Learning Center: VOICE

COMMON causes OF VOCAL PROBLEMS

Here are the most common causes of vocal problems, hoarseness, or dysphonia. The mix of causes depends on where people are seen. In a US insurance database of almost 55 million people, about 1% received a dysphonia diagnosis in a given period. The most frequent diagnoses were acute laryngitis, nonspecific dysphonia, benign vocal fold lesions, and chronic laryngitis. Primary care doctors most often diagnosed acute laryngitis, while otolaryngologists more often found specific laryngeal conditions. Laryngeal cancer made up 2.2% of the diagnoses and was most common in men over 70 [4]. In a specialty voice center, about 55% of new voice patients had no structural abnormality on examination, and unilateral vocal fold paralysis was the most common specific diagnosis after nonspecific dysphonia [5].

Acute laryngitis

Acute laryngitis is swelling of the vocal folds that lasts less than about three weeks. It usually comes with a cold or other viral infection, or follows a bout of shouting or heavy voice use. Swollen folds vibrate less evenly, so the voice becomes rough, lower, or may be lost for a time. Treatment is supportive: resting the voice, drinking fluids, and treating the cold.

Antibiotics do not help. A Cochrane review of three randomized trials (351 adults) found no improvement in objective voice measures with penicillin or erythromycin compared with placebo. Erythromycin gave a small short-term improvement in some patient-reported symptoms, but the evidence was very low quality and the reviewers judged it not worth the cost, side effects and antibiotic resistance [6]. The 2018 hoarseness guideline makes a strong recommendation against routine antibiotics for hoarseness [3].

Chronic laryngitis

Chronic laryngitis is longer-lasting irritation and swelling of the larynx. Common contributors are smoking, heavy voice use, allergies and postnasal drainage, dry air, and inhaled steroid medicines for asthma or COPD. Dysphonia has been reported in 5% to 58% of people using inhaled corticosteroids [7]. In a study of 6,551 adults with dysphonia diagnosed by an otolaryngologist and 6,551 matched controls, inhaled steroid use was associated with about five times the odds of dysphonia (odds ratio 5.11) [8]. Using the lowest effective dose, a spacer, and rinsing the mouth and gargling after each dose reduce the risk [7]. Inhaled steroids should not be stopped without talking with the prescribing doctor.

Acid or nonacid reflux from the stomach into the throat (laryngopharyngeal reflux) is often blamed for chronic hoarseness, but the evidence for treating it with acid-reducing medicine is weak. In a UK trial of 346 adults with persistent throat symptoms, lansoprazole twice daily for 16 weeks did no better than placebo, at 16 weeks or at 12 months [9]. The hoarseness guideline recommends against prescribing reflux medicine for hoarseness alone unless the larynx has been examined or there are other signs of reflux disease [3]. Reflux treatment still has a place in people with heartburn or other typical reflux symptoms.

Functional dysphonia and muscle tension dysphonia

In functional dysphonia the voice is abnormal even though the vocal folds look structurally normal. The most common form is muscle tension dysphonia, in which the muscles in and around the larynx work too hard or out of balance during speech. It often begins after a cold, a period of heavy voice use, or stress, and the strained pattern continues after the trigger is gone. It is one of the most common diagnoses in voice clinics [5].

Voice therapy is the main treatment. In a randomized trial, both stretch-and-flow therapy and resonant voice therapy produced large improvements in VHI scores, with no meaningful difference between them [10]. A network meta-analysis of 13 randomized trials found that stretch-and-flow phonation, resonant voice therapy, a comprehensive voice rehabilitation program, and vocal function exercises all improved VHI scores [11]. Many of these trials are small, but the results point the same way.

Benign lesions

Benign (noncancerous) growths on the vibrating edge of the vocal folds stop the folds from closing evenly and dampen their vibration. They are most often caused by repeated impact during voice use (phonotrauma).

Vocal fold nodules. Nodules are small, firm, callus-like swellings that form on both vocal folds, facing each other, at the point of greatest impact. They are common in teachers, singers, and others with high voice demands, and in children. A meta-analysis of 62 studies with more than 100,000 teachers found that 37.7% had a voice disorder at the time of study and 63.1% had had one during their lives [12]. Voice therapy is the first treatment for nodules, and surgery is kept for nodules that still limit the voice after therapy. A review of the evidence found that support for both behavioral and surgical treatment comes mostly from small or observational studies [13].

Vocal fold cysts and polyps. A cyst is a fluid-filled or mucus-filled sac within the soft layer of one fold. A polyp is a soft swelling, often on one side, that may follow a single episode of forceful voice use or bleeding. When surgery is needed, it is done through the mouth with a microscope (phonomicrosurgery), removing the lesion while preserving as much of the normal vibrating tissue as possible. In a prospective study of 42 patients, the mean VHI score improved from 49.6 to 26.8 after surgery, with significant gains for polyps and cysts [14]. In a series of 224 patients with benign lesions treated with voice therapy and, when needed, surgery, about two thirds had surgery, and average VHI-10 scores after treatment returned to the normal range for all lesion types except one fibrous type [15]. About a third of the patients in that series improved enough without surgery.

Malignant tumors

Squamous cell carcinoma. Almost all cancers of the larynx are squamous cell carcinomas, which start in the lining. Tobacco and alcohol are the main causes. In a pooled analysis of international studies, about 89% of laryngeal cancers were attributable to tobacco, alcohol, or both [16]. Cancer that starts on the vocal fold itself (glottic cancer) changes the voice early, often while the tumor is still small. That is one reason persistent hoarseness in a smoker needs an examination [3].

Early glottic cancer has a very good outlook with either radiation therapy or removal through the mouth with a laser (transoral laser microsurgery). In a randomized trial of 56 men with T1a glottic cancer, five-year disease-specific survival was 97% after laser surgery and 100% after radiation, and the larynx was preserved in 97% and 92%, with no significant differences [17]. The trial was small, so the choice between the two usually depends on the tumor's location, voice goals, and the patient's preferences. More detail is on the larynx tumors page.

Lymphoma. Lymphoma that starts in the larynx is rare, making up less than 1% of laryngeal tumors. Its early symptoms are subtle and nonspecific, and it is managed in the same way as non-Hodgkin lymphoma elsewhere in the body [18].

Neurological conditions

Diseases of the brain, nerves and muscles can change the voice, and a voice change is sometimes the first sign. A laryngeal examination and, when needed, a neurology evaluation help sort these out [19].

• Vocal fold paralysis. Injury to the recurrent laryngeal nerve leaves one vocal fold weak or still, so the voice becomes breathy and weak and liquids may go down the wrong way. In a 20-year series of 827 patients, surgery was the most common cause (37%). Neck and chest operations such as spine surgery and carotid surgery have overtaken thyroid surgery as the leading surgical cause [20]. After thyroid surgery, temporary nerve weakness occurs in about 10% and permanent weakness in about 2% on average, depending on how carefully the larynx is examined [21]. Treatment options include voice therapy, injection of filler into the weak fold, and surgery that moves the fold toward the middle [3]. The swallowing page covers the effect on swallowing.

• Multiple sclerosis. Voice changes are more common in more severe disease. Typical complaints are voice breaks, vocal fatigue, and a breathy voice [19].

• Vocal tremor. Essential tremor can cause a rhythmic shaking of the voice, most noticeable on long vowels. Botulinum toxin injections are the most commonly used treatment, and propranolol helps some patients. In a prospective study of 18 patients, voice-related quality of life improved by an average of 22 points with botulinum toxin and 9 points with propranolol [22]. Overall the evidence for vocal tremor treatment is limited.

• Laryngeal dystonia/Spasmodic dysphonia. Laryngeal dystonia, also called spasmodic dysphonia, is a neurologic disorder in which the laryngeal muscles spasm during speech [23]. In the more common adductor type the voice sounds strained and choked with breaks. In the abductor type it drops into breathy whispers. Botulinum toxin injected into the affected muscles is the standard treatment. In a 12-year experience with more than 900 patients, adductor patients reached an average of 90% of normal function, lasting about 15 weeks per injection. Abductor patients reached about 67%, lasting about 10 weeks. The main side effects were temporary breathiness and coughing on liquids [24]. Injections are repeated every few months [3].

• Parkinson's disease. Parkinson disease often makes the voice softer, monotone and hoarse, and patients may not notice how quiet they have become. LSVT LOUD is an intensive program of 16 sessions over four weeks that trains patients to speak louder. In a UK trial of 388 people with Parkinson disease, LSVT LOUD reduced VHI scores by 8 points compared with no therapy and by about 10 points compared with standard speech therapy, which itself showed no benefit [25].

• Amyotrophic lateral sclerosis. In ALS that begins in the muscles of speech and swallowing (bulbar onset), slurred speech and voice change can be early signs [19].

• Myasthenia gravis. This autoimmune disease of the nerve-muscle junction can cause a voice that tires and weakens with use and recovers with rest [19].

Systemic conditions

Diseases that affect the whole body can involve the larynx. When a voice problem does not fit a typical pattern, these are considered.

• Hypothyroidism. Low thyroid hormone can cause swelling of the vocal folds and a lower, rougher voice. In a study of 120 people with hypothyroidism, measures of voice quality differed from those of healthy controls, and voice problems were more common in those with higher TSH levels [26].

• Rheumatoid arthritis. Arthritis can affect the cricoarytenoid joints, which move the vocal folds, causing hoarseness, pain, or stiff folds. It can also cause small "bamboo nodules" on the folds [27].

• Systemic lupus. Lupus can cause swelling, ulcers, bamboo nodules, joint stiffness, or narrowing of the airway below the folds [27].

• Granulomatosis with polyangiitis (formerly Wegener's granulomatosis). This form of vasculitis characteristically narrows the airway just below the vocal folds (subglottic stenosis), causing noisy breathing and voice change. In a French series of 81 patients with non-traumatic, non-cancer narrowing of the subglottis or trachea, it was the most common cause (41%), and the narrowing was the first sign of disease in two thirds of all patients [28].

• Sarcoidosis. Ear, nose and throat involvement occurs in 5% to 15% of people with sarcoidosis. In the larynx it usually causes swelling above the vocal folds, with hoarseness, cough, or trouble breathing [29].

• Amyloidosis. Abnormal protein deposits can form firm, waxy swellings in the larynx. It is uncommon and is confirmed by biopsy [30].

• Tuberculosis. Laryngeal tuberculosis is the most common granulomatous disease of the larynx. In a study of 24 patients with active disease, 95.8% had dysphonia and the vocal folds were involved in 87.5% [31]. It is treated with tuberculosis medicines.

Aging

With age the vocal fold muscle can thin and the folds can bow, leaving a gap when they close. This is called presbyphonia or vocal fold atrophy. The voice becomes weaker, breathier, and tires more easily, and people may avoid social situations because others cannot hear them. In a survey of 117 adults aged 65 and older, 47% reported a voice disorder during their lives and 29% had one at the time of the survey [2]. Voice changes in older adults should still be examined, since other causes are common.

Voice therapy helps. A systematic review of 23 studies with 1,050 patients (average age 72) found improvements in patient-reported voice outcomes, an average 5.4-second increase in how long patients could sustain a sound, and better acoustic measures after therapy [32]. In a small randomized trial, vocal function exercises and phonation resistance training exercises (PhoRTE) both improved voice-related quality of life [33]. When a large gap remains, injection of filler into the folds or surgery to close the gap is an option [3].

VOCAL HYGIENE (BEING GOOD TO YOUR LARYNX)

Vocal hygiene means habits that protect the vocal folds. The guideline recommends counseling patients on these measures [3]. They are low cost and low risk, but on their own they are usually not enough to treat an established voice disorder.

• Stay hydrated. A systematic review found that drinking water improved acoustic measures of the voice, while fasting without fluids and mouth breathing made them worse. Steam inhalation and humid air also helped. Caffeine did not appear to harm the voice [34].

• Don't smoke or vape. Smoking irritates the lining of the larynx and is the main cause of laryngeal cancer [16].

• Use the voice efficiently. Avoid shouting, talking over background noise, and long periods of heavy voice use without breaks. Teachers and others who speak for a living can use a personal amplifier. Rest the voice when it is hoarse from a cold.

• Limit throat clearing. Frequent hard throat clearing strikes the folds together. A sip of water or a swallow is gentler.

• Take care with inhaled steroids. Use a spacer and rinse and gargle after each dose [7].

• Get help for a voice that stays hoarse. Hoarseness lasting more than 4 weeks should be examined [3].

Advice alone has limits. In a randomized trial of 58 teachers with voice disorders, only those who did vocal function exercises reported a significant improvement in VHI scores. Those given vocal hygiene instruction alone did not improve significantly [35]. When a voice problem is established, structured voice therapy works better than advice alone [11].

• Link to ENTHealth website on How to Prevent Hoarseness.

ADDITIONAL LINKS

• Do you wish your voice sounded better sometimes? This YouTube video demonstrates vocal exercises that train your voice to improve your vocal quality and stamina. Yes, these exercises may seem silly, but are effective and work like physical therapy of the larynx. Do them in your car! Do them in the shower!

Related Learning Center pages: swallowing, larynx tumors, thyroid tumors, obstructive sleep apnea.

Summary

• Voice problems are common, affecting about 3 in 10 adults at some point, and more often teachers and older adults.

• Most hoarseness is from short-lived laryngitis and gets better in a few weeks without antibiotics.

• Hoarseness lasting more than 4 weeks, or with warning signs such as a neck lump, breathing trouble, recent surgery, or smoking, should be examined with laryngoscopy.

• Reflux medicine, steroids, and imaging are not recommended for hoarseness before the larynx has been examined.

• Voice therapy is the main treatment for muscle tension dysphonia, nodules, and the aging voice. Surgery helps cysts, polyps, and lesions that do not respond to therapy. Botulinum toxin is the standard treatment for laryngeal dystonia.

• Early cancer of the vocal fold usually causes hoarseness early and has a very good outlook with treatment.

References

1. Roy N, Merrill RM, Gray SD, et al. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115(11):1988-95. doi:10.1097/01.mlg.0000179174.32345.41

2. Roy N, Stemple J, Merrill RM, et al. Epidemiology of voice disorders in the elderly: preliminary findings. Laryngoscope. 2007;117(4):628-33. doi:10.1097/MLG.0b013e3180306da1

3. Stachler RJ, Francis DO, Schwartz SR, et al. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018;158(1_suppl):S1-S42. doi:10.1177/0194599817751030

4. Cohen SM, Kim J, Roy N, et al. Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope. 2012;122(2):343-8. doi:10.1002/lary.22426

5. de la Fuente J, Garrett CG, Ossoff R, et al. A Case Series of the Probability Density and Cumulative Distribution of Laryngeal Disease in a Tertiary Care Voice Center. Ann Otol Rhinol Laryngol. 2017;126(11):748-754. doi:10.1177/0003489417728945

6. Reveiz L, Cardona AF. Antibiotics for acute laryngitis in adults. Cochrane Database Syst Rev. 2015;(5):CD004783. doi:10.1002/14651858.CD004783.pub5

7. Galván CA, Guarderas JC. Practical considerations for dysphonia caused by inhaled corticosteroids. Mayo Clin Proc. 2012;87(9):901-4. doi:10.1016/j.mayocp.2012.06.022

8. Naunheim MR, Huston MN, Bhattacharyya N. Voice Disorders Associated With the Use of Inhaled Corticosteroids. Otolaryngol Head Neck Surg. 2023;168(5):1034-1037. doi:10.1002/ohn.198

9. O'Hara J, Stocken DD, Watson GC, et al. Use of proton pump inhibitors to treat persistent throat symptoms: multicentre, double blind, randomised, placebo controlled trial. BMJ. 2021;372:m4903. doi:10.1136/bmj.m4903

10. Watts CR, Hamilton A, Toles L, et al. Intervention Outcomes of Two Treatments for Muscle Tension Dysphonia: A Randomized Controlled Trial. J Speech Lang Hear Res. 2019;62(2):272-282. doi:10.1044/2018_JSLHR-S-18-0118

11. Barsties V Latoszek B, Watts CR, Neumann K. The effectiveness of voice therapy on voice-related handicap: A network meta-analysis. Clin Otolaryngol. 2020;45(5):796-804. doi:10.1111/coa.13596

12. Baghban K, Golmohamadi G, Asadollahpour F. The Worldwide Prevalence of Voice Disorders Among Schoolteachers: A Systematic Review and Meta-Analysis. J Voice. 2025. Online ahead of print. doi:10.1016/j.jvoice.2025.04.018

13. Birchall MA, Carding P. Vocal nodules management. Clin Otolaryngol. 2019;44(4):497-501. doi:10.1111/coa.13324

14. Johns MM, Garrett CG, Hwang J, et al. Quality-of-life outcomes following laryngeal endoscopic surgery for non-neoplastic vocal fold lesions. Ann Otol Rhinol Laryngol. 2004;113(8):597-601. doi:10.1177/000348940411300801

15. Akbulut S, Gartner-Schmidt JL, Gillespie AI, et al. Voice outcomes following treatment of benign midmembranous vocal fold lesions using a nomenclature paradigm. Laryngoscope. 2016;126(2):415-20. doi:10.1002/lary.25488

16. Hashibe M, Brennan P, Chuang SC, et al. Interaction between tobacco and alcohol use and the risk of head and neck cancer: pooled analysis in the International Head and Neck Cancer Epidemiology Consortium. Cancer Epidemiol Biomarkers Prev. 2009;18(2):541-50. doi:10.1158/1055-9965.EPI-08-0347

17. Pakkanen P, Irjala H, Ilmarinen T, et al. Survival and Larynx Preservation in Early Glottic Cancer: A Randomized Trial Comparing Laser Surgery and Radiation Therapy. Int J Radiat Oncol Biol Phys. 2022;113(1):96-100. doi:10.1016/j.ijrobp.2022.01.010

18. Markou K, Goudakos J, Constantinidis J, et al. Primary laryngeal lymphoma: report of 3 cases and review of the literature. Head Neck. 2010;32(4):541-9. doi:10.1002/hed.21104

19. Wolf C, Elahi B, Charous S. An Overview of Laryngologic Manifestations of Neurologic Diseases. Curr Neurol Neurosci Rep. 2024;24(12):571-580. doi:10.1007/s11910-024-01374-7

20. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007;117(10):1864-70. doi:10.1097/MLG.0b013e3180de4d49

21. Jeannon JP, Orabi AA, Bruch GA, et al. Diagnosis of recurrent laryngeal nerve palsy after thyroidectomy: a systematic review. Int J Clin Pract. 2009;63(4):624-9. doi:10.1111/j.1742-1241.2008.01875.x

22. Justicz N, Hapner ER, Josephs JS, et al. Comparative effectiveness of propranolol and botulinum for the treatment of essential voice tremor. Laryngoscope. 2016;126(1):113-7. doi:10.1002/lary.25485

23. Simonyan K, Barkmeier-Kraemer J, Blitzer A, et al. Laryngeal Dystonia: Multidisciplinary Update on Terminology, Pathophysiology, and Research Priorities. Neurology. 2021;96(21):989-1001. doi:10.1212/WNL.0000000000011922

24. Blitzer A, Brin MF, Stewart CF. Botulinum toxin management of spasmodic dysphonia (laryngeal dystonia): a 12-year experience in more than 900 patients. Laryngoscope. 1998;108(10):1435-41. doi:10.1097/00005537-199810000-00003

25. Sackley CM, Rick C, Brady MC, et al. Lee Silverman voice treatment versus NHS speech and language therapy versus control for dysarthria in people with Parkinson's disease (PD COMM): pragmatic, UK based, multicentre, three arm, parallel group, unblinded, randomised controlled trial. BMJ. 2024;386:e078341. doi:10.1136/bmj-2023-078341

26. Mohammadzadeh A, Heydari E, Azizi F. Speech impairment in primary hypothyroidism. J Endocrinol Invest. 2011;34(6):431-3. doi:10.1007/BF03346708

27. Kotla A, Thayer E, Gheriani GA, et al. Autoimmune Disorders Affecting the Larynx: Review of Laryngoscopic Findings and Approach to Multidisciplinary Management. Ann Otol Rhinol Laryngol. 2026;135(6):476-484. doi:10.1177/00034894251408704

28. Catano J, Uzunhan Y, Paule R, et al. Presentation, Diagnosis, and Management of Subglottic and Tracheal Stenosis During Systemic Inflammatory Diseases. Chest. 2022;161(1):257-265. doi:10.1016/j.chest.2021.07.037

29. Cereceda-Monteoliva N, Rouhani MJ, Maughan EF, et al. Sarcoidosis of the ear, nose and throat: A review of the literature. Clin Otolaryngol. 2021;46(5):935-940. doi:10.1111/coa.13814

30. Loehrl TA, Smith TL. Inflammatory and granulomatous lesions of the larynx and pharynx. Am J Med. 2001;111 Suppl 8A:113S-117S. doi:10.1016/s0002-9343(01)00856-7

31. Lucena MM, da Silva Fdos S, da Costa AD, et al. Evaluation of voice disorders in patients with active laryngeal tuberculosis. PLoS One. 2015;10(5):e0126876. doi:10.1371/journal.pone.0126876

32. Saccente-Kennedy B, Gillies F, Desjardins M, et al. A Systematic Review of Speech-Language Pathology Interventions for Presbyphonia Using the Rehabilitation Treatment Specification System. J Voice. 2026;40(3):706-732. doi:10.1016/j.jvoice.2023.12.010

33. Ziegler A, Verdolini Abbott K, Johns M, et al. Preliminary data on two voice therapy interventions in the treatment of presbyphonia. Laryngoscope. 2014;124(8):1869-76. doi:10.1002/lary.24548

34. Alves M, Krüger E, Pillay B, et al. The Effect of Hydration on Voice Quality in Adults: A Systematic Review. J Voice. 2019;33(1):125.e13-125.e28. doi:10.1016/j.jvoice.2017.10.001

35. Roy N, Gray SD, Simon M, et al. An evaluation of the effects of two treatment approaches for teachers with voice disorders: a prospective randomized clinical trial. J Speech Lang Hear Res. 2001;44(2):286-96. doi:10.1044/1092-4388(2001/023)