All patients who present with hoarseness should be questioned about the history, the duration, and the progression of symptoms. Hoarseness may be categorized as chronic or acute. Acute hoarseness is rarely secondary to a malignant process. Acute hoarseness usually results from vocal abuse, laryngitis, or smoking. Malignancy should be considered in patients with chronic hoarseness, but the differential also includes GERD, polyps, nodules, neurologic disorders, papillomas, and functional voice disorders (see eTable 19-8 online).

Other symptoms can coexist with hoarseness. Cough can be secondary to irritation of the vocal cords from acute or chronic inflammation but can also indicate cancer of the larynx or lung. Dysphagia or odynophagia can be present from disorders of the pharynx and esophagus. Hemoptysis with hoarseness should be considered secondary to a malignancy until proved otherwise. A history of smoking and vocal abuse is an important consideration. Clear visualization of the larynx by indirect or direct laryngoscopy is absolutely necessary for all patients who present with hoarseness that does not resolve on its own or with medical therapy. This can require referral to an otorhinolaryngologist unless the family physician has training and experience in the procedures.

An unusual cause of voice problems is spasmodic dysphonia (or laryngeal dystonia). The exact etiology is unknown but is thought to be a CNS condition classified under "focal dystonias." It typically causes a harsh staccato voice but may cause breathiness. Spasmodic dystonia responds poorly to voice therapy but has been shown to respond very well to botu-linum toxin injections into the larynx, done endoscopically or externally. The treatment weakens the muscles and lessens the symptoms for several months. Repeat injections are usually done, and response to treatment can decrease over time.

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