Chapter 57

### Introduction

Hoarseness results from imperfect phonation due to impairment of normal vocal cord mobility or vibration. It is an important symptom as it may signal a serious cause such as malignancy or a disease with potential for airway obstruction.1

Raymond L Carroll 1996

Hoarseness (dysphonia) is defined as an altered voice due to a laryngeal disorder.2 It is an important symptom of laryngeal disease presenting in general practice, and ranges from the very common, trivial, self-limiting condition of viral upper respiratory tract infection to a life-threatening disorder (see Table 57.1). It may be of sudden presentation lasting only a few days or develop gradually and persist for weeks or months. The cut-off point between acute and chronic hoarseness is three weeks duration, by which time most self-limiting conditions have resolved. Hoarseness pertains to harsh, raspy, gravelly or rough tones of voice rather than pitch or volume. Rarely, hoarseness can be a functional or deliberate symptom referred to as ‘hysterical aphonia’.3 In this condition, patients purposely hold the cords apart while speaking.

Table 57.1

Hoarseness: diagnostic strategy model

Key facts and checkpoints

• In acute hoarseness the diagnosis is usually obvious from the history alone. Examples include acute upper respiratory tract infection (URTI) or vocal overuse.

• Think ‘hypothyroidism’ if unusual hoarseness develops.

• Laryngeal cancer must be excluded if hoarseness persists for longer than 3 weeks in an adult. It can arise intrinsic or extrinsic to the vocal cords.

• Intermittent hoarseness is invariably secondary to a benign disorder. Constant or progressive hoarseness suggests malignancy.

• Non-malignant vocal cord lesions, which include polyps, vocal nodules, contact ulcers, granulomas, other benign tumours and leucoplakia, account for about half of all voice disorders.

• In cases of chronic hoarseness the larynx must be visualised for diagnosis but the following are common:

• children—‘screamer’s nodules’

• Acute laryngeal oedema may develop as a ...

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