Hoarseness is an extremely common yet varied symptom. An abnormal voice may sound raspy, breathy, or weak, or the pitch may be inappropriate. Often when a patient complains of hoarseness, the voice actually sounds normal but fatigues too quickly or requires too much effort. All of these symptoms indicate a problem with sound production within the larynx. Sometimes voice production is normal, but the sound is altered by abnormal resonance. For example, a peritonsillar abscess can cause a "hot potato voice," and a patient with a cold sounds hyponasal. Thus, the first task in diagnosing acute hoarseness is to define the precise nature of the problem. Is the problem in the larynx, the resonators, or the articulators? And exactly what is preventing production of a normal voice?
Diagnosis of a voice disorder entails two components: establishing the mechanism by which the voice is disrupted and then determining the etiology of the pathology. Table 1 lists mechanisms for hoarseness. Identifying the mechanism, however, does not always reveal the etiology. For example, evaluation may reveal that hoarseness is due to nodules on the vocal folds. The etiology of vocal nodules is most often voice abuse, and the vast majority of vocal nodules respond to speech therapy. Rarely, though, a nodule on the vocal fold is caused by rheumatoid arthritis (RA). In a patient with known RA, a vocal nodule can immediately be considered to be rheumatoid (see Chapter 1 for detailed discussion of RA manifesting in the head and neck). In a patient without known arthritis, a rheumatoid etiology would not be considered in the differential diagnosis until the patient fails to respond to a trial of voice therapy. Another issue is that more than one etiology may conspire in the genesis of a laryngeal pathology. For example, mucosal disruption due to a systemic illness such as pemphigoid can make a patient more susceptible to the ill effects of voice overuse or gastroesophageal reflux.
The three most common causes of acute hoarseness are upper respiratory infection, vocal abuse, and gastroesophageal reflux. Such problems generally resolve within two to six weeks. Vocal symptoms that persist beyond this time require investigation. Chronic hoarseness is most often due to chronic laryngitis, with causative factors that include acid reflux, voice abuse, smoking, allergies, and old age. Systemic illnesses are rarely found to be the cause of hoarseness. Although many systemic illnesses have the potential to affect the voice by impairing mucosal vibration or vocal fold motion, hoarseness is not often the presenting sign. Nevertheless, systemic illness does have a place in the differential diagnosis of hoarseness or laryngeal paralysis, but only when common causes are excluded or when the patient is already known to have a systemic disease. The following systemic diseases are known to adversely affect the voice.
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