Abstract
Hoarseness of voice is one of the common symptoms with which patient presents to an otorhinolaryngologist. Hoarseness is a symptom of diverse etiology. The aim of the study was to study the problem of hoarseness relating to its incidence and to identify the common etiologies and predisposing factors leading to hoarseness of voice. This study comprises of 70 cases of hoarseness presenting to Department of Otorhinolaryngology, VIMS, Ballari, Karnataka from October 2015 to March 2017. After taking a thorough history, a complete otolaryngological examination was carried out and supported by relevant investigations, diagnosis was reached. The incidence of hoarseness of voice was noted to be 0.21% in our study. The majority of patients were in 31–40 years and 51–60 years of age group, and male to female ratio was 3.7:1, farmers constituted single largest group (34.3%), and most of the patients were from the rural area (82.9%). Smoking was the commonest habit (54.29%) predisposing to hoarseness of voice. Maximum patients presented with hoarseness of duration of 1–3 months. Laryngeal malignancy was the commonest aetiology noted in our study (38.6%). A complaint of hoarseness may represent a serious disease and, therefore, should not be ignored, especially if present for more than 2 weeks. It needs a complete evaluation to rule out malignancy as a cause.
Keywords: Hoarseness, Vocal cord, Laryngoscopy, Laryngeal neoplasm
Introduction
Voice is not just a tool of communication, but it also carries our ideas, emotions, and personality. Every human voice is linked to anatomical, physiological, biological, cultural, sociolinguistic, and behavioural factors. Voice alone can communicate several nonverbal messages. The normal voice should possess specific characteristics of pitch, loudness, and quality, which make clear meaning and elicits an emotional response to ensure a pleasant tonal effect upon the listener. Phonation is an incredible human performance [1]. Speech is the primary skill, which most clearly separates human beings from animals [2].
Hoarseness of voice is a symptom and not a disease per se. It is the quality of voice that is rough, grating, harsh, and more or less discordant and has a lower pitch than usual for the individual. For the production of hoarse voice, there exists a change in anatomical structures and pathophysiological processes. Setting the air column in vibration by the larynx is purely a mechanical process. Anything that impairs the perfect working of this mechanism produces hoarseness. Although many causes of hoarseness of voice are benign, it can be a harbinger of many sinister pathologies like malignancy [3]. Hoarseness of voice is a common complaint in today’s stressed and fast-paced life. In India and other developing countries, the prevailing lower economic status, poorer nutrition and general health, different food habits, vocal habits, smoking and drinking habits, unhealthy environment and various social customs influence the incidence of hoarseness [4].
Materials and Methods
This study was done in the Department of ENT, Vijayanagar Institute of Medical Sciences, Bellary, Karnataka, India, during the period from October 2015 to March 2017. The study was approved by the institutional ethical committee (IEC). Patients of all age groups and sexes presenting to the ENT department with hoarseness of voice were included as the subjects of the study. Post laryngectomy patients, patients with craniofacial or velopharyngeal problems, patients with dysarthria, pregnant women and psychiatric patients were excluded from our research. Then a detailed history was taken with the aid of proforma. This was followed by thorough ENT and systemic examination, and clinical diagnosis was reached in support of the relevant investigations, including direct laryngoscopic examination, suspension microlaryngoscopy, videolaryngoscopy, which may or may not be followed with biopsy of the concerning lesion as per the case necessitates. The results were then analyzed, employing standard statistical methods.
Observations and Results
The incidence of hoarseness of voice was estimated to be 0.21% of the total patients who attended the ENT department during the study period. Maximum number, i.e., 16 cases (22.9%) each, belonged to 31–40 years of age group and 51–60 years age group (Table 1). Minimum number, i.e., 2 cases (2.9%), belonged to more than 71 years of age group. The youngest patient was 11 years old, and the eldest patient was of 85 years of age. Male: Female ratio in our study was 3.7:1, with males being 78.6% and females contributing to 21.4% (Fig. 1). The majority of patients, i.e., 24 cases (34.3%), belonged to farmers and the least belonged to homemakers, 7 cases (10%) (Table 2). The highest number of cases, i.e., 58 cases (82.9%), were from rural areas. Among the associated symptoms along with hoarseness, cough has the highest frequency 24 (27.59%), followed by dysphagia in 17 (19.54%), breathlessness in 11 (12.64%), regurgitation or reflux symptoms in the throat in 8 (9.20%) and neck swelling in 2 (2.30%). No associated symptoms apart from hoarseness were present in 25 (28.74%) patients. Smoking was the commonest habit noted in 38 cases (34.86%) followed by usage of tobacco preparations in 25 cases (22.93%) and alcoholism in 20 cases (18.34%). The usage of tobacco preparation includes tobacco chewing, betel nut chewing, pan chewing, and Gutka use (Table 3). Twenty-nine cases (41.4%) in our study had evidence of voice abuse; the remaining cases (58.6%) didn’t have (Fig. 2). When the duration of hoarseness of voice was considered the most number of patients, 33 cases (47.1%), presented with hoarseness during 1–3 months duration followed by 4–6 months age group, 12 cases (17.1%) (Table 4). The majority of cases, i.e., 27 (38.6%) presented with ulcero-proliferative growth of larynx followed by laryngeal congestion/oedema/granuloma in 14 cases (20%), polypoidal growth 11 cases (15.70%) nodular growth and vocal cord paralysis with 7 cases in each (10%), cystic lesion in 3 cases (4.30%) and vocal cord papilloma in 1 case (1.40%). Most frequent aetiology noted was laryngeal malignancy comprising 27 cases (38.6%) followed by chronic laryngitis 14 cases (20%), vocal cord polyp 10 cases (14.3%), vocal cord palsy 7 cases (10%), vocal cord nodule 5 cases (7.1%), vocal cord cyst 3 cases (4.3%), vocal cord papilloma 2 cases (2.9%), tuberculosis of larynx and laryngeal trauma with 1 case each (1.4%) (Table 5).
Table 1.
Age distribution of the study participants
| Number | % | |
|---|---|---|
| 11–20 | 7 | 10.0 |
| 21–30 | 7 | 10.0 |
| 31–40 | 16 | 22.9 |
| 41–50 | 9 | 12.9 |
| 51–60 | 16 | 22.9 |
| 61–70 | 13 | 18.6 |
| > 71 | 2 | 2.9 |
| Total | 70 | 100.0 |
Fig. 1.
Sex distribution of the study sample
Table 2.
Occupation
| Occupation | Gender | Total | |
|---|---|---|---|
| Female | Male | ||
| Farmer | |||
| Count | 0 | 24 | 24 |
| % | 0.0% | 43.6% | 34.3% |
| Home maker | |||
| Count | 7 | 0 | 7 |
| % | 46.7% | 0.0% | 10.0% |
| Labour | |||
| Count | 0 | 12 | 12 |
| % | 0.0% | 21.8% | 17.1% |
| Student | |||
| Count | 3 | 6 | 9 |
| % | 20.0% | 10.9% | 12.9% |
| Other profession | |||
| Count | 5 | 13 | 18 |
| % | 33.3% | 23.6% | 25.7% |
| Total | |||
| Count | 15 | 55 | 70 |
| % | 100.0% | 100.0% | 100.0% |
Table 3.
Habits encountered which are predisposing to hoarseness of voice
| Habits | Number | % |
|---|---|---|
| Smoking | 38 | 34.862 |
| Usage of Tobacco preparations | 25 | 22.936 |
| Alcoholism | 20 | 18.349 |
| NIL | 26 | 23.853 |
| Total | 109 | 100 |
Fig. 2.
History of voice abuse
Table 4.
Duration of hoarseness
| Duration in months | Frequency | Percentage |
|---|---|---|
| < 1 | 9 | 12.9 |
| 1–3 | 33 | 47.1 |
| 4–6 | 12 | 17.1 |
| 7–9 | 4 | 5.7 |
| 9–12 | 7 | 10.0 |
| Greater than 12 | 5 | 7.1 |
| Total | 70 | 100.0 |
Table 5.
Aetiology of hoarseness of voice
| Diagnosis | Number | % |
|---|---|---|
| Laryngeal malignancy | 27 | 38.6 |
| Chronic laryngitis | 14 | 20.0 |
| Vocal cord polyp | 10 | 14.3 |
| Vocal cord palsy | 7 | 10.0 |
| Vocal cord nodule | 5 | 7.1 |
| Vocal cord cyst | 3 | 4.3 |
| Vocal cord papilloma | 2 | 2.9 |
| Tuberculosis of larynx | 1 | 1.4 |
| Laryngeal trauma | 1 | 1.4 |
Discussion
Hoarseness is one of the most prevalent symptoms and is invariably the earliest manifestation of a large variety of conditions affecting larynx. Hoarseness of voice can result in impedance to communication. When the voice deteriorates, the whole personality suffers, giving rise to feelings of insecurity and inadequacy. Hoarseness lasting longer than 2 weeks needs to be evaluated thoroughly to rule out malignancy as a cause. A detailed history and a meticulous clinical examination can narrow down the differential diagnoses of hoarseness of voice. Seventy patients who presented with hoarseness of voice were studied during the study period. In our study period, the incidence of hoarseness of voice was 0.21%.
Sambu Baitha [5] noted that the incidence of hoarseness was 0.32%. In our study population age of patients with hoarseness of voice ranged from 11 to 85 years. Maximum number, i.e., 16 cases (22.9%), belonged to 31–40 years of age group and 51–60 years age group. Swapan Ghosh [6] et al. reported that maximum patients, i.e., 28 cases (28%) were in the age group of 21–30 years. In a retrospective study involving 251 cases by Banjara et al. [7], the majority of patients were seen in the 21–30 age group (22.31%) and 51–60 age group (22.31%) which is similar to our study. According to Herrington Hall et al., laryngeal pathologies occurred primarily in older age groups, with females presenting at a slightly younger age group than males [8]. Among our study subjects, 55 cases (78.6%) were males, and 15 cases (21.4%) were females. Thus male to female ratio is 3.7:1 which is in correlation with other studies that show a male predominance. The male preponderance in India may be attributed to the habits predisposing to hoarseness of voice, such as smoking, alcoholism, and tobacco chewing, are found mainly in males. Secondly, there may be more chances of increased occupational hazards in the male population as most of the rural women in India stay indoors. Lastly, it may be due to more attendance in Outpatient Department in rural areas by males than females. When the occupation of the patients presenting with hoarseness was taken, 24 cases (34.3%) were farmers, and homemakers accounted for the least number of cases, i.e., 7 cases (10%). In the study by Sambu Baitha et al. [5], the majority of patients were of labourer class (36.36%). Herrington Hall et al. [8] also looked at the influence of occupation on hoarseness of voice. They found that the presence of laryngeal pathologies tend to reflect both the amount of voice use and the conditions under which voice was used. Our study revealed that the majority of patients, i.e., 58 cases (82.9%), were hailing from the rural area and 12 cases (17.1%) hailing from the urban area. Also, in the study by Sambu Bhaita [5], patients were predominantly of rural regions comprising 83 cases (75.5%) and patients from the urban areas forming only 27 cases (24.5%) with a rural: urban ratio of 3:1. Our study had a rural: urban ratio of 4.8:1 as our hospital mainly caters to the health care needs of people of the northeastern part of Karnataka with more rural areas.
Hoarseness was noted in all the 70 cases (100%). Next, common symptom was cough in 24 patients (27.59%) followed by dysphagia in 17 cases (19.54%), breathlessness in 11 cases (12.64%), heartburn in 8 cases (9.20%) and neck swelling in 2 patients (2.30%). No symptoms apart from hoarseness were noted in 25 cases (28.74%). Apart from hoarseness, Sambu Bhaita et al. [9] had noted other common presentations being cough, fever and vocal fatigue in descending order of frequency. The commonest habit noted in our study was smoking in 38 (34.9%) cases, and the least common practice was alcoholism in 20 cases (18.3%). Usage of tobacco preparations in the form of Gutka/Betelnut with tobacco/Pan chewing was noted in 25 cases (22.9%). Smoking was the commonest habit in a study by Banjara et al. [7] in 43% cases, alcoholism in 29.48%, and tobacco/Gutka chewing in 29.48% cases. The study by Sambu Baitha [9] showed voice abuse in 40.9% as the major contributory factor for hoarseness which correlates well with the incidence in our study i.e., 41.4%. As per Hirschberg et al., a rapid change in civilization, industrialization, or profession often leads to a heightened rate of voice abuse [10]. In our study, the duration of hoarseness ranged from 1 week to 5 years and the maximum number of patients, i.e., 33 (47.1%), presented during 1-3 months duration. Banjara et al. [7] also found out that most of the presenting complaints (61.35%) were seen within 3 months, which correlates with our study. This also emphasizes the fact that patients with change of voice seek medical care early as compared to other laryngeal symptoms like globus sensation or lymphadenopathy. On indirect laryngoscopic examination (IDL), our most frequent finding was ulceroproliferative growth involving larynx or laryngopharynx, 27 cases (38.6%), followed by laryngeal congestion/oedema/granuloma which was noticed in 14 cases (20%). In contrast, Sambu Baitha et al. [5], noted congestion of vocal cords in 34.54%, and growth in only 9% of cases on IDL examination. Out of the 70 cases of this study, 51 case’s biopsy specimens were subjected to histopathological examination. They were found to be squamous cell carcinoma in 27 cases (38.6%), squamous papilloma in 2 cases (2.9%), hyperplastic epithelium in 7 cases (10.0%) and nonspecific inflammatory changes in 15 cases (21.4%). We recognized malignancy of larynx was the commonest aetiology, i.e., 27 cases (38.6%). Out of which 26 cases (96.3%) were males, and one (3.7%)was female. Malignancy remained the commonest aetiology for hoarseness among males in our study. In the study by Smita et al. also malignancy was the commonest aetiology of which supraglottic growth being the commonest [11]. This highlights the fact that there may be a paradigm shift in the leading cause of hoarseness from benign conditions to laryngeal malignancies. In the study by Sambu Bhaita [5] incidence of malignancy was 14.54% with male to female ratio as 15:1. In the study by Kadambari [3] incidence of malignancy was 18%, and in the study by Swapan Ghosh [6] incidence of malignancy was only 8%. The next common etiology in our research was chronic laryngitis in 14 cases (20%). Among females, the commonest etiology was chronic laryngitis i.e., 8 cases (36.36%).In both studies of Parikh [4] and Sambu Baitha [5], chronic laryngitis was the most frequent aetiology comprising 48% in each, whereas in the study by Swapan Ghosh [6], it was only 6%. The least number of cases in our study were 1 case each of TB larynx and laryngeal trauma (1.4% each). The incidence of TB was 23%, 5.45%, and 1%, respectively, in studies by Parik [4], Sambu Baitha [5], and Kadambari [3], respectively. The incidence of larynx tuberculosis in our study correlates with the study by Kadambari et al. [3]. The frequency of laryngeal tuberculosis is probably less now because of the early detection and management of pulmonary tuberculosis [12]. Stroboscopy, which is used for detailed evaluation of the vocal fold vibration patterns, could not be used for our study because of its non-availability.
There is a highly significant association (p < 0.01) of malignancy with habits such as smoking, use of tobacco preparations including tobacco chewing/betel nut chewing/pan chewing or gutka, and alcoholism. Many case-control studies have shown a multiplicative effect of tobacco and alcoholism on laryngeal malignancy. Alcohol is believed to cause carcinogenesis through acetaldehyde exposure, malnutrition, and desiccation of mucosa. Tobacco acts via polycyclic aromatic hydrocarbon like benzopyrene, whose products bind directly to DNA and RNA and leads to carcinogenesis. Sambu Baitha et al. [9] has demonstrated a strong correlation between tobacco use and laryngeal cancer, and its increase in incidence depends on increase in the number of cigarettes smoked per day.
The risk of carcinoma increases in smokers 4 to 40 times as compared to non-smokers and heavy alcohol intake increases the risk by three times as compared to non-drinkers [13]. According to the study by Gaurav Kataria et al. [14], among 37 patients (20.55%) with chronic laryngitis, the commonest predisposing factor noted was the usage of tobacco preparations and smoking which was present in 20 patients (54.05%). Smoking and tobacco chewing together constitute major predisposing factors in malignancy, acute and chronic laryngitis, and leukoplakia. In our study, out of 14 patients diagnosed as chronic laryngitis 6 had a history of tobacco smoking, 5 had habit of chewing tobacco preparations, and 5 had habit of alcoholism. Our study also revealed that six patients i.e., 42.85%, had no predisposing factors but still developed chronic laryngitis, which is a notable finding as chronic laryngitis is a precancerous lesion.
Conclusion
Voice disorders, as such, have a profound impact on a person’s social and personal life. In our present study, the incidence of hoarseness of voice was 0.21%, and the maximum number of cases, i.e., 16 cases (22.9%) each, were in the age group of 31-40 years and 51–60 years and a male predominance were noted in our study.
Our study also revealed that farmers had the maximum incidence of hoarseness of voice (34.3%). Cases predominated in people hailing from the rural area, and the majority of patients had a duration of hoarseness between 1 and 3 months (47.1%). Smoking is the commonly encountered habit, and the second most common habit was chewing tobacco preparations, and voice abuse was noted in 2/5th of patients. On indirect laryngoscopy, laryngeal growth was the commonest finding, and on histopathology, squamous cell carcinoma was most common. Thus laryngeal malignancy comprised the most common aetiology followed in decreasing order by chronic laryngitis, vocal cord polyp, vocal cord palsy, vocal cord nodule, vocal cord cyst, vocal cord papilloma, laryngeal tuberculosis, and laryngeal trauma respectively. However we recommend more studies with larger sample size to be done to validate whether malignancy is on the rise in rural India as the leading cause of hoarseness. Almost 1/3rd patients of our study had no risk factors for the symptom of hoarseness of voice such as smoking, usage of tobacco preparations, and alcoholism. We infer from our study that although patients with no risk factors may be less likely to develop malignant condition, he/she is equally prone to develop chronic laryngitis which is a premalignant condition causing hoarseness of voice. Our study emphasizes the need for more awareness and deaddiction programs, especially in the rural areas showcasing the ill effects of tobacco and alcoholism. Facilities should be provided at the peripheral hospitals to screen the at-risk patients, and appropriate referral of patients requiring detailed evaluation should be made to tertiary care facilities. Our study also reiterates that stringent measures should be taken at the primordial level for preventable morbidities arising from hoarseness of voice.
Funding
No external sources of funding involved in this article.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
Informed Consent
Informed consent was obtained from all individual participants included in the study and from the parent or guardian when the patient is minor
Ethical Standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards
Footnotes
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References
- 1.Maheshwari S. Management of hoarseness. Asian J Ear Nose Throat. 2003;1(1):1–9. [Google Scholar]
- 2.English GM (1996) Otolaryngology. Revised edition Lippincot-Raven, vol 3, pp 1–25
- 3.Batra K, Motwani G, Sagar PC. Functional voice disorders and their occurrence in 100 patients of hoarseness as seen on fibreoptic laryngoscopy. Indian J Otolaryngol Head Neck Surg. 2004;6(2):91–95. doi: 10.1007/BF02974305. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Parik N. Aetiology study of 100 cases of hoarseness of Voice. Indian J Otolaryngol Head Neck Surg. 1991;43(2):71–73. doi: 10.1007/BF02992547. [DOI] [Google Scholar]
- 5.Baitha S, Raizada RM, Kennedy Singh AK, Puttewar MP, Chaturvedi VN. Clinical profile of Hoarseness of voice. Indian J Otolaryngol Head Neck Surg. 2002;54(1):14–18. doi: 10.1007/BF02910998. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Ghosh SK, Chattopadhyay S, Bora H, Mukherjee PB. Microlaryngoscopic study of 100 cases of Hoarseness of voice. Indian J Otolaryngol Head Neck Surg. 2001;53(4):270–272. doi: 10.1007/BF02991545. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Banjara H, Mungutwar V, Singh D, Gupta A. Hoarseness of voice: a retrospective study of 251 cases. Int J Phonosurg Laryngol. 2011;1(1):21–27. doi: 10.5005/jp-journals-10023-1006. [DOI] [Google Scholar]
- 8.Herrington-Hall BL, Lee L, Stemple JC, Niemi KR, McHone MM. Description of laryngeal pathologies by age, sex, and occupation in a treatment-seeking sample. J Speech Hear Disord. 1988;53(1):57–64. doi: 10.1044/jshd.5301.57. [DOI] [PubMed] [Google Scholar]
- 9.Baitha S, Raizada RM, Singh AKK, Puttewar MP, Chaturvedi VN. Predisposing factors and aetiology of Hoarseness of voice. Indian J Otolaryngol Head Neck Surg. 2004;56(3):186–190. doi: 10.1007/BF02974347. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Hirschberg J, Dejonckere PH, Hirano M, Mori K, Schultz-Coulon HJ, Vrticka K. Voice disorders in children. Int J Pediatr Otorhinolaryngol. 1995;32(Suppl):S109–S125. doi: 10.1016/0165-5876(94)01149-R. [DOI] [PubMed] [Google Scholar]
- 11.Soni S, Chouksey S. A study of clinicopathological profile of patients of hoarseness of voice presenting to tertiary care hospital. Indian J Otolaryngol Head Neck Surg Off Publ Assoc Otolaryngol India. 2017;69(2):244–247. doi: 10.1007/s12070-017-1112-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Shrestha BL, Amatya RCM, Kc S, Shrestha I, Pokharel M. Aetiological factors of hoarseness in patients attending at Kathmandu University Hospital. Bangladesh J Otorhinolaryngol. 2013;19(1):14–17. doi: 10.3329/bjo.v19i1.11877. [DOI] [Google Scholar]
- 13.Cowls SR. Cancer of larynx occupational and environmental associations. South Med J. 1983;76(6):894–898. doi: 10.1097/00007611-198307000-00020. [DOI] [PubMed] [Google Scholar]
- 14.Kataria G, Saxena A, Singh B, Bhagat S, Singh R. Hoarseness of voice :etiological spectrum. Otolaryngol Online J. 2015;5(1.5):13–22. [Google Scholar]