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What are Hoarseness and Voice Loss?
The term hoarseness refers to a change in the voice, which may become:
- harsh and raspy
- low and gravelly (husky)
- shaky or trembling
- noticeably higher or lower in pitch than usual
The underlying cause is often something entirely benign, such as:
- talking loudly or for long periods
- excessive shouting
- gastroesophageal reflux
and the condition typically resolves on its own within a few days.
Depending on the underlying cause, hoarseness may be accompanied by other symptoms, such as:
- cough
- difficulty swallowing
- fever
- difficulty breathing
Among the many possible causes of hoarseness is laryngeal cancer, although there are certainly far more common and less serious explanations. Still, it’s important to stress that any voice change that cannot be explained by an obvious cause (such as the flu) should always be evaluated by a doctor.
It’s also worth noting that straining your voice while already hoarse can lead to serious problems, sometimes even permanent damage. A hoarse voice is a symptom that should never be ignored, and vocal rest is always essential for recovery.
For information on hoarseness in children, please see our dedicated article.
How Does the Voice Work?
The sound of your voice is produced by the vibration of the vocal cords, two bands of smooth muscle tissue positioned opposite each other inside the larynx (voice box). The larynx is a structure located roughly at the level of the throat, specifically between the base of the tongue and the top of the trachea, which leads to the bronchi and, further down, the lungs.
When we’re not speaking, the vocal cords remain open to allow normal breathing. To produce speech, the brain triggers and coordinates a series of complex, finely tuned mechanisms:
- The vocal cords vibrate as air is exhaled from the lungs.
- These vibrations generate sound waves that travel through the throat, nose, and mouth, structures that allow sound to resonate and then be properly shaped into speech.
- Voice quality, volume, and pitch are determined by the size and shape of the vocal cords and the resonating cavities. This is why every person’s voice sounds unique.
Causes of Voice Disorders
Acute Laryngitis
Acute laryngitis is the most common cause of hoarseness and sudden voice loss. It causes temporary swelling of the vocal cords, often following a cold, an upper respiratory infection, or allergies, although the majority of cases are caused by a viral infection (meaning antibiotics are of no use).
Swelling of the vocal cords changes the way they vibrate during speech, which in turn produces an altered voice.
Treatment depends heavily on the underlying cause, but in most cases the following is sufficient:
- rest
- plenty of fluids
- mild anti-inflammatory medication, if needed
Tracheitis, an inflammation of the trachea, can also cause hoarseness.
Chronic Laryngitis
The term “chronic laryngitis” refers to inflammation of the vocal cords that persists over a long period, and its causes are generally different from those of viral infections and common colds.
The most common causes include:
- acid reflux (discussed further below)
- exposure to irritants such as cigarette smoke
- infections of the vocal cords, for example fungal infections in patients with weakened immune systems, often related to long-term use of corticosteroid-based asthma inhalers, chemotherapy, or similar treatments
Gastroesophageal Reflux
Gastroesophageal reflux can cause hoarseness because stomach acid travels up into the throat and irritates the mucous membranes, a condition known as laryngopharyngeal reflux. Voice changes caused by reflux typically worsen in the morning and improve slightly throughout the day.
Some patients experience no other symptoms at all, not even the classic heartburn, but more often one or more of the following symptoms may also be present:
- hoarseness (chronic or intermittent)
- difficulty swallowing
- a lump-in-the-throat sensation
- a dry, irritating cough
- sore throat
Vocal Strain and Overuse
Shouting at a stadium, raising your voice in a loud nightclub, singing at very high pitches, or talking for too long without giving your voice a break can all cause temporary hoarseness. Using your voice is a lot like physical exercise: you need to avoid overdoing it and take regular breaks to prevent excessive strain on the vocal cords.
Straining or overusing the voice can lead to benign lesions on the vocal cords, or even vocal cord hemorrhage.
In these cases, vocal rest and adequate hydration are usually enough. However, certain groups of people, such as:
- teachers
- singers
- public speakers
may develop hoarseness that simply won’t go away. In these cases, it’s essential to see an ENT specialist to investigate the underlying cause and learn how to prevent future episodes.
Vocal Cord Disorders
Benign Vocal Cord Lesions
Nodules, polyps, and cysts are benign (non-cancerous) growths that develop on or along the vocal cords:
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Vocal nodules are a common problem among professional singers. They typically form in pairs on opposite sides of the vocal cords as a result of excessive pressure or friction, in a way similar to how a callus forms on a foot from wearing shoes that are too tight. While often clinically insignificant, they are frequently accompanied by dysphonia (a general term for voice disorders, ranging from hoarseness to complete voice loss), which initially appears after vocal strain but can eventually persist even at rest over time.
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A vocal polyp typically occurs on only one side of the vocal cord.
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A cyst is a firm mass of tissue enclosed within a membrane sac inside the vocal cord.
The most common treatments for nodules, polyps, and cysts include:
- vocal rest
- voice therapy (speech therapy)
- surgical removal of the growth, in some cases
Vocal Cord Hemorrhage
If you suddenly lose your voice after screaming, shouting, or otherwise straining it, you may be experiencing a vocal cord hemorrhage. This occurs when a small blood vessel on the surface of the vocal cord ruptures, causing blood to seep into the surrounding tissue. In some cases, this leads to a very rapid onset of hoarseness that only shows up while singing, not while speaking.
It’s essential to rest your voice immediately and see a specialist.
Vocal Cord Paralysis and Paresis
Hoarseness and other voice problems can also stem from disorders affecting the nerves and muscles of the larynx or pharynx. The most common neurological disorder affecting the larynx is paralysis or weakness of one or both vocal cords.
Vocal cord paralysis is a voice disorder that occurs when one or both vocal cords can no longer open or close properly. It can be caused by:
- head injuries, neck injuries, or chest trauma
- lung cancer, thyroid cancer, and similar conditions
- infections (such as Lyme disease)
People with certain neurological conditions, such as multiple sclerosis or Parkinson’s disease, or those who have had a stroke, may be more prone to this condition. In many cases, however, the exact cause remains unknown.
Treatment typically involves voice therapy and, in some cases, surgery.
Paralysis affecting both vocal cords is rare and usually presents as noisy breathing or shortness of breath while speaking or breathing. If only one vocal cord is paralyzed or weakened, voice quality tends to be affected rather than breathing itself.
Neurological Conditions
Neurological conditions affecting the areas of the brain that control the muscles of the throat or larynx can cause hoarseness and other voice disorders. As mentioned, Parkinson’s disease or a stroke can explain this symptom, but it’s also worth mentioning spasmodic dysphonia, a rare neurological disorder that causes hoarseness and can also affect breathing. Treatment in these cases depends on the specific underlying condition.
Other Disorders
Thyroid problems and trauma to the larynx can also cause voice disorders, as can laryngeal cancer.
Chronic hoarseness (lasting more than three weeks) should therefore be considered a warning sign that warrants medical evaluation. Pay attention to your voice, it can provide valuable clues about your health! Laryngeal cancer is highly treatable when diagnosed in its early stages.
Hoarseness is also the most common symptom of recurrent respiratory papillomatosis, a rare airway infection caused by the human papillomavirus (HPV), which can lead to the growth of benign tumors in the larynx.
Can Medications Damage Your Voice?
Certain medications and herbal remedies can have voice changes as a possible side effect. In most cases, the underlying mechanism involves one of the following:
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Reduced hydration of the mucous membranes covering the vocal cords, which need to stay well lubricated to function properly. When these membranes become dry, speaking becomes more difficult, making proper hydration essential for vocal health.
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Thinning of the blood (from anticoagulants and antiplatelet drugs), which increases the risk of vocal cord injury or bleeding following strain or trauma.
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Fluid retention (edema), which can cause swelling of the vocal cords.
Medications that may potentially cause hoarseness or other voice changes include:
- antidepressants
- muscle relaxants
- diuretics
- blood pressure medications (for high blood pressure)
- antihistamines (used for allergies)
- anticholinergics (used to treat asthma)
- high-dose vitamin C (more than 5 grams per day)
It’s also worth noting that:
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ACE inhibitors (angiotensin-converting enzyme inhibitors, used to control blood pressure) can cause coughing or a dry throat in more than 10% of patients. Excessive coughing or throat dryness can contribute to vocal cord injury.
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Oral contraceptives can cause fluid retention (edema) in the vocal cords, since they contain estrogen.
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Estrogen-based hormone replacement therapy, used during menopause, can have effects of varying intensity on the voice.
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Insufficient dosing of thyroid hormone replacement medication in patients with hypothyroidism.
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Anticoagulants (blood-thinning medications) can increase the risk of vocal cord hemorrhage or polyp formation following trauma.
When to Contact a Doctor
You should see a doctor if hoarseness lasts more than three weeks, especially if there’s no cold, flu, or other obvious respiratory illness that could explain the symptom.
Report the following to your doctor immediately:
- coughing up blood
- a visible or palpable lump in the neck
- pain while swallowing or speaking
- difficulty breathing
- complete loss of voice lasting more than a few days
Diagnosis
To reach an accurate diagnosis, it may be necessary to consult an otolaryngologist (ENT specialist), who will typically begin with a thorough medical history (a conversation to gather information about your health status, risk factors, and lifestyle) before performing a visual examination of the vocal cords using a laryngoscope, a thin instrument equipped with a camera that allows direct visualization of the vocal cords.
Remedies and Treatment
Managing hoarseness depends heavily on its underlying cause, though occasional episodes, such as those caused by a common cold, generally resolve on their own within a few days.
When hoarseness is secondary to another underlying condition, treating the primary cause is essential to fully resolve the symptom.
Vocal cord nodules or polyps are typically managed with voice therapy (speech therapy), sometimes combined with medication, as the first-line treatment, while surgery is only rarely necessary.
In patients without a clear diagnosis, doctors often prescribe antacids or proton pump inhibitors as an empirical trial to check for the possible presence of gastroesophageal reflux.
Natural Remedies
Helpful natural approaches for preventing and managing voice loss or hoarseness include:
- Resting your voice (avoid whispering, which can actually worsen inflammation).
- Staying well hydrated (water is the best choice).
- Quitting smoking (and avoiding secondhand smoke exposure).
- Reducing alcohol consumption, since alcohol has both an irritating and dehydrating effect.
- Cutting back on caffeine.
- Chewing sugar-free gum, which can help stimulate saliva production and keep the vocal cords hydrated.
- Avoiding throat clearing, an action that further irritates the affected tissues.
Tips to Keep Your Voice Healthy
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Yelling, shouting, and generally straining your voice can lead to injury and, in some cases, permanent damage.
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Warm up your voice before straining it or using it for extended periods. Singers are well known for warming up before performances, but many people don’t realize that vocal warm-ups are just as important before other types of vocal effort, such as teaching a class, giving a speech, or speaking in public. A simple warm-up might involve a descending scale of vowel sounds, trilled the way children often do.
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Learn proper breathing techniques. Good breathing is fundamental to a healthy voice.
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Use a microphone when speaking in public whenever possible, to reduce strain on your voice.
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Quit smoking.
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Reduce or avoid caffeine and alcohol, both of which dehydrate the body.
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Drink plenty of water to keep the vocal cords properly lubricated.
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Humidify the air in your home.
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Avoid spicy foods.
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Never strain your voice further when hoarseness is already present.
Frequently Asked Questions
How can I get my voice back?
Unfortunately, recovery usually takes time and patience (and possibly a visit to a specialist if hoarseness doesn’t resolve within a few days). The following can help:
- Give your voice complete rest.
- Drink plenty of fluids.
- Avoid exposure to smoke (both active and secondhand).
- Avoid alcohol and caffeine.
- Chew sugar-free gum to stimulate saliva production.
- Avoid throat clearing and whispering, both of which further irritate the vocal cords.
