Why is My Voice Hoarse and What Can I Do About It?

10 min read  |  April 03, 2023  | 

Do you strain when speaking? Does your job demand constant talking or singing, and your voice is hoarse from overuse?

Vocal strain and hoarseness happen for many reasons. Fortunately, one of the nation’s most innovative voice treatment programs is right here in Miami.

The Estefan Voice Studio within the Department of Otolaryngology at the University of Miami Health System is the first of its kind in Florida and one of a few in the U.S. The studio features sound dampening walls, recording equipment, and the latest diagnostic technology.

The Otolaryngology Department is staffed by otolaryngologists, laryngologists, voice pathologists, and professors from the Frost School of Music at the University of Miami. The team treats voice disorders in teachers, singers, actors, and other professional speakers. They can rebuild voices after radiation treatment. Even enthusiastic sports fans who lost their voice while cheering find help here.

Speech language pathologist Adam Lloyd, SLP, focuses on voice health. “It’s not easy to find a speech pathologist who specializes in voice problems. We are often found in academic medicine centers like UHealth,” Dr. Lloyd says.

He works closely with David Rosow, M.D., a laryngologist and director of the Division of Laryngology and Voice. Dr. Rosow treats voice, vocal fold, and swallowing disorders.

The source of speech

The voice, Dr. Lloyd says, “Starts with the power supply – our lungs send air pressure up to the vocal folds, causing them to vibrate. Articulators bounce the sound around and shape it into consonants and vowels. That’s how we’re understood.”

The tongue, teeth, and soft palate are examples of articulators.

“One of the first things we do is talk with a patient to get to know them and understand the quality of their voice. The patients read sentences to quantify what we’re hearing. We get an idea of what’s going on before we do a physical exam.”

Terms used to describe vocal quality include:

  • Raspy or hoarse
  • Rough
  • Strain – when you hear effort in the voice
  • Weak and breathy
  • Tremors or a vocal catch

“Hoarseness is an umbrella term we use to describe a voice problem,” Dr. Lloyd says.

Understanding vocal quality

Vocal sound is measured through acoustic analysis, a process which creates a ‘digital footprint’ of the voice. “Using a spectrogram (image) to producean audio wave, we can tell how smooth or loud a voice is. Zooming into this image tells us the pitch and harmonics. Evaluating acoustic values gives us an idea which values are out of normal range,” says Dr. Lloyd.

A voice range profile provides an image of how a patient produces pitch and loudness throughout their entire range. This gives Dr. Lloyd something to compare to, pre- and post-treatment. To measure air flow and how it interacts with the vocal cords, Dr. Lloyd uses phonatory aerodynamic software.

Diagnosing the cause of voice problems

“My role is to look at the voice and vocal cords and figure out where the problem lies. This is done either through placing a scope through the nose or through the mouth – often referred to as laryngoscopy. I then place a microphone on the neck, which extracts the number of times the vocal folds vibrate and tells a strobe light when to flash. This allows me to visualize the vocal fold vibration in slow motion,” says Dr. Rosow.

This process is called stroboscopy, and it allows him to see how the vocal cords vibrate and close, as well as spot any growths, redness, or excess mucus. It’s helpful in diagnosing any underlying issues in the voice-box (larynx) or vocal cords. Stroboscopy is a quick office procedure done under local anesthesia.

Stroboscopy helps Dr. Rosow diagnose several types of vocal conditions:

  1. Acute laryngitis usually happens within three to seven days after a viral or bacterial infection begins. It is often treatable with rest and hydration.
  2. Chronic laryngitis commonly accompanies acid reflux (heartburn). Symptoms include coughing, difficulty swallowing, and hoarseness that is worse in the morning.
  3. Muscle strain occurs when the muscles squeeze tightly over the vocal folds and prevent them from functioning well.
  4. Nodules are calluses formed due to chronic overuse of the vocal folds beating together. Though benign, nodules create a raspy, breathy voice.
  5. Hemorrhage or bleeding in the vocal fold happens from yelling or screaming for a prolonged period. “We see this in some Miami Heat fans after a game and in people who live in a household with a lot of yelling,” Dr. Rosow says.
  6. Vocal fold paralysis on one side of the folds prevents them from moving. People with this condition can barely whisper and have difficulty swallowing, speaking, and coughing. When both vocal folds are paralyzed Dr. Rosow says, “It is like breathing through a straw and is much more challenging to treat.  Any surgery to improve the voice worsens the airway. It’s a compromise; taking away just enough voice to provide just enough breathing. In some cases, I remove some tissue to enhance the breathing.”
  7. Cancerous voice problems such as vocal fold cancer are uncommon but can develop in smokers and drinkers. “These problems are treated with surgery or radiation, usually on an outpatient basis and in most cases, with excellent outcomes,” Dr. Rosow says.
  8. Hoarseness from ALS. Lou Gehrig’s disease (ALS) is a neuromuscular disease that weakens the diaphragm and vocal folds. Breathing becomes shallow and labored, and the vocal folds become compromised. “It’s challenging because of its progressive nature. We use vocal therapy with patients, but we don’t overtax the muscles,” Dr. Rosow says. UHealth’s ALS Center uses several types of assistive technology to help people with ALS communicate.

Healing and training your voice

“Healing the voice starts with the least invasive option. We don’t do surgery unless absolutely necessary,” Dr. Rosow says. The first step is often voice therapy, which Dr. Lloyd describes as  physical therapy for the voice. “We work with the breath and muscles and how they shape sounds. For example, a semi-occluded vocal tract exercise shapes sounds in a certain way and vibrates the vocal folds. By teaching patients to use their voice efficiently, we remove muscle strain in the throat.”

Dr. Lloyd uses a variety of “props” in his work, including pianos, tubes, straws, exercise balls, and even kazoos. Mirrors allow patients to see what they are doing as they speak. “We follow the principles of exercise physiology: intensity, frequency, overload, specificity, and reversibility. The voice is like a musical instrument; we can use it in different ways.” People who use their voices professionally, Dr. Lloyd says, are “vocal athletes” who can train their voice like an athlete.

Some patients require surgery to improve or restore vocal function.

“Most voice surgery is endoscopic and minimally invasive. It’s generally an outpatient procedure done in the office within 30 to 60 minutes, sometimes in as little as five to ten minutes. Recovery requires resting the voice, but no dietary changes,” Dr. Rosow says. Some of the surgeries he  performs are only available at UHealth.

To treat vocal cord cancer, Dr. Rosow uses a laser to cut through and vaporize the tumor with precision. The procedure returns the vocal cord to its normal size, cures the cancer, and restores vocal function. “Almost nobody else performs laser procedures in the office; we have offered patients this option for over 10 years.”

Vocal fold polyps are common in professional speakers and singers.

“They begin as a rounded growth on the vocal fold. When a blood vessel ruptures, it forms a polyp. Using a very delicate laser fiber micro-instrument through a microscope, I vaporize the polyp, sparing the normal tissue. The procedure takes about two minutes and is sometimes done in the office, under local anesthesia. Patients can eat and drink normally after one hour,” Dr. Rosow says.

To treat vocal fold paralysis, he passes a needle through the neck into the throat and injects a filler into the fold. By slowly inflating the fold, he improves the patient’s voice.

“This procedure takes about five minutes in the office; there is no need for hospitalization.”

Many patients come to UHealth with a paralyzed vocal fold. “Neck, thyroid, and carotid artery surgeries can cause paralysis,” Dr. Rosow says. While some nerve damage is irreversible, “A surgical implant can push the fold into a better position and restore the voice.”

Voice problems, Dr. Rosow says, also happen from intubation, when a breathing tube is placed down the  throat. Many hospitalized COVID-19 patients had to be intubated to help them breathe.

“Intubation is typically very safe, but it passes by and sometime injures the vocal folds. The injury can be temporary or permanent,” Dr. Rosow says. If you experience problems after intubation, have your vocal folds evaluated.

Is your voice telling you something?

Many patients tell Dr. Rosow and Dr. Lloyd, “There’s something different about my voice.”

They may also have difficulty swallowing or breathing or a lump in their neck. Vocal changes lasting longer than two or three weeks should be evaluated by a laryngologist or ear, nose, and throat specialist.

Radiation treatment for cancer can also affect the voice.

“Radiation eventually causes long-term nerve damage. The vocal folds and throat muscles stiffen, making it difficult to swallow pills,” Dr. Rosow says. “It’s important to look at the folds to diagnose the problem and evaluate the patient’s swallowing ability. We have ways to improve vocal fold function.”

He is also seeing an uptick in vocal complications due to COVID-19, such as chronic coughing, difficulty breathing, weakened voice, and vocal folds injured by intubation.

Allergies, sinus issues, acid reflux, and laryngitis are common in professional speakers.

“Get evaluated if coughing, constant phlegm build-up, an ongoing tickle, or if a sore throat is interfering interfere with your work. It’s typically something benign,” Dr. Rosow says.

Catching the problem early makes it easier to fix.

“Listen to your body. You know when something’s wrong. You might just need to drink more water, you might need voice therapy or a small surgery,” Dr. Lloyd says.

Words to the wise

Dr. Lloyd helps teachers and other professional “voice users” be aware of how they use their voice.

“You need to understand how much effort you use when speaking. A hyper-functional voice irritates the vocal folds.” He teaches people to use their voice with the least amount of effort. It may help to do vocal warmup exercises or use a microphone.

“If there is scarring, aging or atrophy in the vocal folds, you need an evaluation of how your vocal folds come together; that changes the kind of therapy we recommend.”

The key point, Dr. Rosow says, is getting evaluated.

“Many patients ignore voice problems for years. They may have had a small tumor that grew into a cancer. If something lasts for more than a few weeks, get it checked. And please be picky about who does your surgery. If the surgeon removes too much tissue from the vocal folds or they get scarred, they don’t grow back. You want a surgeon who performs these surgeries regularly and properly. Your voice really affects your life.”

To make an appointment with a UHealth voice specialist, call 305-243-3564 or visit

Story compiled by Nancy Moreland.

Join us for World Voice Day on April 14, 2023!

Your Voice Matters: UHealth and Frost School of Music Celebrate World Voice Day

 1:30 pm to 3:15 p.m.
Clarke Recital Hall
5501 San Amaro Drive, Coral Gables, FL 33146: Directions

RSVP by phone or email to Adam Lloyd, SLP-D, CCC-SLP, MM

To Live Stream on YouTube: Click here

Featured topics:

  • What to expect at your voice evaluation
  • Your vocal footprint
  • Psychology of the singing voice
  • Emotional preparation for performance

Featured speakers:

  • Vocal Health and Singing Experts from UHealth Department of Otolaryngology and Frost School of Music
  • Performances by Frost students in classical, contemporary, and jazz styles of singing

Originally published on: June 15, 2022

Tags: otolaryngology in Miami, vocal care in Miami, vocal problems, voice problems

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