Hoarse Voice in Adults and Children: Causes, When to Worry and What Actually Helps
Hoarse, croaky or strained sounding voice is something almost everyone experiences at some point, usually after a cold, a big night of yelling at the football or after a period of talking too much. Most of the time it clears up on its own within a couple of weeks. If the hoarse voice persists, it is worth understanding why this is occurring because hoarseness is not a single problem. It is a symptom with a long list of possible causes, each needing a different management approach. This guide discusses those causes in plain language, what current medical guidelines say about when to get it checked and what evidence based treatment is available for adults and children.
What Do Doctors Mean by Hoarseness?
The medical term is dysphonia, any change in your voice quality, pitch, loudness or how much effort it takes you to speak to the point where it affects how you communicate or how you feel about your voice.
It is very common and approximately one in thirteen adults will experience hoarseness in any given year and approximately one in three people will deal with it at some point in their life. The single most important rule is if it lasts more than four weeks get it looked at.
It is important to remember that if hoarseness has not improved within four weeks, it should be assessed with a visual assessment of the voice box (larynx and vocal cords using a small endoscope). This is performed in the office routinely and is usually a quick and very well tolerated procedure in both children and adults using a very thin flexible high resolution digital camera that is gently passed into the nose and can view the upper airway and voice box.
Assessment of a hoarse voice should not be delayed for four weeks in some situations.
In some,it should happen sooner or sometimes even straight away if there are some concerning features. These include:
- A neck lump as well as the voice change.
- Recent surgery involving the head, neck or chest or recent anaesthesia with the use of an endotracheal (breathing) tube placed during the operation.
- Difficulty breathing or a harsh or high pitched breathing sound at rest (stridor) for a significant history of smoking.
- The person relies significantly on their voice for work such as a singer, teacher or professional performer.
The guidelines are also clear on what isn’t required before the examination of the voice box. A hoarse voice should not be treated before being assessed with antibiotics, oral steroids or reflux medications as” a just in case” scenario.
It is not necessary for a CT scan or MRI to be ordered before an ENT Surgeon has actually assessed the voice box with the fibreoptic camera. These recommendations exist because such treatments have not been shown to reliably help hoarse voices and going straight to treating the problem without finding the real cause can expose people to unnecessary irradiation.
Common Causes of Hoarseness and How Each is Treated.
Viral laryngitis.
This is by far the most common cause of hoarse voice, which is inflammation of the vocal cords following a cold or upper respiratory tract infection. This typically improves within 1 – 2 weeks with conservative treatment. As it is a viral infection, antibiotics will not help in line with the recommendations against routinely prescribing antibiotics for hoarse voices. Resting the voice, staying hydrated and simply giving it time is the approach to management.
Vocal Cord Nodules and Polyps (Overuse Injuries of the Voice)
Vocal nodules are small bumps(nodules) or sometimes soft swellings (polyps) that develop on the vocal cords from repeated strain of the voice.
This occurs in shouting, singing or talking loudly over long periods of time. They are especially common in teachers, singers and children who yell or scream. The guidelines recommend voice therapy and working with a Speech Pathologist to retrain how the voice is used. It is highly effective. Surgery is only considered if the voice has not been improved with proper voice therapy in adults and surgery for children is rarely performed for vocal nodules. The guidelines are explicit in stating that surgery is not the first step for most people with vocal nodules and polyps.
Muscle Tension Dysphonia
This occurs when the muscles surrounding the larynx become tense during speaking, often without any visible structural issue with the vocal cords themselves. Sometimes this is linked to stress, overuse of the voice or compensating for another underlying issue. Voice therapy with a Speech Therapist is again the mainstay of treatment and this focuses on releasing the excessive tension and retraining the muscles for efficient voice use.
Laryngopharyngeal Reflux
Reflux of stomach acid up into the throat can irritate the vocal cords and cause chronic hoarseness. This is exactly why the guidelines state that reflux medication should not be prescribed for isolated hoarseness based on symptoms alone without examination of the larynx first by a fibreoptic endoscopy to confirm that reflux is actually a possible cause.
Vocal Cord Paralysis or Weakness
One or both vocal cords may not move properly, sometimes following surgery near the voice box such as thyroid surgery or chest surgery, a viral illness or sometimes for no clear identifiable reason. This typically causes a breathy weak voice and is diagnosed directly by viewing the vocal cords. Depending on the cause and severity, treatment may range from voice therapy alone through to procedures that reposition or bulk up the affected vocal cord.
Spasmodic Dysphonia and Laryngeal Dystonia.
This is a laryngeal condition involving involuntary spasms of the vocal cord muscles leading to a strained, strangled or breathy sounding voice that comes and goes. It is often worse on certain sounds or words. If voice therapy doesn’t help,the guidelines specifically recommend Botox injections into the affected muscles as the evidence based treatment for this condition. This is not a life threatening condition and not everyone chooses to pursue treatment. It is a personal decision according to how much it is affecting your life.
Recurrent Respiratory Papillomatosis.
A condition more common in children where water-like growths caused by HPV develop on the vocal cords or airway causing progressive hoarseness and sometimes breathing difficulty. This requires specialist ENT assessment and is managed with surgical removal of the benign growths and is often needed to be repeated many times.
Laryngeal Cancer and Other Serious Causes
This is exactly why persistent hoarseness should not be ignored, particularly with risk factors such as smoking. Direct examination of the larynx and vocal cords is the recommended way to assess this, rather than waiting to see if medication corrects this. The earlier a serious cause is identified the more treatment options are typically available.
Age Related Voice Changes (Presbylarynx)
As we age, the vocal cords naturally lose some bulk and tone leading to weaker breathier or higher pitched voice. Voice therapy can help many people manage this well and in more significant cases procedures to add bulk to the vocal cords may be considered.
Hoarseness in Children and What’s Different
The good news is that some guidelines apply across all ages and the general approach is assess properly, do not guess and treat and assess the larynx. This is important for children as well. There are a few important notes specifically for children.
Vocal nodules from yelling and screaming during play are one of the most common causes of a chronically hoarse voice in children and respond well to voice therapy and do not generally require surgery. A hoarse voice or abnormal sounding cry from birth or early infancy deserves assessment to rule out structural or nerve related causes present from birth. Recurrent respiratory papillomatosis is more common in children than adults and needs specialist ENT management. As with adults persistent hoarseness in a child, especially beyond a few weeks, or breathing difficulties warrants assessment by an ENT Surgeon and endoscopy to assess the airway if possible in the office or potentially under general anaesthesia.
Summary Guidelines
- Wait 2 – 4 weeks if it is simple recent hoarseness with an obvious cause like a cold or form yelling or screaming. Most of these resolve on their own.
- Have it assessed with a fibreoptic endoscopy if this has not improved by four weeks, or sooner if there are any concerning features (neck lumps, breathing difficulties, smoking history, recent surgery or heavy professional voice use).
- Avoid unproven “guess treatment” such as antibiotics, steroids and reflux medication. These are not recommended for hoarseness without first assessing what is actually causing the problem and CT scan are not required prior to a direct assessment of the voice box with a fibreoptic camera.
- Voice therapy is the first line of treatment for most cases that are amenable to it such as nodules, polyps and muscle tension dysphonia.
- Surgery and other specific treatment like Botox injections for spasmodic dysphonia are reserved for specific conditions when they are generally indicated and not used as a first step treatment.
Frequently Asked Questions About Hoarseness
How long can a hoarse voice last before I should see someone?
If it has not improved within about four weeks, current guidelines recommend that you have your larynx examined with a fibreoptic camera. Have it checked sooner if you notice a neck lump, breathing difficulty, have had recent surgery in the head, neck or chest or a general anaesthetic requiring intubation.
Will antibiotics correct my hoarse voice?
Usually not. Most hoarseness is caused by a viral infection, muscle strain or reflux, none of which respond to antibiotics. Guidelines specifically recommend against routinely prescribing antibiotics for hoarseness.
Do I need a CT Scan For a Hoarse Voice?
Not before your larynx and vocal cords have been examined directly with a fibreoptic camera. The guidelines recommend against ordering a CT or MRI scan as a first step for assessment of hoarseness as a direct assessment of the voice box and larynx gives more useful information.
Is Hoarseness in Children Usually Serious?
Most commonly no. It is often caused by vocal cord nodules from shouting, yelling or singing. These respond well to voice therapy. Regardless, hoarseness lasting more than a few weeks or present from birth should be assessed.
Can Voice Therapy Really Fix a Hoarse Voice?
For many common causes, including nodules, polyps and muscle tension dysphonia yes. Voice therapy with a Speech Pathologist is the recommended first line treatment and can be very effective before surgery is ever considered.
If you experience hoarseness that persists, get your voice properly assessed.
