Hoarseness
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Direct answer
Hoarseness — dysphonia — lasting more than three weeks in an adult is an indication for visualisation of the larynx, because the symptom spans harmless overuse and curable early cancer with nothing in the voice quality alone to separate them. The commonest benign causes organise by pattern: vocal nodules in voice abusers (bilateral, at the junction of the anterior and middle third of the cords, treated with voice therapy), polyps (unilateral, often haemorrhagic), Reinke oedema (bilateral diffuse "sacculated" swelling giving the deep smoker's voice, also linked to hypothyroidism), contact granulomas over the vocal processes (intubation or reflux-related), and recurrent respiratory papillomatosis from human papillomavirus types 6 and 11. Laryngopharyngeal reflux, acute laryngitis, vocal cord palsy and puberphonia complete the standard differential, and videolaryngostroboscopy is the examination that resolves it.
What you must remember
- The three-week rule: hoarseness beyond three weeks — with smoking, dysphagia, otalgia, weight loss or a neck node — warrants laryngoscopy.
- Vocal nodule: "singer's nodules", bilateral symmetrical swellings at the anterior-middle third junction of the true cords from phonotrauma; treatment is voice therapy (hygiene, hydration, technique), not surgery first.
- Vocal polyp: usually unilateral, may follow a bleeding episode into Reinke's space; endoscopic microsurgery when persisting.
- Reinke oedema: diffuse bilateral gelatinous swelling of the cords, classically in heavy-smoking middle-aged women, with a deep, monotonous voice; check thyroid function — hypothyroidism is an Indian exam favourite association — and treat by smoking cessation with microflap surgery when needed.
- Contact granuloma/ulcer: over the arytenoid vocal process, associated with trauma (intubation), hard glottal attack and reflux; manage reflux and voice, excise only if persistent or suspicious.
- Recurrent respiratory papillomatosis: HPV 6 and 11; juvenile-onset disease is aggressive and recurrent, adult disease milder; treatment is microdebrider or laser removal, with adjuvants such as cidofovir or bevacizumab for refractory disease — never a single cure.
- Laryngopharyngeal reflux: hoarseness worse in the morning, globus, throat clearing and cough without heartburn; proton pump inhibitor trial plus behaviour, with pH-impedance when the diagnosis is contested.
- Red-flag pairings: persistent hoarseness with otalgia (referred via vagus/tympanic branch), dysphagia, neck node or stridor — suspect malignancy; a smoker's hoarse voice for two months is cancer until laryngoscopy says otherwise.
Worked example: four voices in one voice clinic
A 26-year-old teacher loses the top of her range by Friday and her voice cracks; stroboscopy shows symmetric nodules meeting at the glottic front. Voice therapy — hydration, amplification in class, replacing throat-clearing with a swallow of water — resolves most nodules in weeks; surgery is the exception. Next, a 52-year-old who has smoked bidis for thirty years reports a deep, effortful voice for a year; the cords are diffusely swollen and polypoid — Reinke oedema. Check thyroid-stimulating hormone, since hypothyroidism is common in Indian women and worsens the oedema, then counsel that microflap surgery without absolute smoking cessation is doomed.
Third, a 38-year-old hoarse six weeks after intensive care intubation has a granuloma capping the right vocal process — reflux control, soft-voice use and time resolve most, with serial laryngoscopy confirming the mass behaves. The fourth voice is why the clinic exists: a 61-year-old smoker with three months of worsening hoarseness, left otalgia, weight loss and a firm neck node; white irregular thickening fixes the left cord's vibration, and biopsy confirms squamous carcinoma. The teacher gets therapy, the smoker gets a scope — the difference was never audible over the phone.
Where students slip
Candidates send every hoarse patient to voice rest: rest suits acute laryngitis and overuse, but nodules need active therapy, reflux needs acid and behaviour measures, and suspected cancer needs a scope — blanket rest only delays diagnosis. Reinke oedema's deep voice is attributed to ageing without mentioning smoking or the thyroid. Papillomatosis is treated as excise-once-and-cured, though its defining property is recurrence. Finally, referred otalgia with hoarseness — vagal sensory fibres to the deep ear — is under-recognised as a herald of laryngeal and hypopharyngeal malignancy.
Frequently asked questions
How long can hoarseness persist before laryngoscopy is mandatory?
Beyond three weeks in an adult — earlier still with smoking, alcohol use, dysphagia, otalgia, weight loss or a neck lump, any of which raises suspicion of laryngeal malignancy.
What are vocal nodules and how are they treated?
Symmetric phonotraumatic swellings at the junction of the anterior and middle thirds of both vocal cords, treated primarily with voice therapy; surgery only for persisting, fibre-like lesions.
Which conditions produce Reinke oedema and what must be checked?
Chronic smoking and hypothyroidism produce the diffuse bilateral cord swelling that deepens the voice; thyroid function testing and absolute smoking cessation precede microflap surgery.
Which virus causes recurrent respiratory papillomatosis and its behaviour?
Human papillomavirus types 6 and 11, causing recurrent glottic papillomas — juvenile-onset disease being more aggressive — managed by repeated endoscopic excision with adjuvants for refractory disease.
Why can hoarseness present with ear pain?
Referred otalgia via vagal sensory fibres (the auricular branch of the vagus serving the deep ear) is a classic referred symptom of laryngeal and hypopharyngeal cancer.