Hoarseness, Stridor & Laryngeal Disorders
A hoarse voice or a noisy breath is really a question of anatomy
Evaluating hoarseness
When to scope. Hoarseness (dysphonia) that has not resolved or improved within 4 weeks needs laryngoscopy, usually flexible laryngoscopy in the office. Red flags move that to now: tobacco use, a neck mass, dysphagia or odynophagia, hemoptysis, referred otalgia, weight loss, stridor, and recent neck or chest surgery or intubation. Professional voice users merit early evaluation because small lesions matter to them.
Don't treat blind: empiric antireflux therapy (unless classic GERD symptoms are present), corticosteroids, and antibiotics should not precede laryngoscopy, and CT or MRI should not be ordered before the larynx has been seen. Imaging follows the scope, for example contrast CT along the nerve's course once a paralyzed fold is found.
Benign laryngeal disease
Acute laryngitis. A viral upper respiratory infection or a bout of vocal overuse inflames the folds; hoarseness resolves within about 2–3 weeks with voice rest, hydration, humidified air, and avoidance of smoke and irritants. Antibiotics and steroids do not help.
| Lesion | Features | Treatment |
|---|---|---|
| Nodules | Bilateral, symmetric, junction of anterior and middle thirds; chronic overuse (singers, teachers, shouting children) | Voice therapy first; surgery rarely |
| Polyp | Usually unilateral, often hemorrhagic; smoking, acute phonotrauma | Microlaryngeal excision plus voice therapy |
| Reinke edema | Bilateral diffuse floppy swelling; heavy smokers, deep gravelly voice | Stop smoking; surgery if severe |
| Papillomas | Exophytic, recurrent; HPV 6/11 | Repeated surgical debulking |
Laryngopharyngeal reflux. Refluxed acid and pepsin irritate the larynx, producing hoarseness, chronic throat clearing, globus, and cough, often without heartburn. Laryngoscopy shows posterior (interarytenoid) erythema and edema. Management is lifestyle change plus a twice-daily PPI trial for about 2–3 months once the larynx has been examined. Contact granulomas on the vocal processes are linked to reflux and intubation trauma.
Recurrent respiratory papillomatosis. Low-risk HPV types 6 and 11 cause exophytic papillomas, mostly on the vocal folds. The juvenile form is acquired during vaginal birth from maternal genital warts and presents with progressive hoarseness and a weak cry, then stridor that is easily mistaken for asthma or croup. Lesions recur and need repeated surgical debulking (microdebrider or laser), with adjuvant cidofovir or bevacizumab for aggressive disease; HPV vaccination prevents it.
Vocal fold paralysis
Anatomy. The recurrent laryngeal nerves, branches of the vagus, supply every intrinsic laryngeal muscle except the cricothyroid, which is innervated by the external branch of the superior laryngeal nerve. The left RLN hooks under the aortic arch and passes through the aortopulmonary window; the right loops under the right subclavian artery. Both ascend in the tracheoesophageal groove beside the thyroid.
Causes. Thyroid and parathyroid surgery threaten either nerve. Because of its long intrathoracic course, the left nerve is also injured by left lung or hilar tumors, mediastinal lymph nodes, aortic arch aneurysm, PDA ligation or cardiac surgery, and a massively enlarged left atrium or dilated pulmonary artery (Ortner, or cardiovocal, syndrome). Right apical (Pancoast) tumors can involve the right nerve.
| Feature | Unilateral | Bilateral |
|---|---|---|
| Fold position | One fold paramedian | Both folds near midline |
| Voice | Breathy and weak; weak cough | Often fairly normal |
| Airway | Aspiration of thin liquids | Inspiratory stridor, airway compromise |
| Classic setting | Thoracic tumor, neck or chest surgery | After total thyroidectomy |
| Action | If unexplained, contrast CT from skull base to aortic arch; voice therapy or medialization | Secure the airway: reintubation or tracheostomy |
Injury to the external branch of the superior laryngeal nerve during ligation of the superior thyroid vessels paralyzes the cricothyroid; the voice tires easily and loses its high range, a career problem for singers.
Laryngeal cancer
Risk and behavior. Nearly all laryngeal cancers are squamous cell carcinomas, and tobacco and alcohol multiply each other's effect. The subsite decides how the tumor presents and spreads.
| Feature | Glottic | Supraglottic | Subglottic |
|---|---|---|---|
| Frequency | Most common | Second | Rare |
| First symptom | Early hoarseness | Late dysphagia, odynophagia, referred otalgia, neck mass | Airway obstruction |
| Lymphatics | Sparse; nodes rare | Rich; nodes common, often bilateral | Paratracheal nodes |
| Outlook | High cure rates | Worse | Worse |
Workup and treatment. A suspicious lesion leads to direct laryngoscopy with biopsy, contrast CT of the neck, and chest imaging for staging and a second primary. Early (T1–T2) glottic cancer is treated with a single modality, radiation or endoscopic laser resection, preserving the voice. Advanced disease receives concurrent chemoradiation with cisplatin for organ preservation, or total laryngectomy when cartilage is destroyed; the patient then breathes through a permanent tracheostoma and speaks with a tracheoesophageal voice prosthesis or an electrolarynx.
Stridor in infants and children
Localizing the noise. Stridor is the sound of turbulent flow through a narrowed airway. The extrathoracic airway collapses during inspiration, so supraglottic and glottic lesions cause inspiratory stridor; fixed narrowing of the subglottis or cervical trachea is heard in both phases (biphasic); intrathoracic tracheal or bronchial narrowing worsens on expiration and sounds like wheeze. Stertor, a low snoring noise, arises higher, from the adenoids, tonsils, and nasopharynx.
| Cause | Clues | Management |
|---|---|---|
| Laryngomalacia | Inspiratory; worse supine, feeding, crying; thriving infant | Reassure; supraglottoplasty if severe |
| Vocal cord paralysis | Unilateral: weak cry, feeding trouble (left after PDA ligation or cardiac surgery). Bilateral: stridor with near-normal cry (Chiari II, hydrocephalus) | Treat the cause; airway support if bilateral |
| Subglottic stenosis | Biphasic; prior prolonged NICU intubation; recurrent or prolonged croup | Endoscopic dilation or reconstruction |
| Subglottic hemangioma | Biphasic, worsening over the first months; beard-distribution skin hemangioma in about half | Confirm endoscopically; oral propranolol |
| Vascular ring | Biphasic stridor, dysphagia, eased by neck extension | Surgical division |
Laryngomalacia. The most common cause of infant stridor is a floppy supraglottis (omega-shaped epiglottis, short aryepiglottic folds, prolapsing arytenoids) that collapses on inspiration. Noise begins in the first weeks, is worse supine, with feeding, and with crying, eases prone, peaks around 4–8 months, and resolves by 12–24 months. Flexible laryngoscopy confirms it. Most infants need only reassurance and treatment of coexisting reflux; failure to thrive, apnea, cyanosis, or pulmonary hypertension calls for supraglottoplasty.
Foreign body aspiration. Toddlers of 1–3 years aspirate nuts, food, and small toys. A sudden choking episode is followed by cough, unilateral wheeze, and decreased breath sounds. Most objects are radiolucent, so the clue is air trapping: on expiratory or decubitus films the affected lung stays inflated. Rigid bronchoscopy is both diagnostic and therapeutic. For complete obstruction, give back blows and chest thrusts under 1 year and, from age 1, back blows alternating with abdominal thrusts (AHA 2025), without blind finger sweeps.
Acute febrile stridor is a separate problem (croup, epiglottitis, bacterial tracheitis). An adolescent with asthma-like attacks of inspiratory stridor and normal oxygenation may have vocal cord dysfunction, with paradoxical fold adduction on inspiration seen at laryngoscopy.