Unexplained Hoarseness

“Dear Dr. Jahn: My doctor says my larynx is normal, but I’m still slightly hoarse. What is going on?”

This is a frustrating, and not infrequent, occurrence. The voice is not right; you go to the doctor, who looks down at the larynx, and pronounces that everything looks fine. But why are you still hoarse?

What is the correlation between the appearance and the function of the larynx? While in some cases what we see explains what you feel (and hear), in other cases the correlation is not so clear.

To begin, most larynges do not look perfect. Even if the voice is at its finest, depending on the instrument used for examination, it may be possible to identify tiny imperfections and asymmetries. While the magnifying videostroboscope is the best way to identify structural problems, it is important not to obsess over these minute structural details, provided the voice is fine.

Laryngology for singers is a functional, not an aesthetic discipline. I have seen a number of singers who are overwhelmed by the amount of visual information presented in these examinations. It is up to the doctor to sort out what is functionally significant, and what is merely incidental. For example, a small blood vessel on the upper surface of a vocal fold is usually not significant. It only becomes important if the patient presents with a history of recurrent hemorrhage, or hoarseness that can be clearly tied to this anatomic variant.

Taken to the next level, even vocal folds with potentially important abnormalities, such as nodules, may be acceptable if there is no impairment to the voice. Particularly among pop singers, but even with some operatic voices, the singer can function acceptably, and for a long time, with small swellings. These are not cancerous, and there is no reason to treat them until they significantly impede performance.

The flip side of this situation is the normal appearing larynx which produces a hoarse voice. How can this happen? Quite easily, if we consider two points:

1. Limitations of the physical examination. Examination of the larynx can be performed with a mirror, a flexible nasal scope, and a rigid oral scope, with or without video magnification and strobe. Each of these techniques has limitations. The mirror does not analyze minor degrees of stiffness or asymmetry of movement. The flexible nasal scope gives a fuzzier image, which can miss tiny lesions. Videstroboscopy can give a distortion of color, since the image is electronically processed by the video monitor, rather than seen by the observer’s eye. And each of these methods looks only at the upper surface and free margin of the vocal folds. There is no way to examine the undersurface of the folds in the office, and in some cases this is where an enlarged blood vessel or polyp may lurk.

2. Inferring function from structure. It is very easy for a healthy larynx to produce an unhealthy voice. Abnormal posturing of the vocal folds can produce a voice that is hoarse, breathy, choked, or pressed. If the laryngeal position is very high and forward in the neck, if the vocal folds are overly compressed, if the false vocal folds are squeezed together, the voice may become so hoarse as to actually disappear. It surprises many people that the larynx in “acute laryngitis” often looks nearly normal. The voice disappears due to edema and spasm in the pharynx, causing the pharyngeal muscles to pull the larynx up into a high, non-functional position.

How can you maximize the value of your laryngeal examination?

During examination, be sure that you demonstrate to the doctor what brings on your hoarseness. The vocal folds at rest may “look fine,” but singing at the top of your range may show abnormalities of structure or posture. If your hoarseness comes on typically after fifteen minutes of warming up, there is no point looking at the larynx before you have vocalized.

If hoarseness is intermittent, the examination should try to catch the moment when dysfunction occurs. Until we develop a 24hour laryngeal monitor, identifying transient vocal dysfunction will continue to be an elusive goal for both patient and laryngologist.

Anthony Jahn, M.D.

Anthony Jahn M.D. is an otolaryngologist with a subspecialty interest in ear diseases, disorders of hearing and balance, and disorders of the voice. He is a professor of clinical otolaryngology at Mount Sinai School of Medicine and is the noted author of Care of the Professional Voice. For more resources, go to his website www.earandvoicedoctor.com.