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A 67-year-old man with a 40-pack-year history of smoking presents with worsening hoarseness that began approximately 6 weeks ago. He complains of globus sensation and difficulty swallowing solid foods. He denies odynophagia, otalgia, hemoptysis, and hematemesis. There is no associated cough, and he has not had any constitutional symptoms such as fevers, chills, or recent weight loss.

Hoarseness in a middle-aged man with the above symptoms is very common, and the differential diagnosis is long (all the diseases below are possibilities in this case scenario). The patient's smoking history and duration of symptoms should raise concern for a possible laryngeal malignancy. However, more common diagnoses such as laryngopharyngeal reflux (LPR) and benign vocal fold (cord) lesions should be considered as well.


The evaluation of hoarseness typically involves first ruling out the most serious pathologies, such as laryngeal squamous cell carcinoma (SCC) in adults or recurrent respiratory papillomatosis (RRP) in children, and then proceeding with a more focused and subtle evaluation to uncover any of the many benign pathologies that affect the larynx. Treatment of these benign pathologies must take into account the patient's lifestyle and voice needs. It also often incorporates education on vocal hygiene, which involves increasing hydration, decreasing mucus and vocal abuse, and reducing acid reflux if a factor.


  • Hoarseness, dysphonia, vocal strain, breathiness, raspiness.

  • Vocal cords, true vocal cords, true vocal folds, glottis (Figure 38-1).

  • False vocal folds, false vocal cords (mucosal folds in the supraglottis, just superior to the true vocal folds and separated from the true folds by the ventricle).

  • Flexible fiberoptic laryngoscopy, nasopharyngeal scope (NP scope), transnasal fiberoptic laryngoscopy.

  • Stroboscopy, videolaryngostroboscopy (VLS), strobe exam.


Normal larynx (true and false vocal folds). FVF, False vocal fold; TVF, true vocal fold (cord). (Reproduced with permission from C. Blake Simpson, MD.)


  • The most common cause of hoarseness in adults and children overall is viral infection causing laryngitis (Figure 38-2).

  • LPR disease may be present in up to 50% of patients presenting with voice and laryngeal disorders.1 It is less commonly the sole cause of hoarseness (Figures 38-3 and 38-4).

  • Hoarseness can be a symptom of laryngeal cancer. It is estimated there were 13,000 new diagnoses of laryngeal cancer in the United States in 2017. The average age at diagnosis is 65 with a strong male predominance.2 SCC accounts for 95% of laryngeal cancer1 (Figure 38-5).

  • RRP represents the most common benign neoplasm of the larynx among children and should be considered in children with chronic hoarseness. A known risk factor for juvenile onset is the triad of a firstborn child (75%), teenage mother, and ...

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