Hoarseness (dysphonia) is a subjective alteration in voice quality. There are many causes of hoarseness (Figure 32.1). Common causes include laryngitis, vocal cord nodules and muscle tension dysphonia. If hoarseness persists for more than 3 weeks it may be secondary to a malignancy and needs referral for specialist ENT assessment.

Acute laryngitis

This is a common feature of upper respiratory tract infections and can last up to 2 weeks. Treatment is with fluids, analgesia and anti-inflammatory drugs. Voice rest should be encouraged during the acute phase, especially avoidance of whispering, shouting and forcing the voice.

Chronic laryngitis

Smoking, alcohol and excessive or misuse of the voice, for example in professional voice users (e. g. teachers, actors) can cause chronic inflammation. Advise voice rest and smoking cessation. For prolonged symptoms get the help of a speech and language therapist (SALT). In smokers, chronic laryngitis can progress to dysplasia, then carcinoma in situ and finally invasive carcinoma.

Vocal cord palsy

Hoarseness, and in some cases aspiration, can be caused by inability of one or both of the cords to appose (Figure 32.2). The laryngeal muscles are mainly supplied by the recurrent laryngeal nerves, branches of the vagus nerve. Any pathology that affects these nerves can cause hoarseness. Causes of vocal cord paralysis include trauma to the nerve, which may be iatrogenic (i. e. after thyroid or parathyroid surgery), a mediastinal mass (e. g. bronchogenic carcinoma) and thyroid malignancy.

Vocal cord nodules

Repeated trauma to the edge of the cords - typically caused by excessive or untutored voice projection - can cause submucosal fibrosis and the development of nodules (Figure 32.3). Voice rest and SALT are usually all that are needed. Vocal cord nodules are also see in children as a cause for hoarseness; treatment is the same.

Muscle tension dysphonia

Voice problems can be caused by incoordination of the laryngeal muscles. SALT assessment and exercises are the main management of this disorder.

See Chapter 31.

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