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Hoarseness in adults

Jean M Bruch, DMD, MD
Dipti V Kamani, MD
Section Editor
Daniel G Deschler, MD, FACS
Deputy Editor
Daniel J Sullivan, MD, MPH


"Hoarseness" is a term often used to describe any change in voice quality. This reflects a variety of complaints including vocal tremor, weakness, fatigue, altered pitch, breathiness, or strained voice quality.

The approach to the adult who presents with hoarseness will be reviewed here. The approach to hoarseness in children is discussed separately. (See "Hoarseness in children: Evaluation".)


The main functions of the larynx involve phonation, respiration, swallowing, and Valsalva:

Phonation refers to production of a primary vocal tone at the level of the vocal folds. Vocal quality is then modified by resonation through the upper airway and sinonasal tract and articulated into speech.

Airway patency and protection is important during respiration and swallowing. The normal swallow mechanism includes laryngeal elevation, posterior deflection of the epiglottis, inhibition of respiration, and closure of the vocal folds to prevent aspiration of ingested material.

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Literature review current through: Nov 2017. | This topic last updated: Nov 21, 2017.
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  1. Citardi MJ, Gracco CL, Sasaki CT. The anatomy of the human larynx. In: Diagnosis and Treatment of Voice Disorders, Rubin JS, Sataloff RT, Korovin GS, Gould GS, Gould (Eds), Igaku-Shoin, New York 1995.
  2. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009; 141:S1.
  3. Reveiz L, Cardona AF, Ospina EG. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev 2007; :CD004783.
  4. Wood JM, Athanasiadis T, Allen J. Laryngitis. BMJ 2014; 349:g5827.
  5. Remacle M, Lawson G. Diagnosis and management of laryngopharyngeal reflux disease. Curr Opin Otolaryngol Head Neck Surg 2006; 14:143.
  6. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 1991; 101:1.
  7. Cherry J, Margulies SI. Contact ulcer of the larynx. Laryngoscope 1968; 78:1937.
  8. Zhukhovitskaya A, Battaglia D, Khosla SM, et al. Gender and age in benign vocal fold lesions. Laryngoscope 2015; 125:191.
  9. Bouchayer M, Cornut G. Microsurgery for benign lesions of the vocal folds. Ear Nose Throat J 1988; 67:446.
  10. Havas T, Lowinger D, Priestley J. Unilateral vocal fold paralysis: causes, options and outcomes. Aust N Z J Surg 1999; 69:509.
  11. Randolph GW, Kamani D. The importance of preoperative laryngoscopy in patients undergoing thyroidectomy: voice, vocal cord function, and the preoperative detection of invasive thyroid malignancy. Surgery 2006; 139:357.
  12. Baron EM, Soliman AM, Gaughan JP, et al. Dysphagia, hoarseness, and unilateral true vocal fold motion impairment following anterior cervical diskectomy and fusion. Ann Otol Rhinol Laryngol 2003; 112:921.
  13. Sulica L. The natural history of idiopathic unilateral vocal fold paralysis: evidence and problems. Laryngoscope 2008; 118:1303.
  14. Ramadan HH, Wax MK, Avery S. Outcome and changing cause of unilateral vocal cord paralysis. Otolaryngol Head Neck Surg 1998; 118:199.
  15. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope 2007; 117:1864.
  16. Ishman SL, Halum SL, Patel NJ, et al. Management of vocal paralysis: a comparison of adult and pediatric practices. Otolaryngol Head Neck Surg 2006; 135:590.
  17. Yin SS, Qiu WW, Stucker FJ, et al. Evaluation of bilateral vocal fold dysfunction: paralysis versus fixation, superior versus recurrent, and distal versus proximal to the laryngeal nerves. Am J Otolaryngol 1997; 18:9.
  18. Bosley B, Rosen CA, Simpson CB, et al. Medial arytenoidectomy versus transverse cordotomy as a treatment for bilateral vocal fold paralysis. Ann Otol Rhinol Laryngol 2005; 114:922.
  19. Merati AL, Heman-Ackah YD, Abaza M, et al. Common movement disorders affecting the larynx: a report from the neurolaryngology committee of the AAO-HNS. Otolaryngol Head Neck Surg 2005; 133:654.
  20. Sewall GK, Jiang J, Ford CN. Clinical evaluation of Parkinson's-related dysphonia. Laryngoscope 2006; 116:1740.
  21. Kent RD, Kent JF, Weismer G, et al. Impairment of speech intelligibility in men with amyotrophic lateral sclerosis. J Speech Hear Disord 1990; 55:721.
  22. Liu WB, Xia Q, Men LN, et al. Dysphonia as a primary manifestation in myasthenia gravis (MG): a retrospective review of 7 cases among 1520 MG patients. J Neurol Sci 2007; 260:16.
  23. Ruotsalainen J, Sellman J, Lehto L, Verbeek J. Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Otolaryngol Head Neck Surg 2008; 138:557.
  24. Bartels H, Dikkers FG, van der Wal JE, et al. Laryngeal amyloidosis: localized versus systemic disease and update on diagnosis and therapy. Ann Otol Rhinol Laryngol 2004; 113:741.
  25. Alaani A, Warfield AT, Pracy JP. Management of laryngeal amyloidosis. J Laryngol Otol 2004; 118:279.
  26. Motta G, Salzano FA, Motta S, Staibano S. CO(2)-laser treatment of laryngeal amyloidosis. J Laryngol Otol 2003; 117:647.
  27. Bachor E, Bonkowsky V, Hacki T. Herpes simplex virus type I reactivation as a cause of a unilateral temporary paralysis of the vagus nerve. Eur Arch Otorhinolaryngol 1996; 253:297.
  28. Parano E, Pavone L, Musumeci S, et al. Acute palsy of the recurrent laryngeal nerve complicating Epstein-Barr virus infection. Neuropediatrics 1996; 27:164.
  29. Rosen CA, Anderson D, Murry T. Evaluating hoarseness: keeping your patient's voice healthy. Am Fam Physician 1998; 57:2775.
  30. Diagnosis and Treatment of Voice Disorders, Rubin JS, Sataloff RT, Korovin GS (Eds), Plural Publishing, San Diego 2006.
  31. Sulica L. Hoarseness. Arch Otolaryngol Head Neck Surg 2011; 137:616.
  32. Reveiz L, Cardona AF. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev 2015; :CD004783.
  33. Schalén L, Christensen P, Eliasson I, et al. Inefficacy of penicillin V in acute laryngitis in adults. Evaluation from results of double-blind study. Ann Otol Rhinol Laryngol 1985; 94:14.
  34. Schalén L, Eliasson I, Kamme C, Schalén C. Erythromycin in acute laryngitis in adults. Ann Otol Rhinol Laryngol 1993; 102:209.
  35. Rafalskiy VV, Gurevitch AS, Otvagin IV, Dovgan EVA. Randomized comparative study of 7-days courses of fuzafungine vs. fuzafungine and clarithromycin in patients with acute laryngitis. 52nd Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC) of the American Society for Microbiology. 2012; Vol. 52:L1299. http://www.icaaconline.com/php/icaac2013abstracts/data/papers/2012/L1/2012_L1-299.htm (Accessed on July 08, 2015).
  36. Ruotsalainen JH, Sellman J, Lehto L, et al. Interventions for treating functional dysphonia in adults. Cochrane Database Syst Rev 2007; :CD006373.
  37. Wang CT, Liao LJ, Cheng PW, et al. Intralesional steroid injection for benign vocal fold disorders: a systematic review and meta-analysis. Laryngoscope 2013; 123:197.
  38. Pedersen M, McGlashan J. Surgical versus non-surgical interventions for vocal cord nodules. Cochrane Database Syst Rev 2012; :CD001934.
  39. Wang CC, Chang MH, De Virgilio A, et al. Laryngeal electromyography and prognosis of unilateral vocal fold paralysis--a long-term prospective study. Laryngoscope 2015; 125:898.
  40. Sridharan SS, Rosen CA, Smith LJ, et al. Timing of nimodipine therapy for the treatment of vocal fold paralysis. Laryngoscope 2015; 125:186.
  41. Rosen CA, Smith L, Young V, et al. Prospective investigation of nimodipine for acute vocal fold paralysis. Muscle Nerve 2014; 50:114.
  42. Mattsson P, Björck G, Remahl S, et al. Nimodipine and microsurgery induced recovery of the vocal cord after recurrent laryngeal nerve resection. Laryngoscope 2005; 115:1863.
  43. Montgomery WW, Montgomery SK. Montgomery thyroplasty implant system. Ann Otol Rhinol Laryngol Suppl 1997; 170:1.
  44. Aynehchi BB, McCoul ED, Sundaram K. Systematic review of laryngeal reinnervation techniques. Otolaryngol Head Neck Surg 2010; 143:749.
  45. Whurr R, Nye C, Lorch M. Meta-analysis of botulinum toxin treatment of spasmodic dysphonia: a review of 22 studies. Int J Lang Commun Disord 1998; 33 Suppl:327.
  46. Troung DD, Rontal M, Rolnick M, et al. Double-blind controlled study of botulinum toxin in adductor spasmodic dysphonia. Laryngoscope 1991; 101:630.