The underlying causes of hoarseness include everything from voice overuse to more serious conditions, including cancer.

Hoarseness is a common condition that can have various underlying causes, ranging from voice overuse to being an indication of more serious conditions, including cancer, according to Dr. Scott Kay, a board-certified ear, nose and throat (ENT) specialist and founder of Princeton Otolaryngology Associates.

Following, Dr. Kay offers advice to primary care practitioners about how to diagnosis and treat hoarseness and guidelines for when it’s time to refer patients to a specialist.

First, what is hoarseness?

“Any change in the voice that the patient complains about should get the primary care doctor’s attention,’’ Dr. Kay explained. “The problem may not always be consistent. Patients may complain about fluctuations in the voice. They may not be able to project, or their voice may sound spasmodic. Other times, patients experience a rough or breathy sound to the voice.’’

One of the most common causes of hoarseness is viral infections.

“Any kind of infection that causes even the slightest amount of edema to the vocal cords will cause a change in that person’s voice,’’ Dr. Kay explained. “Vocal cords are thin membranes that lay on top of a tendon. The way those membranes vibrate can be altered with the most minute fluid accumulations.’’

Another common cause is known as “singer’s nodules,’’ caused by repetitive overuse and misuse of the voice, including singing loudly for extended periods of time or shouting, Dr. Kay said.

“Any traumatic movement of the vocal cord can cause these conditions,’’ Dr. Kay explained. “Even a cough is pretty violent to the vocal cord.’’

Smokers and people who use their voice a lot often experience vocal cord polyps, while reflux is another common culprit, leading to vocal cord granuloma — small areas of inflammation.

Neuromuscular issues can cause vocal cord paralysis, which could be linked to a virus or a tumor elsewhere in the body, such as the lung, brain or neck. Thyroid surgery has also been known to cause vocal cord paralysis. Another common affliction is spastic dysphonia, a neurologic condition that causes a stuttering pattern to the voice.

Less-common causes, Dr. Kay added, are cancer, the HPV virus and antibiotics causing a yeast infection in the vocal cords.

If a patient’s hoarseness is constant, this suggests a nodule, tumor or polyp on the vocal cord or paralysis when one vocal cord is not working at all.

Tracking Down the Cause of Hoarseness

In the primary care setting, physicians can begin to identify the cause by determining whether a patient’s hoarseness is constant or fluctuating.

“If it’s fluctuating, then it’s more consistent with reflux,’’ Dr. Kay explained. “The same is true for people with neurological conditions.’’

If the condition is constant, this suggests a nodule, tumor or polyp on the vocal cord or paralysis when one vocal cord is not working at all, according to Dr. Kay.

Frequency of voice use, smoking and suffering from gastroesophageal reflux disease (GERD) are other important factors to be explored, as is age, with older people more likely to experience hoarseness, especially if they go long periods without using their voice.

Absent an obvious finding, it may be difficult for primary care physicians to parse out the cause of hoarseness, Dr. Kay said. They can prescribe voice rest, but if that does not work, it is best to refer to a specialist.

“In cases where it’s thought to be due to voice misuse, prescribe voice rest for three days,’’ Dr. Kay said. “If it continues to be an issue, then a referral should be made because it could be indicative of more serious conditions.’’

In cases where the patient’s problem fluctuates and GERD symptoms are presented, primary care physicians can treat with a proton pump inhibitor such as Nexium or an H2 blocker like Pepcid.

Dr. Kay cautions against waiting too long to refer a patient to a specialist.

“If a patient experiences hoarseness that is constant for more than a few weeks, that should raise suspicion,’’ Dr. Kay said. “Even a patient who complains about their voice not being normal warrants further investigation.’’

Difficulty breathing or swallowing calls for immediate referral to an ENT or the emergency room, he added.

Listening to a patient’s voice provides immediate clues as to the cause of hoarseness.

Dr. Kay’s Approach to Evaluating and Treating Hoarseness

Listening to a patient’s voice is the first step that Dr. Kay takes when seeing a patient for hoarseness. This provides immediate clues as to the cause of the problem. Next, he uses a small device to examine the throat and larynx, a procedure known as laryngoscopy.

“That will tell me if there’s paralysis or a lesion on the vocal cord,’’ Dr. Kay explained. “Next would be to treat it or to move on to what’s called video stroboscopy.’’

This involves having a patient speak into a microphone that triggers a strobe light showing the movement of vocal cords in slow motion.

“Depending upon the results of those studies, I may order a CAT scan or an MRI if I suspect there is cancer or some sort of paralysis involved,’’ Dr. Kay said.

Depending on the cause of the hoarseness, Dr. Kay would employ various treatments, including antibiotics, antifungals or steroids and voice rest or therapy.

If a lesion, tumor, cyst or polyp is identified, microscopic laryngeal surgery is required to remove the pathology. While this procedure is done under general anesthesia in the hospital, it is minimally invasive, requiring no skin incisions. For cancer patients, removal of the lesion would be coupled with radiation therapy.

Another potential treatment is vocal cord injections for people with paralysis or weak vocal cords.

“I use hydroxyapatite, which is the same substance used for improving the appearance of facial wrinkles,’’ Dr. Kay explained.

Dr. Kay works closely with primary care physicians when treating patients for hoarseness and other conditions.

“When primary care physicians refer a patient, I always send a letter of my findings and how I’m managing the condition,’’ he said. “I keep them up to date with any developments and am always available to talk to physicians at any time.’’

For more information about the evaluation and treatment of hoarseness and other services provided by Princeton Otolaryngology Associates, or to make an appointment to see Dr. Kay at the practice’s Monroe or Plainsboro offices, call 609-445-4445 or visit drscottkay.com.