Chapter 27: Dysphonia

Dysphonia represents impaired voice production or altered voice quality affecting approximately ten percent of the population, with particularly higher prevalence in children, elderly adults, and individuals whose professions demand extensive vocal use such as educators and performing artists. The chapter distinguishes dysphonia as a clinical diagnosis from hoarseness, which describes the patient's subjective experience of voice abnormality. Voice production occurs through vibration of the vocal cords as exhaled air passes through the larynx, with pitch determined by cord length and tension under vagus nerve control. Age-related changes substantially alter voice characteristics, with older males experiencing progressive weakening and higher pitch due to muscle atrophy and tissue stiffening, while older females typically develop lower-pitched voices secondary to menopause-induced mucoid edema in submucosal tissue layers. The chapter emphasizes that persistent hoarseness lasting beyond four weeks warrants comprehensive medical evaluation, particularly to exclude laryngeal malignancy, the most common serious etiology occurring in males aged fifty to seventy with tobacco and alcohol exposure histories. Critical red flag symptoms include stridor, hemoptysis, dysphagia, unintentional weight loss, and unilateral otalgia despite normal otologic examination, all suggesting possible malignancy requiring urgent otolaryngology referral. Viral infection remains the most frequent cause of acute hoarseness, though differential diagnoses encompass vocal cord lesions, gastroesophageal reflux disease, postnasal drainage, neurological disorders including Parkinson disease, and medication side effects from anticholinergic agents. Physical examination findings including hard fixed lymphadenopathy and vocal cord paralysis warrant specialist evaluation via direct laryngoscopy. Management emphasizes vocal hygiene modifications including absolute voice rest while avoiding whispering, elimination of laryngeal irritants, adequate hydration, environmental humidification, and avoidance of drying medications. Antireflux therapy should only be initiated when significant reflux symptoms are documented, while speech-language pathology intervention provides evidence-based treatment once serious pathology is excluded.