Hoarse voice 101: All you need to know to sound your best

What is hoarse voice?

Hoarse voice is a symptom in which voice quality is affected. Furthermore, there can be deteriorations in pitch, loudness, or effort on speaking. When severe and prolonged, hoarseness can affect our ability to communicate and work, and our quality of life.

Hoarseness is common and affects nearly one in three people at some time in their life. Although it is usually temporary and recovers quickly by itself. For example, hoarseness after a cough or cold, or excessive voice use like shouting or cheering at a sports event. In these situations, there is usually minor injury to the vocal folds which repairs itself quickly without serious consequences.

Most of the time hoarseness is not dangerous. However, there are times when it requires urgent care, or could even potentially be harmful or life-threatening.

When should I see a specialist for my hoarse voice?

If you are reading this, it may mean you are sufficiently concerned about your condition to seek help. You should seek a medical opinion if:

Hoarse voice occurs together with breathing difficulty or there is noise from the throat during breathing.

Hoarseness does not resolve or improve within two to three weeks. However, do not wait if your voice is worrying you.

You recently underwent surgery to the head, neck, or chest. Or recently had a general anesthetic involving insertion of a breathing tube.

There is a lump in the neck.

You smoke (this includes exposure to second-hand tobacco smoke).

You use your voice professionally, and the hoarseness is affecting your ability to carry out your work.

In these situations, consult a specialist without delay to achieve a diagnosis and start appropriate treatment.

What happens when I see the specialist?

The History

We need to hear from you about the onset and progression of your symptoms. In addition, we need to know about other medical conditions that you have. We may also ask you about other ear, nose and throat complaints, symptoms in other parts of the body, medications taken, and dietary and smoking habits.

Finally, we need to know how you use your voice professionally and recreationally. As well as the impact that hoarseness has on your daily activities and work.

The Examination

Following the history, the specialist will examine your voice box and surrounding structures. This includes listening to the voice, as well as examining structures in the neck, throat and nose.

A key part of the examination is diagnostic laryngoscopy, which involves looking at the vocal folds using a special camera passed through the nose or mouth. This allows us to see the structure and movements of the vocal folds.

Videostroboscopy

Videostroboscopy is an additional way of examining the vocal folds. It uses a strobe light to see how the vocal folds vibrate in slow motion. This allows us to see small details such as how a lesion on the vocal folds affects vibration, and how well the margins of the vocal folds come together during vibration (which is the part that matters most during voicing).

Other Investigations

Occasionally we need to assess certain structures in the neck in more detail. Scans, such as an ultrasound, CT, or MRI scan, can help with this.

Inter-Disciplinary Approach

Hoarseness can be affected by problems in other body systems. These include the respiratory, gastro-intestinal, neurological, or even psychological systems. We will sometimes recommend additional assessment by specialists in these systems.

All these assessments aim to identify not only the causes of hoarseness, but also factors that may modify management.

What treatments are available for hoarse voice?

Lifestyle

We can often improve a voice problem simply by making some lifestyle changes. Examples of changes that can improve vocal health include moderating voice use, avoiding tobacco smoke or other fumes, dietary modifications to prevent acid reflux, and staying well hydrated.

Speech Therapy and Voice Physiotherapy

Some voice problems are amenable to speech therapy and voice physiotherapy. These methods aim to correct maladaptive voicing patterns and improve efficiency of voicing through specific exercises. such exercises may include breathing exercises, stretching exercises for the voice, as well as exercises to improve voicing technique. Consistent practice is the key to success. It may help the therapist to see your voice box before starting therapy. Hence we sometimes recommend joint assessment with the therapist, which can improve outcomes for patients.

Medicines for Hoarseness

We sometimes treat hoarse voice with medicines. These medicines include anti-reflux medicine, steroids, and antibiotics, depending on the situation. We usually need to look at the vocal folds to decide whether medication will help.

Surgery for Hoarse Voice

Some voice conditions need surgery. Examples of such conditions include:

Benign lesions. Benign lesions of the vocal folds include polyps, cysts, or papillomas. They may require surgery if they cause significant hoarseness and do not improve with non-surgical treatment. Read more about micro-surgery and laser surgery of the voice box for benign lesions.

Malignant lesions. A suspected malignant lesion may need surgery to biopsy the lesion or remove it completely. Read more about micro-surgery and laser surgery of the voice box for malignant lesions. Some biopsies can be done under local anesthetic in the clinic, during which we may also examine the esophagus to exclude co-existing (synchronous) tumours, using transnasal esophagoscopy.

Paralysis of one vocal fold. Paralysis of one vocal fold makes the voice weak and breathy. In addition your cough and swallowing may be weak. We can correct the problem by injecting the paralysed vocal fold to bulk it up. This procedure, known as injection laryngoplasty, can be performed under local anesthesia (less precise) or general anesthesia (more precise). Alternatives include inserting an implant into the voice box. Or attaching a new nerve to the paralyzed nerve or muscle. [Read more]

Paralysis of both vocal folds. Paralysis of both vocal folds creates a different problem in which the patient cannot open their vocal folds and has difficulty breathing. To breathe, a tracheostomy (surgical opening in the neck) may be needed. However, tracheostomy can be uncomfortable and burdensome for patients. Hence laser surgery may be used to widen the vocal fold opening, allowing patients to breathe without a tracheosotomy.

Spasmodic dysphonia. Spasmodic dysphonia is a condition in which abnormal spasms (aka dystonias) of the voice box muscles cause difficulty speaking clearly. Patients with this condition can benefit greatly from minimally invasive botulinum toxin injections into the vocal muscles. [Read more]

How we can help at Advanced ENT

Expert Care for Hoarse Voice

Dr Lau specialises in diagnosis and treatment of patients with hoarse voice. He completed speciality Fellowship training in Laryngology, Voice and Swallowing disorders at the University of British Columbia, Canada from 1999 to 2001, and helmed the Voice Clinic at the Singapore General Hospital until 2013, when he entered private practice. He remains a visiting consultant at the Singapore General Hospital specifically to manage patients with voice and swallowing disorders.

Dr Lau also remains academically active in the field of laryngology. He is a founding member and inaugural president of the Asia Pacific Laryngology Association, which brings specialists together from around the Asia Pacific to share ideas. He is also an executive committee member of Performing Arts Medicine Singapore, which addresses medical issues in relation to performers.

Comprehensive Treatment for Voice Disorders

Dr Lau treats a comprehensive range of voice disorders. He is skilled in the art of micro-laryngeal surgery, and is also one of a small handful of surgeons in Singapore skilled at laser surgery of the voice box. Dr Lau has experience and success in managing a range of difficult laryngeal conditions such as early laryngeal cancer, recurrent respiratory papilloma, contact granuloma, and bilateral vocal fold paralysis.

Dr Lau is also experienced in treating unilateral vocal fold paralysis, using both office-based and operating room techniques. He introduced office-based injection laryngoplasty for vocal fold paralysis to ENT practice in Singapore in 2002, has continued to develop methods to improve the techniques’ efficacy, and has researched and published on the topic of injection laryngoplasty. He is also performs laryngeal electromyography to aid diagnosis and prognosticate recovery where needed.

Another condition that Dr Lau treats is spasmodic dysphonia. He performs both EMG-guided and endoscopic-guided techniques for botulinum toxin injection of the vocal folds, and surgical methods for treating the condition.

Read more about all the services we offer for throat, voice and swallowing disorders.

Holistic Approach

“I emphasize careful and accurate diagnosis, and guiding patients through the best treatment path, be it surgical or non-surgical.

I believe in combining state-of-the-art equipment, up-to-date evidence based methods, and an understanding of the patient’s individual needs, to achieve the best outcomes.”

Specialist Ear Nose and Throat Clinic at Gleneagles Hospital Singapore