Hoarseness, more strictly termed dysphonia, can be qualified specifically. In order to phonate, produce a sound, the vocal cords must move and oppose at the midline (adduction). To breathe, the vocal cords must open (abduction). A breathy voice is caused by incomplete closure, as seen with a unilateral vocal cord paralysis. Aphonia, the inability to create any vocal sound, is usually due to vocal cords that remain far abducted during attempted phonation, but can be due to mucosal swelling or irregularities precluding any vibration from occurring along the vocal cord. A strained voice usually implies a narrowing at the level of the vocal cords, as with a laryngeal mass such as papillomatosis or carcinoma. A tremulous voice may indicate a neurological disorder, such as spasmodic dysphonia or Parkinson’s disease.

The most common cause of hoarseness, viral laryngitis, is self-limited and usually resolves after 1–2 weeks. Any hoarseness persisting for longer than 3 or 4 weeks necessitates timely otolaryngic referral.

Tobacco use, in both smoked and chewed forms, is the single greatest risk factor for squamous cell carcinoma of the upper aerodigestive tract. Alcohol, while not independently a risk factor for development of cancer, has a compounded effect in the presence of tobacco use.

The vast majority of noncancerous causes of hoarseness are not associated with bloody sputum. Hemoptysis or bloody oral secretions are a red flag for malignancy in the upper aerodigestive tract or the lungs.

The most common type of cancer found in the larynx, as well as in the entire upper aerodigestive tract, is squamous cell carcinoma. The pathogenesis is closely linked to tobacco use in any form and is likely related to chronic inflammation and increased cellular turnover causing metaplasia, dysplasia, and eventual carcinoma.