Hoarseness

Hoarseness—a rough or harsh sound to the voice—can result from infections, 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 caused by aging, which leads to diminished control of the vocal cords.

History and physical examination

Obtain a patient history. First, consider the patient’s 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?

Inspect the oral cavity and pharynx for redness or exudate, possibly indicating an upper respiratory tract infection. Palpate the neck for masses and the cervical lymph nodes and the thyroid gland for enlargement. Palpate the trachea to determine if it’s 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 neck and chest veins may indicate compression by an aortic aneurysm.

Take the patient’s vital signs, noting especially fever and bradycardia. Examine him 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

In this disorder, retrograde flow of gastric juices into the esophagus may then spill into the hypopharynx. This, in turn, irritates the larynx, resulting in hoarseness as well as a sore throat, a cough, throat clearing, and a sensation of a lump in the throat. The arytenoids and the vocal cords may appear red and swollen.

Hypothyroidism

Hoarseness may be an early sign of hypothyroidism. Others include fatigue, cold intolerance, weight gain despite anorexia, and menorrhagia.

Laryngeal cancer

Hoarseness is an early sign of vocal cord cancer, but it 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 by direct laryngoscopy usually reveals mild, moderate, or severe dysphagia.

Laryngitis

Persistent hoarseness may be the only sign of chronic laryngitis. In acute laryngitis, hoarseness or a complete loss of voice develops suddenly. Related findings include pain (especially during swallowing or speaking), a cough, fever, profuse diaphoresis, sore throat, and rhinorrhea.

Rheumatoid arthritis

Hoarseness may signal laryngeal involvement. Other findings include pain, dysphagia, a sensation of fullness or tension in the throat, dyspnea on exertion, and stridor.

Sjögren’s syndrome

This rheumatic disorder produces hoarseness, but its cardinal signs are dry eyes, nose, and mouth. Initially, the patient complains of gritty, burning pain around the eyes and under the lids. Ocular dryness also leads to redness, photosensitivity, impaired vision, itching, and eye fatigue. Examination reveals enlarged lacrimal glands and corneal ulcers.

The patient may complain of a dry, sore mouth and difficulty chewing, talking, or swallowing. He may also exhibit nasal crusting, epistaxis, enlarged parotid and submaxillary glands, dry and scaly skin, a nonproductive cough, abdominal discomfort, and polyuria.

Thoracic aortic aneurysm

Depending on the size and exact location of the aneurysm, patients may remain asymptomatic. When the aneurysm exerts pressure on surrounding structures, however, patients may experience a variety of symptoms. Hoarseness occurs when the aneurysm compresses nerves associated with the larynx. Other clinical features may include a brassy cough; dyspnea; wheezing; a substernal aching in the shoulders, lower back, or abdomen; a tracheal tug; facial and neck edema; jugular vein distention; dysphagia; prominent chest veins; stridor; penetrating pain that’s especially severe when the patient is supine; and, possibly, paresthesia or neuralgia.

Tracheal trauma

Torn tracheal mucosa may cause hoarseness, hemoptysis, dysphagia, neck pain, airway occlusion, and respiratory distress.

Vocal cord nodules or polyps

Raspy hoarseness, the chief complaint, accompanies a chronic cough and a crackling voice.

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.

Other causes

Inhalation injury

An inhalation injury from a fire or an 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 lead  to respiratory distress.

Treatments

Occasionally, surgical trauma to the recurrent 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 often stems from acute laryngotracheobronchitis (croup). Acute laryngitis in children younger than age 5 may cause respiratory distress because the larynx is small and prone to spasm if irritated or infected. This may cause partial or total obstruction of the larynx. Temporary hoarseness often results from laryngeal irritation due to aspiration of liquids, foreign bodies, or stomach contents. Hoarseness may also stem from diphtheria, although immunization has made this disease rare.

Help the child with hoarseness rest his voice. Comfort an infant to minimize crying, play quiet games with him, and humidify his environment.

Patient counseling

Stress to the patient the importance of resting his voice because 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.

Book Source Details

• Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
• Author(s): Springhouse
• Year of Publication: 2006
• Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.

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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Professional Guide to Signs & Symptoms (Fifth Edition) Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2006 ISBN: 1-58255-510-9

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