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For further information, see CMDT Part 8-27: Dysphonia, Hoarseness, & Stridor

Key Features

Essentials of Diagnosis

  • The primary symptoms of laryngeal disease are hoarseness and stridor

General Considerations

  • Hoarseness is caused by an abnormal vibration of the vocal folds

Acute hoarseness

  • Acute laryngitis is the most common cause of hoarseness

  • Acute laryngitis is thought to be viral in origin, although Moraxella catarrhalis and Haemophilus influenzae isolates from the nasopharynx occur at higher than expected frequencies

Persistent hoarseness

  • Vocal fold nodules or polyps (from overuse of voice or improper use over extended periods of time) produce prolonged hoarseness

  • Vocal fold polypoid changes (from vocal abuse, smoking, chemical industrial irritants, or hypothyroidism)

  • Gastroesophageal reflux is a common cause of chronic hoarseness and should be considered if other causes of abnormal laryngeal airflow (such as tumor) have been excluded by laryngoscopy; < 50% of patients have typical symptoms of heartburn and regurgitation

  • In patients with a history of tobacco use, laryngeal cancer or lung cancer (leading to paralysis of a recurrent laryngeal nerve) must be strongly considered in persistent hoarseness

Clinical Findings

Symptoms and Signs

  • The voice is "breathy" when too much air passes incompletely apposed vocal folds, as in unilateral vocal fold paralysis or vocal fold mass

  • The voice is harsh when the vocal folds are stiff and vibrate irregularly, as is the case in laryngitis or malignancy

  • Heavy, edematous vocal folds produce a rough, low-pitched vocal quality

  • Stridor, a high-pitched sound, is the result of turbulent airflow from a narrowed upper airway

    • Airway narrowing at or above the vocal folds produces inspiratory stridor

    • Airway narrowing below the vocal folds produces either expiratory or biphasic stridor

  • In gastroesophageal reflux–induced hoarseness, the voice is usually worse in the morning and improves during the day; associated symptoms include a feeling of a lump in the throat or an excessive desire for throat clearing

Differential Diagnosis

  • Laryngitis

  • Voice overuse

  • Vocal fold nodules, polyps, or papillomas

  • Intubation granulomas

  • Laryngeal cancer

  • Lung cancer

  • Unilateral vocal cord paralysis

  • Hypothyroidism

  • Retrosternal goiter, thyroiditis, multinodular goiter, or thyroid carcinoma

  • Gastroesophageal reflux

  • Angioedema


Imaging Studies

  • Consider chest radiograph for tumor

Diagnostic Procedures

  • Evaluation of an abnormal voice begins with obtaining a history of the circumstances preceding its onset and an examination of the airway

  • Laryngoscopy should be done when hoarseness has persisted for > 2 weeks

  • In gastroesophageal reflux, nonresponders to medical management should undergo pH testing and manometry



  • Erythromycin may reduce the severity ...

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