Acute hoarseness is associated with etiologies of acute vocal cord edema, erythema, and dysfunction.

Viral infection, voice abuse, sudden excessive smoking, inhalation of irritant gases, aspiration, excessive gastroesophageal reflux (laryngopharyngeal reflux), and occasionally allergic reactions (hay fever) may result in acute hoarseness. In some instances, patients will become acutely hoarse after vocal abuse as a result of hemorrhage into the vocal fold.

Acute Laryngeal Edema. Acute laryngeal edema may present as part of a generalized edematous allergic response involving the lips, the tongue, and other hypopharyngeal tissues (angioedema). Foods are important précipitants, especially seafood and nuts; medications (especially angiotensin-converting enzyme inhibitors) can have a similar effect. Rarely, edema can develop from hereditary deficiency of C1 esterase inhibitor, as occurs in hereditary angioneurotic edema. The voice may progress from hoarse to muffled, signaling potential airway difficulties.

Mechanical Trauma. Swelling forms in response to mechanical trauma, such as dental surgery or intubation for general anesthesia. Rarely, traumatic or difficult intubation may lead to arytenoid dislocation, creating a very weak and hoarse voice with pain on swallowing.

Croup and Epiglottitis. In the pediatric population, subglottic edema from viral laryngotracheal bronchitis (croup) can obstruct the airway. In adults, acute epiglottitis has been noted with increasing frequency. As noted previously, it is associated with risk of airway obstruction, especially in the setting of H. influenzae infection, although rapid progression to airway obstruction is rare in adults. Symptoms include fever, severe sore throat, dysphagia, dyspnea, and muffled voice.

Chronic hoarseness raises questions about serious underlying pathology, although some causes are more harmless than life threatening.

Chronic Laryngitis and Contributing Factors. Chronic laryngitis causes a low, raspy voice; a nonproductive cough; and a “dry throat” sensation. There is usually little or no pain. The voice waxes and wanes, typically worsening as the day progresses. Gastroesophageal reflux disease (also known as laryngopharyngeal reflux disease) has been recognized as a common contributing factor. Another typical patient is a heavy smoker who continually talks, subjecting oneself to a combination of chemical irritation and vocal abuse. In rare instances, an infectious or chronic inflammatory condition (e.g., tuberculosis, mycosis, or sarcoidosis) may produce a similar picture.

Chronic Laryngeal Edema. Chronic laryngeal edema with development of dependent polyps represents another form of chronic laryngitis; it may arise in the setting of hypothyroidism, radiation therapy to the neck, or chronic sinusitis with persistent drainage and cough. Patients with this condition speak in a lowered, gravelly voice with short phonation time. Women may also present with a very low “male”-sounding voice. In severe cases, stridor may be present on deep inspiration.

Leukoplakia. Leukoplakia, another form of chronic laryngitis, is the term for the white scalelike appearance of hyperkeratotic changes involving the vocal cords. It occurs secondary to chemical irritation, especially from tobacco smoke and alcohol exposures. Symptoms include hoarseness without pain. Leukoplakia, which may be a premalignant state in 2% to 10% of cases, cannot be distinguished visually from squamous cell carcinoma in situ or early invasive cancer.

Contact Ulcers. Contact ulcers of the larynx occur on the posterior one third of the vocal cords, where the arytenoid cartilage is covered only by a thin layer of mucosa. Once this mucosa is abraded, an ulcer often forms. Symptoms are painful phonation and a weakened, breathy voice. Occasionally, blood-tinged sputum may be present. Chronic ulcerations may in time develop into granulations that hold the cords apart, and at times, these may become large enough to cause some respiratory obstruction. The ulcerations and subsequent granulations result most commonly from acute or chronic laryngeal intubation, but classically, they are the result of vocal abuse by orators who misuse their larynx by attempting to lower the pitch of their voice when speaking forcefully. Recently, gastroesophageal reflux also has been found to play a role in the development of contact ulcers.

Vocal Cord Paralysis. Vocal cord paralysis occurs with recurrent laryngeal or vagal nerve injury. Usually, just one cord is paralyzed (except in patients with severe central nervous system disease), causing a weak, breathy voice. The position of the cord is affected by the amount of time that has elapsed since injury because paralyzed cords tend to move toward the midline. The degree of paralysis and the clinical presentation depend on where the neural injury is located. Injury to a vagus nerve results in the loss of all ipsilateral laryngeal muscle function and sensation, leading to aspiration and a weak, breathy voice. A more peripheral injury of the recurrent laryngeal nerve leads to little if any aspiration and a voice that is hoarse and somewhat weak but less breathy. Viral neuritis and thoracic malignancy are the most common causes; with the former, function usually returns in 6 to 9 months.

Laryngeal Carcinoma. Laryngeal carcinoma usually occurs in patients with a history of smoking and drinking. If the vocal cords are involved, progressive hoarseness is an early sign, but if the tumor arises on the epiglottis, hypopharynx, or false cords, hoarseness may be a late development. Pain secondary to ulceration is also a late symptom and is often perceived as referred otalgia, especially when swallowing. These patients may have a mildly fetid breath. Patients with a hypopharyngeal or laryngeal cancer can present with an unexplained lymph node in the neck. The voice quality is extremely variable, ranging from breathy (commonly with large exophytic lesions preventing apposition of the cords) to strained or aphonic (commonly with ulcerative or lesions eroding the vocal fold).

Vocal Cord Nodules and Polyps. Vocal cord nodules may develop when edematous cords are used excessively. With continued excess voice use, fibrous tissue begins to collect at the junction of the anterior one third and the posterior two thirds of the vocal cord. This results in a lowered, breathy voice, which can harm a singing or speaking career. Vocal cord nodules (usually bilateral) typically occur in younger patients with a history of excessive voice use. Singers, teachers, and orators are at particular risk. These patients can often describe the history of onset for the hoarseness in the way in which it affects their voice. Pain may be present as the patient increasingly strains to generate a voice. The raspy quality to the voice often becomes more prominent later in the day when additional edema sets in. Patients with vocal cord polyps (usually unilateral) may present with varied types of dysphonia, depending on the size and location of the lesion. In many cases, an odd diplophonia (two frequencies of sound generated by the larynx) can be heard. Smoking and gastroesophageal reflux disease exacerbate both of these diagnoses.

Laryngeal Dystonias and Tremors. Increasingly recognized as causes for dysphonia and hoarseness, the laryngeal dystonias are characterized by a staccato voice breaks with a strained/strangled type of speech in the case of adductor spasmodic dysphonia versus involuntary voice breaks or changes in pitch characteristic of abductor spasmodic dysphonia. These are typically diagnosed based on clinical criteria emphasizing certain characteristic voice patterns with particular speech phrases. Once recognized, the spasmodic dysphonias are often effectively treated with local injections of botulinum toxin. Voice tremor is an increasingly common source of dysphonia or hoarseness in the elderly population. It may or may not be associated with hand tremor or tremor elsewhere. This is largely unresponsive to voice therapy or pharmacologic treatment.