Almost everyone has experienced a bout of hoarseness after singing along at a concert or cheering on a favorite sports team. It’s also not uncommon to get hoarse from a garden-variety case of laryngitis—inflammation of the larynx (or voice box)—brought on by infections that are typically viral, such as the common cold. These conditions are usually self-limiting and improve with rest and plenty of fluids. But there is a surprising array of other health issues that can cause voice problems.

Gastroesophageal reflux. Stomach acids that back up all the way to the larynx can affect your voice. Symptoms include a husky sounding voice, noticeable phlegm, and frequent throat clearing, and are often worse earlier in the day. Treating reflux should resolve voice issues.

The problem is that many people and primary care doctors alike are too quick to attribute hoarseness to reflux. If hoarseness doesn’t improve after a few weeks of taking reflux medication, it’s time to consider other possible causes.

Vocal fold lesions. Various types of growths or lesions can develop on the vocal folds (also called vocal cords). Nodules can form at points on the folds that experience the most wear and tear when you use your voice, particularly with repetitive voice overuse or misuse.

Polyps are benign masses that can occur following a vocal fold mucosal injury, and cysts can form within the vocal folds underneath their lining. Papilloma are human papillomavirus-related lesions that also can occur in the larynx. Early signs of a lesion include persistent hoarseness, vocal fatigue, limitation of upper vocal range, and increased effort to speak. 

Dysphonias. Dysphonia is the general medical term for hoarseness and can be applied broadly to many types of voice problems. It is also part of the name of some voice disorders. Muscle tension dysphonia refers to voice problems due to excessive laryngeal muscle tension and suboptimal vocal biomechanics. Spasmodic dysphonia is a neurological condition characterized by involuntary spasmodic movements of vocal fold muscles. Functional dysphonia refers to dysphonia caused by disordered use of voice structures that are otherwise normal, and may be related to traumatic events, stress, or exposure to an irritant.

Vocal fold paralysis. Affecting one or both vocal folds, paralysis indicates vocal fold immobility. If one is affected, then the voice is typically breathy, weak, or airy, and this is sometimes accompanied by trouble swallowing (dysphagia). Paralysis of both vocal folds often causes breathing problems due to narrowing of the airway. Causes of paralysis include accidental damage to the nerve supply to the vocal folds during surgery on nearby structures, or a tumor or other growth along one of those nerves. Some people recover on their own, while others require active treatment.

Larynx cancer. A malignant lesion or cancer in the larynx can cause hoarseness and breathing or swallowing problems.  Some other symptoms include pain when swallowing, ear pain, or coughing up blood-tinged secretions.

Neurological diseases. A wide range of neurological disorders, such as Parkinson’s disease, amyotrophic lateral sclerosis (ALS), or tremor, can affect the voice. Reduced voice strength and projection, abnormal articulation, or a shaky voice are possible symptoms. 

When to see a doctor

A voice disorder that persists for two to four weeks or gets progressively worse needs to be evaluated—particularly in a smoker or someone who has some of the associated symptoms discussed above. The specialists who diagnose voice disorders are otolaryngologists, also called ear, nose and throat (ENT) doctors, and laryngologists, subspecialists who focus on the larynx and associated structures.


Treatment depends on the nature of the problem and your vocal goals and needs. Voice disorders due to a typical viral laryngitis will usually resolve with supportive measures such as rest and fluids. Other types of infections or inflammation should improve with the appropriate medication prescribed or recommended by a doctor.

Vocal fold mucosal lesions, such as nodules, are believed to be rooted in voice behaviors, and are treated primarily with voice therapy by a speech pathologist. Voice therapy includes a variety of techniques that will be tailored to an individual patient and may include learning better voice hygiene and vocal mechanics—how to warm up, cool down, and use your voice in a biomechanically favorable way—to help heal the voice and vocal folds.

In fact, voice therapy is part of many treatment plans, especially when the voice disorder stems from how and how much you use your voice. A team approach to treatment that includes a speech pathologist with experience in the vocal arts can be particularly helpful when caring for a singer or other occupational or professional voice user.  Because the principles of healthy voice use for singing can apply to speaking too, a care team with diverse voice-related backgrounds can help many types of patients.

Surgery is also used to treat some types of voice problems, alone or in conjunction with voice therapy or other medical treatments. Laryngeal surgery can be performed endoscopically, often incorporating an operating microscope and surgical laser. Some laryngeal surgical procedures can also be performed under local anesthesia using flexible endoscopes in the outpatient clinic. Open surgery through the neck is indicated for some laryngeal problems.

Prevention tips

With its beauty, strength, and ability to evoke and demonstrate emotion, your voice is part of your unique personality. Here’s how to protect it.

  • Don’t smoke. Apart from all its other ills, smoking is the worst thing possible for your voice and the No. 1 risk factor for developing larynx cancer. Though the risks of vaping are still being investigated, my advice is also not to vape.
  • Use, don’t abuse, your voice. If you’re a screamer or a yeller, you’re putting a lot of strain on your voice-­producing structures. The same is true if you continue to use your voice when it’s already hoarse.
  • Hydrate. Drinking water and noncaffeinated, nonalcoholic beverages, is beneficial for your voice.
  • Use amplification. For any type of public speaking, such as in an outdoor setting, auditorium, or in a gym where you will be inclined to push your voice, use a headset microphone so you can talk with a conversational intensity (without shouting) and yet reach your audience. A headset is ergonomically better than leaning over a microphone. Amplification devices and speakers built into classrooms (often with students in mind) are also very helpful for teachers.
  • Listen to your voice if it is complaining to you. Just as a sore knee is a warning to back off on a running regimen, hoarseness is a sign that something is wrong, and your voice needs a break. If hoarseness persists, get evaluated by a specialist.

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