“Hoarseness” generally refers to a rough quality that the patient, or other listeners, perceive in the voice. However, some patients also consider vocal weakness or breathiness to be “hoarse”. Hoarseness can come from a variety of causes. In most patients, temporary hoarseness accompanies upper respiratory tract infections and resolves without therapy. However, hoarseness that lasts for more than 2 weeks should be evaluated by a physician.
Vocal Cord Nodules, Polyps, and Cysts
These vocal cord lesions are benign lesions that accompany vocal cord trauma. Singers and other professional voice users such as teachers, professors, lawyers, secretaries, customer service representatives, and anyone else who uses his or her voice a great deal to communicate at work or at home is at risk for developing these lesions. In many cases, patients with these benign lesions benefit from voice therapy and improved vocal hygiene. However, for patients who are no longer able to meet their professional voice demands, voice preserving surgery (“phonomicrosurgery”) to remove the nodule, polyp, or cyst can help the improve the patient’s voice.
Vocal Cord Paralysis
The paired vocal cords normally open to breathe and close (come together) during speech. If one vocal cord is paralyzed and does not move, the vocal cords cannot close tightly during speech. The air that leaks out through the gap between the vocal cords often makes the voice weak and breathy. Patients with vocal cord paralysis may also have difficulty drinking liquids without coughing or choking. Such vocal cord paralysis can occur after neck or chest surgery, with some thoracic cancers, after a viral infection, or without any discovered cause. Sometimes the vocal cord motion recovers on its own over time – while the patient is awaiting recovery of vocal fold motion office-based injection of the vocal fold can temporarily re-position it so that voice and swallowing are improved. If the vocal cord does not recover motion on its own, then laryngeal framework surgery can re-position the vocal cord permanently to restore vocal function.
Vocal Cord Cancer (and Pre-Malignancies)
Vocal cord cancers develop slowly over many years. At first the changes are superficial, as the epithelial lining of the vocal cords develop pre-cancerous changes called “dysplasia”. As these pre-cancerous changes accumulate over time, cancer develops. When the cancer remains limited to the epithelial layer, it is called “carcinoma-in-situ”; when the cancer invades into the vocal cord itself, it becomes “invasive carcinoma”. Early cancers may have a superifical white appearance termed “leukoplakia”. Most, but not all, vocal cord cancers occur in smokers. Once diagnosed, early vocal cord cancers can be treated with a novel therapy called pulsed laser photoangiolysis, in which a special laser is used to remove the cancer’s blood supply without causing scarring to the rest of the vocal cord. Larger cancers can be removed with more traditional techniques, such as suspension microlaryngoscopy with resection.
Recurrent Respiratory Papillomatosis
Recurrent respiratory papillomatosis (RRP) is a benign growth that often occurs in the larynx (voicebox) of children and adults. It is thought to be cause by a virus, the Human Papilloma Virus (HPV). Although not cancerous, these growths can cause hoarseness and can even grow large enough to restrict the airway. Because recurrent respiratory papillomas have a very extensive blood supply, they respond well to pulsed laser photoangiolysis, which can reduce the growths without causing scarring to the rest of the vocal cord. Large papillomas are treated in the operating room, while small recurrent respiratory papilloma deposits can be treated in the office. RRP tends to come back even after it is treated, so the goal of therapy is to limit scarring of the vocal cords with each therapy so that voice quality is optimized. Because of this, pulsed laser photoangiolysis is an ideal approach to treating RRP.
Spasmodic dysphonia (SD) is a particular form of laryngeal dystonia – a nervous system disorder in which motions of the vocal cords are affected by uncontrolled spasms. Most patients have spasm of the vocal cords when they close the vocal cords to speak (adductor spasmodic dysphonia) that lead to a choppy, strained voice quality. However, some patients have a spasm that pulls the vocal cords apart during speech (abductor spasmodic dysphonia) – these patients have “breathy breaks” in their speech. Some patients have a combination of the two types. Treatment of spasmodic dysphonia is generally Botox injection to temporarily paralyze the muscles responsible for the spasm.
Muscle Tension Dysphonia
Many patients who develop hoarseness from another cause strain their voices to be heard. As they do this, they use other muscles around the voicebox to help “squeeze” out a stronger voice. For some of these patients, this muscle tension compensation lasts only as long as the original source of the hoarseness does – for instance, a patient with an upper respiratory infection might strain their voice to be heard for the few days when they are sick, but when they recover from the infection they stop straining their voice and go back to their original voice quality. However, other patients continue to strain and squeeze their voices even after the original cause of the hoarseness resolves. This additional straining, which can lead to poor voice quality and even neck muscle tenderness with speaking, is called Muscle Tension Dysphonia. The routine treatment of Muscle Tension Dysphonia is voice therapy by a Speech Language Pathologist, who can train the patient to relax the extra tension in the muscles around the voicebox.
Laryngopharyngeal Reflux (LPR)
There are two kinds of acid reflux disease, Gastroesopheal reflux disease (GERD) and Laryngopharyngeal reflux (LPR). Patients can have the symptoms of one without the other, or they may suffer from both simultaneously. Gastroesophageal reflux disease (GERD) occurs when acid from the stomach comes back up into the esophagus more than normal, leading to irritation of the esophageal lining. Patients with GERD have typical heartburn complaints. If the acid that refluxes from the stomach reaches the level of the throat and voicebox and irritates the tissue there, the patient has laryngopharyngeal reflux (LPR). Patients with laryngopharyngeal reflux (LPR) often complain of the sensation of a ‘lump’ in the throat, post-nasal drip, or chronic sore throat. LPR patients may also have chronic throat clearing and coughing, mild hoarseness, and the sensation of food ‘sticking’ a little bit when they swallow. Patients with LPR are treated with antacid medication, usually including Proton Pump Inhibitors, and lifestyle modifications designed to help suppress reflux irritation. As the irritation in the throat and voicebox resolve over the next several weeks following continued acid suppression, the symptoms generally go away as well.
You may read laryngopharyngeal reflux patient handout concerning lifestyle modifications here.
Transnasal esophagoscopy, which is a technique for examining the esophageal lining in patients with long-term reflux issues, can be performed in the office. You can read more about transnasal esophagoscopy here.
Dysphagia refers to difficulty swallowing. Swallowing is a complex set of coordinated muscle activities that include chewing food to prepare a ‘bolus’ for swallowing; pushing the bolus to the back of the throat; coordinating contractions of the throat muscles to push the bolus towards the esophagus; opening the esophagus to accept the bolus; and contracting the esophageal muscles to move the bolus to the stomach. During a swallow, the vocal cords generally close over the windpipe to prevent aspiration (“food going down the wrong pipe”). Any motor or sensory deficits in the mouth, throat, voicebox, or esophagus can lead to swallowing difficulty. Narrowing (‘strictures’) or out-pouchings (‘diverticuli’) can also lead to swallowing difficulty. Careful history and physical examination performed at the Loyola University Voice and Swallowing Center can help to determine the cause of the dysphagia so that proper treatment can be provided.