What is hoarseness, and is it a sign of something dangerous?

Hoarseness or dysphonia is characterized by alterations in vocal quality, pitch, loudness, or vocal effort that can impair communication or quality of life. It is common and affects nearly one in three people at some time in their life. Hoarseness is usually temporary and recovers quickly by itself, for example hoarseness after a cough or cold, or after an episode of excessive voice use such as 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, but there are times when it requires urgent care, or could even potentially be harmful or life-threatening.


When should I see a specialist?

If you are reading this, it may mean you are sufficiently concerned about your condition to seek help. There are a number of situations in which a medical opinion should be sought without delay. These include:

  • When hoarseness occurs together with breathing difficulty or there is noise from the throat during breathing.
  • Hoarseness that does not resolve or improve within 4 weeks (although you do not need to wait for 4 weeks if you are particularly worried about a serious cause).
  • If you have undergone recent surgery to the head, neck, or chest, or have recently undergone general anesthetic involving insertion of a breathing tube.
  • If there is a lump in the neck.
  • If you smoke (this includes exposure to second-hand tobacco smoke).
  • If you use your voice professionally, and the hoarseness is affecting your ability to carry out your work.

In these situations, consulting a specialist should not be delayed, and an assessment of your voice and vocal folds will help achieve a diagnosis so that appropriate treatment can be implemented.


What will happen when I see the specialist?

The specialist will ask you about the onset and progression of your symptoms and will need to know about any other medical conditions that you have. This may include a discussion about other ear, nose or throat complaints, symptoms in other parts of the body, medications taken, and dietary and smoking habits. The way in which you use your voice professionally and recreationally, and the degree of impact that your hoarseness has on your ability to carry out your daily activities and work are also discussed.

Following this, the specialist will want to 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 passing an endoscope or flexible camera through the nose (or sometimes through the mouth) to visualize the vocal folds. A clear, real time assessment can then be made of the structure and movements of the vocal folds. A strobe light may be used to assess vibration of the vocal folds in more detail by providing a slow-motion image. This examination is known as laryngeal stroboscopy and allows examination of how well the vocal folds vibrate, the way in which 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).

Occasionally, based on the examination findings, scans such as ultrasound of the neck, or computed tomography (CT) or magnetic resonance imaging (MRI) may be ordered.

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


What treatments are available?

Many voice problems can be improved with preventive measures and lifestyle modification to improve vocal health.

Some voice problems are amenable to voice therapy. Voice therapy is carried out with a speech-language pathologist who has expertise in managing voice problems. Voice therapy aims to correct maladaptive voicing patterns and improve efficiency of voicing through specific exercises. Diagnostic laryngoscopy is usually recommended before commencing voice therapy, and we sometimes advocate joint assessment with the speech-language pathologist which can improve outcomes for patients.

Surgery may be recommended as a therapeutic option in certain conditions causing hoarseness. Conditions which may require surgery include:

  1. Benign lesions of the vocal fold such as polyps, cysts, or papillomas that do not respond to conservative treatment. These conditions may require micro-laryngeal surgery (microscopic surgery of the voice box) under general anesthesia, sometimes using a laser to remove the lesion. [Read more about micro-laryngeal surgery]
  2. When there is suspected malignancy or possibility of cancer of the voice box. In this situation, micro-laryngeal surgery may be needed to biopsy the lesion, or even remove it completely where possible (known as an excision biopsy). Biopsies of the larynx are usually carried out under general anesthetic but can sometimes be performed under local anesthetic in the outpatient clinic. The local anesthetic procedure can be combined with a flexible camera examination of the esophagus (food passage) to exclude any co-existing involvement of this area (this is known as a synchronous tumour). The examination of the esophagus is known as a transnasal esophagoscopy. [Read more about trans-nasal esophagoscopy]
  3. Paralysis of a vocal fold. This creates a situation known as glottal insufficiency where the vocal folds are unable to close during voicing. This makes the voice weak and breathy. There may also be difficulty coughing and swallowing. A number of surgical options are available to strengthen the voice, cough and swallowing. These include injection laryngoplasty procedures which can be carried out under local or general anesthesia to bulk up the weak paralyzed vocal fold. Sometimes and implant can be inserted into the voice box, or a new nerve can be attached to the paralyzed nerve or muscle. Each procedure has advantages and disadvantages which may need careful consideration. [Read more about vocal fold paralysis]

Occasionally both vocal folds can be paralyzed. This creates a different situation in which the patient has difficulty breathing as they cannot open their vocal folds. These patients may require, or already have a tracheostomy (an opening in the neck that allows the patient to bypass the voice box for breathing). A tracheostomy can be uncomfortable and troublesome for the patient, and laser surgery can be used to widen the opening at the vocal folds, allowing the patient to breathe without a tracheosotomy.

Some voice conditions require very specific treatments. An example of this is hoarseness caused by spasmodic dysphonia or other types of laryngeal dystonia. Patients with these conditions can be offered botulinum toxin injections for treatment. [Read more about spasmodic dysphonia]

Medications are sometimes prescribed to treat hoarseness, including antibiotics, anti-reflux medication, and steroids. Such medications are not be routinely prescribed, but rather only when there are specific indications, which are best determined by visualization of the voice box and vocal folds.

Treatment (or observation) can result in resolution of symptoms, or improvement or even worsening, and correspondingly this can affect the patient’s quality of life. These changes will need to be monitored and discussed with the specialist.


What we can offer for patients with hoarseness at David Lau ENT Centre

Dr Lau has a special interest, and expertise in diagnosing and treating patients with hoarseness. He underwent Fellowship training in the subspecialty of Laryngology, Voice and Swallowing Disorders, and helmed the Voice Clinic at the Singapore General Hospital until 2013, when he entered private practice. He continues to contribute as a visiting consultant at the Singapore General Hospital and National University Hospital specifically to manage patients with voice and swallowing disorders.

Dr Lau has expertise in diagnosis and management of the full range of voice disorders. He is skilled in micro-laryngeal surgery and laser surgery of the larynx and is able to surgically treat complex lesions such as recurrent laryngeal papillomatosis, early laryngeal cancer, and bilateral vocal fold paralysis.

Office-based procedures and trans-nasal esophagoscopy are also available. Dr Lau is considered to be one of the region’s key opinion leaders in trans-nasal esophagoscopy. [Read more about trans-nasal esophagoscopy]

Dr Lau is also experienced in managing unilateral vocal fold paralysis, both with office-based and operating room techniques. He introduced office-based injection techniques for vocal fold paralysis to ENT practice in Singapore in 2002, has continued to develop methods to improve their efficacy, and has researched and published on the topic of injection laryngoplasty. Diagnostic techniques using laryngeal electromyography are also available.

Dr Lau also has experience in the diagnosis and management of spasmodic dysphonia, including botulinum toxin injection, and surgical methods for treating the condition.

Careful and accurate assessment of the condition is always necessary. We use state of the art videolaryngoscopy and stroboscopy equipment and believe strongly in an individualized and holistic approach that caters to the patient’s condition and needs. Interdisciplinary cooperation working closely with speech-language pathologists and other medical specialists; a multi-facetted approach that manages not just visible disease but also underlying causes; and up to date methods based on latest medical evidence are crucial to Dr Lau’s management of hoarseness.

Dr Lau’s continued dedication to the art of managing hoarseness is recognized in regular invitations to speak and teach at regional congresses. He is also a founder member and current president of the Asia Pacific Laryngology Association which held its inaugural congress in Singapore in 2019.

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