What can a primary care doctor actually determine about hoarseness — without ever looking at the vocal cords? More than you might expect, but far less than a laryngologist. Here is how to think about it.
What Can a Primary Care Doctor Infer About Hoarseness?
If we recall Faith’s illness in How Voice Works, she lost her voice suddenly and went to her primary care physician’s office for advice. He performed a number of typical medical tests and looked into her mouth, but as best we can tell, he never looked at her larynx or her vocal cords. On what basis did he make a diagnosis and on what basis did he offer her treatment advice?
Dr. Marcus’ evaluation must have been largely based on a hunch or a guess, since there is no evidence that he ever saw the vocal cords. That guess might have been based on some sense of whether the hoarseness could be due to a common transient illness — a cold. Perhaps colds had been common for a few weeks in his office. Perhaps some symptoms Faith described matched a cold.
A Case Study in Trial and Error
Let’s consider another patient similar to one we have seen before. Amelia reports annual hoarseness for 30 years that typically starts up in both April and in November. It lasts two to five weeks and often goes away on its own. Her voice fades out as she uses it and she reports discomfort in her neck if she speaks very long. She rates herself as a 4 on the 7-point talkativeness scale. Many times she sees her primary care physician and reports that two courses of antibiotics often seem to make the hoarseness resolve. However, this year the hoarseness persisted after two different antibiotics. Her PCP then tried a course of steroids “to reduce the swelling,” but her voice did not improve. He then tried a one-month course of a proton pump inhibitor since she does have a sense that acid comes up into the back of her throat. This treatment helped reduce the sensation of acid in her throat, but her hoarseness persisted. Then, since her hoarseness seems to often coincide with the springtime allergy season, he tried a steroid nasal spray and an antihistamine. Her voice remained hoarse and she was referred to me for an evaluation.
I listen to Amelia and when she speaks, her speaking voice is at a very low pitch for a female yet occasionally breaks into a high pitch. When she laughs, her voice is normal. When I ask her to yell, she hesitates at this vocal task. When I have her sing a high pitch, her voice is very clear and she smiles, somewhat inappropriately. I examine Amelia’s vocal cords with an endoscope and her vocal cords are normal in appearance, though she is often holding them apart during phonation. She happens to be speaking with her thyroarytenoid muscles relaxed and her surrounding neck muscles very tight. She has a nonorganic dysphonia. She can speak with a clear voice at the higher pitches, so I start there and then gradually move her speaking pitch lower until she has a clear voice at her normal speaking pitch. Within a half hour she can even change from a hoarse voice to a clear voice on command. Her hoarseness has resolved in the office.
Since her husband is present during the exam, I discuss how muscle tightness causes her voice problem and how stress often aggravates muscle tightness and plays a role in the problem. I also discuss how the muscle tightness becomes a habit and that the voice problem is quite likely to return again in the future, especially if there is any stress in her life. Stress frequently causes muscle tension. Finally, I focus on how this disorder could spontaneously resolve and how the assumption that it went away in the past with an antibiotic was an erroneous interpretation of coincidence representing causation. I caution that two courses of antibiotics twice a year, steroids, anti-reflux medication and anti-allergy medication are not only a non-necessary use of her time and her money, but over many years, she is at risk for antibiotic resistance, fungal infections or other medication side effects. I had her work with a voice therapist to solidify the gains she made in the office.
Coincidence is not causation. The assumption that antibiotics resolved Amelia’s hoarseness twice a year for 30 years was simply wrong — and costly.
Rethinking the Standard Treatments
Bacterial infections of the larynx are rather uncommon. Some may cause severe swelling and even airway narrowing as well as rather significant pain. Consequently, antibiotic treatment of hoarseness is quite low on my list of treatment options for acute laryngitis.
Steroids do reduce swelling very effectively. Typically prednisone or methylprednisolone taken as a pill will reduce swelling on the vocal cord within two hours. If a patient has swollen vocal cords — and a corresponding deep pitch from that swelling — these symptoms can be temporarily alleviated with steroids. The steroid effect of reducing swelling is fairly non-specific. Whether the swelling is from a general enlargement and stiffening of the vocal cord, such as from a viral infection, or whether it is from a discrete swelling along the margin of the vocal cord, such as a nodule from overuse, steroids will reduce the swelling. The improvement in the voice is rapid, but temporary. In this manner, treatment with a steroid can almost be used as a diagnostic test.
As for the reflex to treat with anti-reflux medication — proton pump inhibitors or other measures — I would encourage the prescribing physician to hold onto his pen for now. Do allergies cause hoarseness? The lining of the membranous vocal cord is a very different epithelium than the lining of the nasal turbinates. Given the large number of people experiencing nasal symptoms from allergens without any corresponding change in vocal pitch, allergen effect on the vocal cords appears minimal or infrequent, at least relative to the nose.
Using a pulmonary steroid inhaler with the thought that steroids applied topically to the larynx will reduce assumed allergic laryngitis is fraught with an increased incidence of hoarseness — these patients may develop a fungal infection on the vocal cords, stiffening and thickening them from fungal growth. I would save inhaled steroids for patients with asthma and even then use the lowest possible maintenance dose to avoid giving them a hoarse voice from fungal laryngitis.
What the Primary Care Doctor Can Do
Dr. Marcus should first ask himself if he is hearing a speech or a voice problem. If the patient has difficulty forming words, the problem is likely coming from within the mouth — above the speech line. Think first about neurologic problems impairing motion of the lips, tongue and palate.
Then ask: is this a quality of sound or a lack of volume issue? Is this a husky voice, a rough voice, or a mixture of both? Is this a weak voice? If the answer is yes to any of these, the problem lies on the vocal cords.
Next, determine if the hoarseness likely belongs to one of the behavioral hoarseness categories. Is the patient either a vocal overdoer (they give a high score on the 7-point talkativeness scale) or a vocal underdoer? A patient with hoarseness who rates herself a 6 or a 7 on the 7-point scale has at least an 80 percent probability that her hoarseness is due to a swelling on the edge of the vocal cord based on this information alone.
Did the patient lose her voice rather immediately after loud vocal use and then suffer from sustained hoarseness? Think of the likely probability of a hemorrhage or other vocal cord edge swelling. Is the patient an underdoer complaining of hoarseness as well as neck discomfort with episodes of prolonged vocal use? Think about bowing or muscle atrophy — often accompanied by neck pain from neck muscle tightness.
Ask the patient to make a few different types of sounds — low pitch, high pitch, loud and soft. Is there an inconsistency where some sounds are clear and others very rough? Does the patient appear to be holding back or not putting effort toward making a sound? Think about nonorganic voice disorders or inappropriate vocal muscle use.
Voice disorders that come on gradually, have none of the above more obvious explanations for their etiology, and/or persist for more than a week or two probably warrant an examination to determine their etiology — structural or behavioral. There is really no other way to diagnose tumors, fungal infections or paresis without a visual examination of the vocal cords. If Faith has a need to know the cause of her hoarseness, she has a need for an endoscopic examination.
My hope is that Dr. Marcus tells his patient that since he cannot see the vocal cords, his diagnosis is an educated guess — and if the patient needs a more precise diagnosis or fails to improve in a brief period of time, a referral to a laryngologist would be appropriate.
What You Learned
- Antibiotics rarely help hoarseness — bacterial laryngitis is uncommon; most hoarseness resolves coincidentally with antibiotic courses, creating a false impression of efficacy.
- Steroids temporarily reduce swelling — useful as a short-term bridge or diagnostic test, but they treat the symptom, not the cause.
- Talkativeness predicts pathology — a score of 6–7 on the 7-point talkativeness scale carries at least an 80% probability of vocal cord edge swelling.
- Inhaled steroids risk fungal laryngitis — a preventable, iatrogenic cause of hoarseness that compounds the original problem.
- When in doubt, refer — tumors, fungal infections, and nerve paresis cannot be diagnosed without a visual examination of the vocal cords.