Vocal cord polyps arise from misuse or overuse of the voice. This may be the result of chronic irritation, or due to a single traumatic event, such as a scream or cough. Irritants, including cigarette smoke and stomach acid from gastroesophageal reflux disease (GERD), may increase the chances of developing polyps.

How are vocal cord polyps diagnosed?

After taking a thorough history, the physician visualizes the vocal cords using a technique called laryngoscopy. This is usually performed with a flexible fiberoptic endoscope. 

How are vocal cord polyps treated?

Conservative treatment of vocal cord polyps may include eliminating irritating factors, such as excess stomach acid, or cigarette smoke. Voice rest or speech therapy may be recommended. However, unlike vocal cord nodules, polyps are unlikely to resolve with conservative treatment and generally require surgical intervention consisting of a laryngoscopy and excision of the polyp using microscopic technique.

By Ronald Newman, MD

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Laryngopharyngeal Reflux (LPR)

What is Laryngopharyngeal Reflux (LPR)?

Laryngopharyngeal reflux is the backflow of stomach acid into the esophagus, and then into the throat. In Gastroesophageal reflux disease (GERD), the acid irritates the tissues of the esophagus (the feeding tube that connects the stomach and the throat) and the symptoms are primarily heartburn and indigestion.  In LPR, the acid spends very little time in the esophagus and rises to the level of the throat and larynx (voice box) and causes swelling and irritation in these areas. 

What are the symptoms of LPR?

LPR symptoms include the following:

  • Hoarseness
  • Thick or too much mucous in the throat
  • Chronic throat irritation
  • Chronic throat clearing
  • Chronic cough
  • Cough that wakes you from your sleep
  • Sensation of a “lump in the throat”
  • Sore throat
  • Difficulty swallowing
     
How is LPR diagnosed?

The diagnosis of LPR is typically made by a combination of symptoms and physical examination in the clinic.  Other studies, such as a 24-hour pH probe or a barium swallow study, are occasionally used to confirm the diagnosis.

How is LPR treated?

Treatment for LPR includes a combination of behavioral modification and medical therapy.  Behavioral modifications include weight reduction, avoidance of late night eating and avoidance of products/foods that trigger acid reflux.  Common triggers of acid reflux include alcohol, tobacco, spicy foods, fatty foods, caffeine, chocolate and peppermint.  Additionally, sleeping with the head of the bed elevated may be helpful.
 
The goal of medical therapy in LPR is to reduce the production of stomach acid and its affects.  This is primarily achieved through a class of medications called proton-pump inhibitors (prilosec, nexium, aciphex, prevacid, protonix) as well as H2 blockers (pepcid, zantac) and antacids (maalox, mylanta).  Once the diagnosis of LPR has been made, a trial of one or more of these medications is initiated for several weeks to months.  The doses and frequency of these medications are often adjusted based on the patient’s response to treatment.

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