Causes and Treatment of Hoarseness: Nodules, Polyps, Reflux and Surgical Approach

Acute hoarseness (1-2 weeks) is usually due to viral laryngitis or acute voice misuse and self-resolves. Voice rest and avoiding smoking/alcohol suffice during this period.

But hoarseness lasting more than 2 weeks is always a warning sign. For persistent dysphonia, laryngoscopy is mandatory — do not start treatment without finding the cause. Especially in high-risk groups (smokers, drinkers, over 50, GERD patients) this rule should be applied strictly.

Findings warranting urgent evaluation: rapidly worsening voice, blood in saliva, neck mass, weight loss, dysphagia, dyspnoea, ear pain (referred), long smoking history. These are "alarm features" for laryngeal cancer and warrant rapid oncological assessment.

Acute viral laryngitis symptoms: 1-2 weeks of hoarseness, upper respiratory tract infection signs, gradual recovery. Antibiotics usually not needed — viral course. Voice rest, fluids, expectorants suffice. We expand on the clinical framework in our laryngology and voice surgery unit.

The core method for laryngeal evaluation is laryngoscopy. Two main types: flexible fibreoptic laryngoscopy and rigid stroboscopy. Both are done in clinic with local anaesthesia (nasal spray); the patient is seated.

Flexible fibreoptic laryngoscopy: a thin flexible endoscope passes through the nose; larynx and hypopharynx are visualised. Ideal for general anatomical assessment. Vocal cord movement, mucosal status, mass presence and symmetry are evaluated. Takes 2-3 minutes; high comfort.

Stroboscopy: rigid telescope-based advanced assessment. Vocal cord vibratory dynamics, mucosal wave, symmetry and phase difference are visualised in detail. Gold standard for nodules, polyps, small cysts, sulcus vocalis. Mandatory in professional voice users (singers, voice artists).

Imaging: not needed in every case. If laryngeal cancer is suspected, neck CT or MRI is done. PET-CT for advanced-stage distant metastasis screening. Biopsy: if a mass or suspicious lesion is seen, taken under microlaryngoscopy (general anaesthesia).

Vocal cord nodules and polyps are the most common benign laryngeal lesions. Both arise from voice misuse but their clinical pictures and treatment differ.

Nodule: bilateral, symmetric, located at the junction of the anterior 1/3 and middle 1/3 of the vocal cord. Also called "singer's nodule" or "teacher's nodule" — secondary to chronic vocal overuse. Treatment is primarily voice therapy (8-12 weeks); surgery only for large nodules unresponsive to conservative care.

Polyp: usually unilateral, pedunculated or broad-based, arises after an acute vocal trauma (shouting, loud speech). Usually does not respond to conservative therapy; treatment is microlaryngoscopic excision.

Microlaryngoscopic surgery: under general anaesthesia, the larynx is visualised with a microscope and the lesion removed with micro-scissors, micro-forceps or CO2 laser. Takes 20-30 minutes; same-day discharge. Voice rest 7-10 days. Voice therapy continues afterwards — to prevent recurrence.

Reinke's oedema: fluid accumulation in the superficial layer of the vocal cord (Reinke's space). Usually arises from long-term smoking + voice misuse + LPR (laryngopharyngeal reflux). The voice deepens and becomes raspy — also called "smoker's voice". More common in middle-aged female smokers.

Treatment: smoking cessation is mandatory — first step. With LPR, proton pump inhibitor (PPI) for 3-6 months. Voice therapy is adjunctive. Surgery: when conservative therapy fails, microlaryngoscopy with aspirator/cannula fluid aspiration + epithelial flap technique. Smoking must stop to prevent recurrence.

Chronic laryngitis: chronic inflammation of the vocal cords. Causes: smoking, alcohol, environmental irritants (dust, chemicals), chronic cough, postnasal drip, LPR. Treatment is cause-directed — smoking cessation, alcohol restriction, anti-reflux, allergy control. Mucolytics and humid air help.

Vocal cord leukoplakia: white lesion on the vocal cord epithelium. May be premalignant — biopsy is mandatory. Smoking and alcohol are major risk factors. For the related clinical reference, see hoarseness page.

Vocal cord paralysis: an immobile vocal cord due to recurrent laryngeal nerve (RLN) injury. Unilateral (more common) or bilateral (rare).

Causes: thyroid surgery (the most common iatrogenic cause, 1-3%), lung cancer (the left RLN loops around the aorta — mediastinal mass compression), idiopathic (cause unknown, viral aetiology suspected), trauma, brainstem lesions (Wallenberg), neck surgery (carotid endarterectomy).

Clinical findings: hoarseness (weak, breathy voice), aspiration (cough on swallowing), exertional dyspnoea. Bilateral paralysis: airway obstruction — emergency airway management (tracheostomy) may be needed.

Treatment: a 6-12 month wait — 30-50% spontaneous recovery possible. Voice therapy starts during this period. If no recovery, definitive treatments: medialisation laryngoplasty (Type 1 thyroplasty, Isshiki) — silicone implant pushes the paralysed cord toward midline. Vocal cord injection (collagen, hyaluronic acid, calcium hydroxylapatite) — temporary or permanent option. Nerve transfer (ansa cervicalis to RLN) in selected cases.

LPR is characterised by stomach contents (acid + pepsin + bile) reaching the larynx and pharynx. Different from GERD: classic chest pain or heartburn is usually absent — hence "silent reflux". Laryngeal mucosa is very sensitive to acid/pepsin exposure.

Clinical findings: hoarseness (especially morning), throat-clearing/lump sensation (globus), chronic cough, postnasal drip feeling, voice quality varying through the day. On laryngoscopy: posterior commissure thickening, vocal cord oedema, contact ulcer/granuloma (especially over arytenoids).

Diagnosis: clinical + laryngoscopic findings — Reflux Finding Score (RFS) and Reflux Symptom Index (RSI) are used. 24-hour pH-impedance monitoring is the gold standard but rarely needed.

Treatment: lifestyle (no food 3 h before bed, head-of-bed elevation, weight loss, coffee/alcohol/spice limits), proton pump inhibitor (PPI) once or twice daily for 3-6 months. Response is slow — improvement takes weeks to months. Alginate preparations (e.g. Gaviscon Advance) for added protection. In persistent LPR, fundoplication (surgery) can be considered.

Laryngeal cancer is rare but early diagnosis saves lives. Türkiye sees about 4,000-5,000 new cases yearly. 95% in male smokers. Alcohol use multiplies risk 5-10x; smoking + alcohol combine multiplicatively.

Risk factors: smoking (strongest), alcohol, HPV (rising role in oropharyngeal and supraglottic cancers), occupational exposures (asbestos, formaldehyde), GERD/LPR, poor nutrition.

Alarm features: hoarseness for more than 2-3 weeks (especially over 50, with smoking history), blood in saliva, neck mass, dysphagia, ear pain (referred), weight loss, dyspnoea.

Diagnosis: laryngoscopy (lesion visualisation), neck CT and MRI (extent), PET-CT (distant metastasis screening), biopsy (definitive diagnosis under microlaryngoscopy). Staging uses TNM (Tis-T4, N0-N3, M0/M1).

Treatment: early stage (T1-T2) — transoral laser microsurgery (TLM) or radiotherapy (RT), voice-preserving, 85-95% 5-year survival. Advanced stage (T3-T4) — combined chemoradiotherapy or total laryngectomy + neck dissection. After total laryngectomy, voice rehabilitation (oesophageal speech, voice prosthesis, electrolarynx) is needed. We share patient experiences on our second opinion service.