by Dr. Christopher Chang, last modified on
Unfortunately, there is no cookie-cutter treatment for hoarseness except for rare exceptions. However, there are general principles that guide how hoarseness is treated based on diagnosis. Summary of treatment options for a few conditions are described below. Check out general tips to prevent voice problems. Sample audio and video of normal voice function can be found here. Abnormal examples can be found by clicking on links under Voice Index. Photos of voicebox abnormalities can be found here.
Meet The Voice Team at Fauquier ENT, involved from your diagnosis to your treatment.
Speech pathologists and singing voice instructors are always welcome to come to an appointment with their student.
Note that any information provided should not be considered medical advice or a substitute for a consultation with a physician. If you have a medical problem, contact your local physician for diagnosis and treatment.
When Should I Be Concerned? (Back to Top)
As a general rule of thumb, if hoarseness persists beyond 2-3 weeks, one should undergo an evaluation. The principle concern is whether the hoarseness is due to cancer. Cancer is a great mimicer of all the different causes of hoarseness. It can cause a raspy voice...or normal speech, but loss of upper range...or breathy voice...or "laryngitis". Pain is not always present with cancer, though if present, is a cause for greater concern.
Commonly Used Medications (Back to Top)
- Guaifenesin (Mucinex, Robitussin): Breaks up thick secretions to make it easier to cough up. Only works with good hydration.
- Proton Pump Inhibitors (Prilosec, Nexium, Protonix, etc): Prevents reflux from injuring the voicebox.
- Steroids (Decadron, Medrol Dose Pack, Prednisone, etc): Decreases inflammation (and associated swelling) of the vocal cords regardless of the cause of the inflammation.
- Diflucan: Anti-fungal used to treat candidal laryngitis. Common in asthmatics who use steroid inhalers daily.
- Antibiotics: Used to treat bacterial laryngitis (rare!).
- Decongestants (Sudafed): Not usually recommended as it drys up everything including the vocal cords which than exacerbates the hoarseness. The rare exception is with seasonal allergic rhinnitis exacerbations. Of note, if the principle complaint is thick secretions, decongestants often make the secretions even thicker.
- Allergy Medications such as plain antihistamines (allegra, zyrtec, claritin, etc), steroid nasal sprays (flonase, nasonex, etc), astelin, singulair, and saline flushes are quite helpful for singers with allergy.
- Amitriptyline, Nortriptyline, Gabapentin, Ultram: Used to treat chronic dry cough secondary to laryngeal sensory neuropathy.
- Botox: Used to treat spasmodic dysphonia.
Laryngitis (Back to Top)
Treatment depends on the cause of laryngitis... Laryngitis basically means inflammation of the voicebox. But what caused the inflammation in the first place??? Infection (bacterial vs viral vs fungal)? Reflux? Trauma? Allergy? If laryngitis is due to bacterial infection, antibiotics are prescribed +/- steroids. Viral laryngitis is treated with voice rest and steroids. Fungal laryngitis is treated with diflucan +/- laryngeal saline gargles. If due to reflux (GERD/LPR), proton pump inhibitors are given. If due to trauma (ie, strangulation or screaming/coughing), voice rest +/- steroids. Etc. Laryngitis may occasionally be so severe that complete or near-complete loss of voice occurs (aphonia). Regardless of the cause of laryngitis (if that is indeed the correct diagnosis), complete voice rest is mandated (ie, no talking, coughing, straining, whispering, laughing, etc). If talking is absolutely necessary, talk much like one would if the person is directly in front of you in the lobby of a library, but do NOT whisper. Talk in a quiet, low pitch. Do NOT whisper or try to talk such that you aim for a normal voice which would further risk damaging your voice. Rarely, after resolution of a viral laryngitis, a chronic dry cough may persist that can be treated with other medications.
Cancer (Back to Top)
For suspicion of cancer, biopsy is absolutely necessary without question. Without a diagnosis, treatment recommendations cannot be given. Once pathologic diagnosis is obtained, treatment may include surgery or radiation therapy, or both. With massive cancer involvement, chemotherapy may also be needed.
Vocal Cord Mucosal Masses (Back to Top)
Mucosal masses are defined as swelling, nodules, polyps, or any other lump or bump (including cancer) on the vocal cord that involves the vocal cord mucosa only, but nothing else. Treatment depends on the patient's perception of how bad his/her voice is, profession, vocal commitments, innate personality, and a number of other factors. Successful treatment requires a commitment not only from the physician, but from the patient as well.
Treatment, depending on the above issues, may include working with a speech pathologist/voice pedagogue before and after surgical excision. In other cases, surgical excision or working with a speech pathologist/voice pedagogue alone is all that is required. If vocal cord swelling or pre-nodule formation is the cause of vocal dysfunction, this handout is given. Depending on how vascular the mass is, laser treatment (PDL/KTP) may be a non-invasive option.
Vocal Cord Sub-Mucosal Masses (Back to Top)
Muscle Tension Dysphonia (Back to Top)
Muscle tension dysphonia or aphonia is rarely treated with surgery unless there is an underlying hypofunction that is amenable to surgery such as glottal incompetence, vocal cord paralysis, etc. Other types of hypofunction such as COPD are not amenable surgery. If no hypofunction exists or has been reversed, than treatment is working with a speech/voice pathologist. Generally speaking, this type of hoarseness is due to inappropriate muscle contraction resulting in hoarseness, much like what a person does to "fake" a hoarse voice. However, patients with non-organic laryngitis (another name for muscle tension dysphonia in the absence of underlying hypofunction) are not deliberately causing the voice to be hoarse. Rather, they have "forgotten" how to talk normally. Read more about this disorder here.
Vocal Cord Paralysis (Lost/Breathy Voice) (Back to Top)
Paralysis is treated based on symptomatology. If aspiration is an issue, surgical treatment is required. If a patient is unsatisfied with their weak/breathy/lost voice, surgical treatment is required. Voice rehabilitation has limited utility other than instructing the patient on swallowing techniques to try and minimize aspiration.
Surgical treatment actually depends on the etiology and the length of time since the paralysis. Once cancer is ruled-out, there is always the possibility that the paralysis will resolve over time and/or the opposite vocal cord will compensate to the point where the voice essentially is near-normal. One year is an appropriate length of time before permanent surgical procedures are considered. Before one year's time, surgical procedures utilizing temporary implants are considered.
Read an extensive article on the treatment of the paralyzed vocal cord here.
Bowed True Vocal Cords (Lost/Breathy Voice) (Back to Top)
Treatment is geared towards straightening the bowed edge of the true vocal cord. Initially, voice building exercises (VBE) are prescribed. If unsuccessful, surgical procedures can be considered. This is one voice condition in which NOT talking further deteriorates the voice!
Read more about treatment options here.
Spasmodic Dysphonia (Back to Top)
The current standard of care for the treatment of spasmodic dysphonia is BOTOX injections. BOTOX injection under EMG guidance alone is performed by Dr. Chang. Speech therapy may help prolong the effects of BOTOX injections which usually last for about 3-4 months. For more information, click here.
Nasal Sounding Speech (Hyponasal/Hypernasal) (Back to Top)
First of all, nasal sounding speech/voice is a SPEECH problem. Not a voice problem. Click here for more info regarding this difference. This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint. One must first differentiate whether it is a hypernasal or hyponasal speech. Once that differentiation is made, one can figure out what is the cause and treat accordingly. Hypernasal speech is due to inappropriate increased nasal airflow and can be due to velopharyngeal insufficiency (where the soft palate does not make a tight seal with the back of the throat) or a cleft palate in kids. Hyponasal speech is due to inappropriate decreased nasal airflow and is due to nasal obstruction. Such nasal obstruction can be secondary to severe allergies, nasal tumors (polyps, cancer, etc), septal deviation, adenoid hypertrophy, turbinate hypertrophy, choanal atresia, pyriform stenosis, etc. Obviously, treatment depends on the cause which can be determined on physical examination which may include fiberoptic nasal endoscopy. Some examples are provided here. In most instances (notable exception being allergies), surgery is the only option for treatment.
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