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Dysphonia is any alteration of voice quality or vocal effort that impairs communication and affects quality of life. In patients with dysphonia, voice qualities often are described as tremulous, hoarse, strained, or raspy, with altered pitch, breathiness, or vocal fatigue. Dysphonia is a sign of an underlying disease process. Up to one-third of individuals will experience dysphonia in their lifetime. The evaluation includes a history, physical examination, and, in some cases, laryngoscopy. The most common cause of dysphonia is acute laryngitis, with the majority of cases lasting fewer than 3 weeks. Longer duration of symptoms occurs with chronic laryngitis, laryngopharyngeal reflux, muscle tension dysphonia, benign vocal fold lesions, vocal fold paresis or paralysis, and spasmodic dysphonia. Laryngeal malignancy is uncommon; the major risk factors are smoking and concurrent alcohol use. Laryngoscopy should be performed in all patients with dysphonia that does not resolve or improve within 4 weeks or of any duration if a serious underlying etiology is suspected. Management is directed at the underlying etiology. Empiric treatment with antibiotics, corticosteroids, and antireflux drugs should be avoided in the absence of a clear indication. In patients with a definitive diagnosis, management includes vocal hygiene, voice therapy, pharmacotherapy, and surgery.

Case 1. Carla, a 35-year-old woman who is a teacher, reports hoarseness of 2 months’ duration that worsens during the workday. She speaks more loudly at school than she does at other times. She has no throat pain, dysphagia, or dyspnea. She underwent an uncomplicated tonsillectomy in childhood but otherwise has no significant medical or surgical history. Carla takes no prescription drugs, does not smoke cigarettes, and does not drink alcohol. You note that her voice sounds strained and fatigued.

Dysphonia (ie, hoarseness) is defined as any alteration in voice quality or vocal effort that impairs communication and affects quality of life.1 Dysphonia indicates an underlying disease process and should not be considered the result of normal strain.

Prevalence and Etiology

The precise prevalence of dysphonia is unclear. Many studies show that up to one-third of individuals in the population will experience an episode of dysphonia in their lifetime.1 Individuals in occupations requiring intense or prolonged oration (eg, singers, teachers, drill instructors) have been shown to have an average 30% to 50% prevalence of dysphonia.2,3

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