When describing voice complaints, it is important to note that definitions of hoarseness can vary considerably. The patient’s self-perception of the vocal complaints may not be proportionate to the perception by an observer. Oftentimes emotional factors or social factors, such as the diagnosis of throat cancer in a family member, can bring specific awareness for one’s own voice problem that might otherwise have been neglected. Causes of hoarseness prompting investigation are often inaccurate. Laryngitis is considered a common and normal experience and attributed to a myriad of things such as colds and other infections (tonsillitis, strep throat, pneumonia, bronchitis, etc.), allergies, overuse, environment, and reflux.

Hoarseness is a general term that refers to a variety of voice problems. There is no physiological or perceptual definition for hoarseness, and the examiner should try to direct and focus the patient toward more specific symptoms and problems. Examples include change in the quality of voice, altered pitch, changes in vocal stamina, strain, early vocal fatigue, loss of range, inability to project, inability to be heard, difficulty with articulation, or alteration in clarity. In addition, other components of the voice history should include details regarding the onset of symptoms (gradual or sudden), environmental issues (seasonality, pets, chemical triggers, and sensitivities), precipitating events (upper respiratory infections, stress, travel, screaming or shouting), and exacerbating factors (telephone use, diet, and reflux).

Onset of voice problems and inciting factors should be elicited and recorded. An acute onset of voice loss suggests a sudden change in vocal fold pliability or altered vocal behavior. Sudden voice changes occur with vocal hemorrhage, infectious laryngitis, vocal polyp, vocal fold paralysis, and muscle tension dysphonia. More gradual onset of voice changes suggests a more insidious or slow-growing process such as the development of vocal fold nodules, scarring, Reinke’s space edema or polypoid corditis (smoker’s larynx), presbylarynges, laryngopharyngeal reflux, vocal fold keratosis or leukoplakia, and laryngeal cancer. Most voicing disorders, especially in the early stages, will have fluctuating levels of dysphonia. For instances, patients with vocal fold nodules will have a preexisting history of recurrent “laryngitis” with return of normal voice. Vocal fold paralysis may result in a substantial loss of projection and vocal stamina; however, the degree of dysphonia may vary considerably based on the resting position of the immobile vocal fold, the degree of vocal fold edema, and overall energy level of the patient.

The quality of life impact of phonatory disorders is highly specific and individual to the patient. An examiner’s perception may not correlate with the patient’s perspective on the severity of the issue. The magnitude of the clinical problem may not correlate with the perceptual evaluation of hoarseness. The most important factor assessing the impact of someone’s voice dysfunction is usually occupation. The social history is important. A hoarse librarian will not have the same level of impact from dysphonia as a professional singer. The impact of voice dysfunction tends to be highly varied from individual to individual. Some individuals are highly aware of small differences and changes in voice and alterations in voice timbre or frequency. Those with vocally demanding occupations tend to be more aware of minute voice changes than those who do not have significant voice use. Professionals who rely heavily on their voices, such as actors and singers, represent a special class of patients: elite vocal athletes. These individuals produce heavy demands on the vocal folds and test the limits of vocal abilities. Shear trauma or phonotrauma in these individuals are exceedingly high, making them susceptible to vocal injury.

Vocal users can generally be placed into three categories based on voice requirements: the standard user, the vocal professional, and the elite vocal performer. The elite vocal performer is required to use the extreme ranges of his or her phonatory abilities on a daily basis for income. This group includes professional actors, singers, and presenters. Vocal professionals are required to speak in public with large groups on a regular basis; this category includes teachers, clergy, politicians, and attorneys. The standard user or nonvocal professional is not significantly impacted with mild hoarseness or vocal fatigue.

Because the impact of phonatory disorders is highly variable and may not correspond measurably to perceptual difference in actual voice, we frequently utilize quality of life scales. The Voice Handicap Index (VHI) and its abbreviated form, the VHI-10, the Voice Outcome Survey (VOS), and the Voice-Related Quality of Life Survey (VRQL) are all examples of such quality of life measurements (see Tables 14.2 and 14.3). It is extremely useful to have patients fill out these self-questionnaires at the initial visit as well as during subsequent follow-up especially if a medical or surgical intervention has taken place (Table 14.4) (Box 14.1).