What Is Hoarseness?

Hoarseness is also referred to by the medical term "dysphonia." It is an abnormal sound produced when you try to speak. This may be raspy, breathy, soft, tremulous or as changes in the volume of your voice. There may also be some pain or a strained feeling when trying to speak normally. A hoarse voice can be caused by anything that interferes with the normal vibration of the vocal cords, such as swelling and inflammation, polyps that get in the way of the vocal cords closing properly or conditions that result in one or both of the vocal cords becoming paralyzed.

Possible Causes are-

  • Laryngitis
  • Vocal cord cysts or polyps
  • Cancer
  • Neurological conditions
  • Trauma
  • Spasmodic dysphonia
  • Laryngeal nerve paralysis
  • Inhalation of a foreign body or caustic substance.
  • Exposure to other irritating substances
  • Long-term use of inhaled corticosteroids
  • Allergies
  • Acid reflux/Heartburn
  • Thyroid conditions
  • Smoking

Here are some of the images showing common lesions of vocal cords-


Vocal Cord Nodules and Polyps

Vocal cord nodules are benign (noncancerous) growths on both vocal cords that are caused by vocal abuse. Over time, repeated abuse of the vocal cords results in soft, swollen spots on each vocal cord. These spots develop into harder, callous-like growths called nodules. The nodules will become larger and stiffer the longer the vocal abuse continues.

Polyps can take a number of forms. They are sometimes caused by vocal abuse. Polyps appear on either one or both of the vocal cords. They appear as a swelling or bump (like a nodule), a stalk-like growth, or a blister-like lesion. Most polyps are larger than nodules and may be called by other names, such as polypoid degeneration or Reinke's edema. The best way to think about the difference between nodules and polyps is to think of a nodule as a callous and a polyp as a blister.

Nodules and polyps cause similar symptoms:

  • hoarseness
  • breathiness
  • a "rough" voice
  • a "scratchy" voice
  • harshness
  • shooting pain from ear to ear
  • a "lump in the throat" sensation
  • neck pain
  • decreased pitch range
  • voice and body fatigue

If you have experienced a hoarse voice for more than 2 to 3 weeks, you should see a physician. A thorough voice evaluation should include:

  • A physician's examination, preferably by an otolaryngologist (ear, nose, and throat doctor) who specializes in voice.
  • A voice evaluation by a speech-language pathologist (SLP), and
  • Possibly a neurological examination.

The team will evaluate vocal quality, pitch, loudness, ability to sustain voicing, and other voice characteristics. An instrumental examination may take place that involves inserting an endoscope into the mouth or nose to look at the vocal cords and larynx in general. A stroboscope (flashing light) may be used to watch the vocal cords as they move.

Nodules and polyps may be treated medically, surgically, and/or behaviorally. Surgical intervention involves removing the nodule or polyp from the vocal cord. This approach only occurs when the nodules or polyps are very large or have existed for a long time. Surgery is rare for children. Medical problems may be treated to reduce their impact on the vocal cords. This includes treatment for gastroesophageal reflux disease (GERD), allergies, and thyroid problems. Medical intervention to stop smoking or to control stress is sometimes needed.

Many people receive behavioral intervention, or voice therapy, from an SLP. Voice therapy involves teaching good vocal hygiene, reducing/stopping vocal abusive behaviors, and direct voice treatment to alter pitch, loudness, or breathe support for good voicing. Stress reduction techniques and relaxation exercises are often taught as well.

Nodules are most frequently caused by vocal abuse or misuse. Polyps may be caused by long-term vocal abuse but may also occur after a single, traumatic event to the vocal cords, such as yelling at a concert. Long-term cigarette smoking, hypothyroidism, and GERD may also cause polyp formation. Vocal abuse takes many forms and includes:

  • allergies
  • smoking
  • tense muscles
  • singing
  • coaching
  • cheerleading
  • talking loudly
  • drinking caffeine and alcohol (dries out the throat and vocal cords)

It has been noted that, for unknown reasons, vocal nodules occur more frequently in women between the ages of 20 and 50.


The most common ways for the lining to be injured and result in exposed cartilage are:

  • Intubation for surgery (breathing tube placed during all general anesthesia)
  • Intubation for illness (breathing tube placed during hospitalizations, for example, head injuries, lung infections, etc.) Forceful voice use, including:
  • Singing aggressive styles (i.e., gospel, rock, etc.)
  • Singing incorrectly (i.e., poor technique, when unwell)
  • Singing in poor environments (i.e., poor amplification, poor monitors, loud environment, etc)
  • Throat clearing
  • Coughing
  • Shouting

Once the lining is injured, it is difficult for it to heal. You are probably still doing things that prevent the lining from healing (talking, singing, shouting, etc.). When the lining cannot heal, the body tries to cover the cartilage by creating a granuloma.

Imagine what happens when you fall and skin your knee. If you do not touch the area of injury, it will begin to heal and scab over. However, if you keep on picking the scab, the injured area will not heal. Picking the scab is the same thing as continuing to talk after you have injured the vocal lining. The lining cannot heal under these conditions.

The symptoms of a vocal granuloma vary according to your vocal demands.

If you are a vocational voice user (i.e., someone who uses their voice for their living, such as a singer, actor, voiceover artist, etc), you will possibly notice:

  • Chronic hoarseness
  • Pitch change in your voice
  • Significantly decreased range (no longer hitting higher notes easily)
  • Inability to sing quietly
  • Inability to hold a pitch steady
  • Throat pain
  • Voice fatigue

It is rare, if not impossible, to access your full vocal range with a granuloma.

It is not always easy to know if you have a granuloma. Two possible self-checks are

  • See if you feel discomfort when you rub your neck around your larynx (voice box). Often pain develops from granulomas due to incorrect voice use.
  • After a good warm-up, attempt to glissando to the highest notes you can normally reach. If you are unable to reach them comfortably, without increased effort, you may have a granuloma.
  • If you are an avocational voice user, you will possibly notice:
  • Throat discomfort, pain, or tightness
  • Hoarseness in your speaking voice

A granuloma will look like a growth that occurs on one side of the larynx. It occurs in the back of the larynx, at the site of the cartilage.

It may be whitish, yellowish, or occasionally blood-stained. Rarely there are granulomas on both side of the larynx. On stroboscopy, the cord may not vibrate at all due to the weight of the granuloma on the vocal cord. The granuloma may sit on top of the cord and dampen the vibration. In cases of smaller granulomas, the vibration may be less affected.

The only way to know if your symptoms are due to a granuloma is to have your vocal cords examined. This requires the use of videostroboscopy by a laryngologist.

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