Hoarseness
Hoarseness — a rough or harsh sound to the voice — can result from infections or inflammatory lesions or exudates of the larynx, from laryngeal edema, and from compression or disruption of the vocal cords or recurrent laryngeal nerve. This common sign can also result from a thoracic aortic aneurysm, vocal cord paralysis, and systemic disorders, such as Sjögren’s syndrome and rheumatoid arthritis. It’s characteristically worsened by excessive alcohol intake, smoking, inhalation of noxious fumes, excessive talking, and shouting.
Hoarseness can be acute or chronic. For example, chronic hoarseness and laryngitis result when irritating polyps or nodules develop on the vocal cords. Gastroesophageal reflux into the larynx should also be considered as a possible cause of chronic hoarseness. Hoarseness may also result from progressive atrophy of the laryngeal muscles and mucosa due to aging, which leads to diminished control of the vocal cords.
History
Obtain a patient history. First, consider his age and sex; laryngeal cancer is most common in men between ages 50 and 70. Be sure to ask about the onset of hoarseness. Has the patient been overusing his voice? Has he experienced shortness of breath, a sore throat, dry mouth, a cough, or difficulty swallowing dry food? In addition, ask if he has been in or near a fire within the past 48 hours. Be aware that inhalation injury can cause sudden airway obstruction.
Next, explore associated symptoms. Does the patient have a history of cancer, rheumatoid arthritis, or aortic aneurysm? Does he regularly drink alcohol or smoke?
Physical assessment
Inspect the oral cavity and pharynx for redness or exudate, possibly indicating an upper respiratory infection. Palpate the neck for masses and the cervical lymph nodes and the thyroid for enlargement. Palpate the trachea — is it midline? Ask the patient to stick out his tongue; if he can’t, he may have paralysis from cranial nerve involvement. Examine the eyes for corneal ulcers and enlarged lacrimal ducts (signs of Sjögren’s syndrome). Dilated jugular and chest veins may indicate compression by an aortic aneurysm.
Take the patient’s vital signs, noting especially fever and bradycardia. Inspect for asymmetrical chest expansion or signs of respiratory distress — nasal flaring, stridor, and intercostal retractions. Then auscultate for crackles, rhonchi, wheezing, and tubular sounds, and percuss for dullness.
Medical causes
Gastroesophageal reflux
Irritation of the larynx by reflux of gastric juices may result in hoarseness as well as sore throat, cough, throat clearing, and a sensation of a lump in the throat. The arytenoid tissue and the vocal cords may appear red and swollen.
Hypothyroidism
Hoarseness may be an early sign of hypothyroidism. Other signs and symptoms include fatigue, cold intolerance, weight gain despite anorexia, and menorrhagia. Assessment may also reveal coarse hair and alopecia as well as dry, flaky skin and thinning nails.
Laryngeal cancer
Hoarseness is an early sign of vocal cord cancer but may not occur until later in cancer of other laryngeal areas. The patient usually has a long history of smoking. Other common findings include a mild, dry cough; minor throat discomfort; otalgia; and, sometimes, hemoptysis.
Laryngeal leukoplakia
Leukoplakia is a common cause of hoarseness, especially in smokers. Histologic examination from direct laryngoscopy usually reveals mild, moderate, or severe dysphagia.
Laryngitis
Persistent hoarseness may be the only sign of chronic laryngitis. With acute laryngitis, hoarseness or a complete loss of voice develops suddenly. Related findings include pain (especially during swallowing or speaking), cough, fever, profuse diaphoresis, sore throat, and rhinorrhea.
Tracheal trauma
Torn tracheal mucosa may cause hoarseness, hemoptysis, dysphagia, neck pain, airway occlusion, and respiratory distress. The patient with tracheal trauma may also have manifestations of cervical spine injuries.
Vocal cord paralysis
Unilateral vocal cord paralysis causes hoarseness and vocal weakness. Paralysis may accompany signs of trauma, such as pain and swelling of the head and neck. The patient may also experience dysphagia.
Vocal cord polyps or nodules
Raspy hoarseness, the chief complaint, accompanies a chronic cough and a crackling voice. Typically, this condition is painless.
Other causes
Inhalation injury
Inhalation injury from a fire or explosion produces hoarseness and coughing, singed nasal hairs, orofacial burns, and soot-stained sputum. Subsequent signs and symptoms include crackles, rhonchi, and wheezing, which rapidly deteriorate to respiratory distress.
Treatments
Occasionally, surgical trauma to the laryngeal nerve results in temporary or permanent unilateral vocal cord paralysis, leading to hoarseness. Prolonged intubation may cause temporary hoarseness.
Special considerations
Carefully observe the patient for stridor, which may indicate bilateral vocal cord paralysis. When hoarseness lasts for longer than 2 weeks, indirect or fiber-optic laryngoscopy is indicated to observe the larynx at rest and during phonation.
Pediatric pointers
In children, hoarseness may result from congenital anomalies, such as laryngocele and dysphonia plicae ventricularis. In prepubescent boys, it can stem from juvenile papillomatosis of the upper respiratory tract.
In infants and young children, hoarseness commonly stems from acute laryngotracheobronchitis (croup). Acute laryngitis in children younger than age 5 may cause respiratory distress since the larynx is small, and if irritated or infected, subject to spasm. This may cause partial or total obstruction of the larynx. Temporary hoarseness commonly results from laryngeal irritation due to aspiration of liquids, foreign bodies, or stomach contents.
Patient counseling
Stress to the patient the importance of resting his voice: Talking — even whispering — further traumatizes the vocal cords. Suggest other ways to communicate, such as writing or using body language. Urge the patient to avoid alcohol, smoking, and the company of smokers. If he has laryngitis, advise him to use a humidifier.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Hoarse
Read excerpts from these other book chapters related to Hoarse:
Medical Books Excerpts
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- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2008 Williams & Wilkins.
More About Causes of Hoarse
» Next page: Hoarseness (The Diagnostic Approach to Symptoms and Signs in Pediatrics)
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