Intended for healthcare professionals

Endgames Case Report

Hoarseness in a 79 year old woman

BMJ 2013; 346 doi: (Published 25 April 2013) Cite this as: BMJ 2013;346:f2305
  1. Thomas Jacques, core surgical trainee,
  2. Tarik Abed, otolaryngology registrar,
  3. Sunil Sharma, otolaryngology registrar,
  4. Jonathan Philpott, consultant head and neck surgeon
  1. 1Department of Otolaryngology, Southend University Hospital, Westcliff on Sea SS0 0RY, UK
  1. Correspondence to: T Jacques Thomas.Jacques{at}

A 79 year old woman was referred to our ear, nose, and throat outpatient clinic with a history of hoarse voice. This symptom had been present for around three months. It initially fluctuated in severity but eventually became constant. There was no associated pain, weight loss, cough, dysphagia, odynophagia, or other upper airway symptoms. She had not recently had surgery or experienced trauma. Her medical history was of chronic obstructive pulmonary disease, and she was an ex-smoker.

There were no abnormalities on head and neck examination. Flexible laryngoscopy showed no mucosal lesions in the nasopharynx, oropharynx, or hypopharynx. The left vocal cord was normal in appearance but fixed in the paramedian position. Contrast enhanced computed tomography from the skull base to the diaphragm was performed. This showed a large saccular aneurysm of the distal part of the aortic arch, near the origin of the left subclavian artery, measuring 4.5 cm in diameter (figure).

Sagittal contrast enhanced computed tomogram showing a saccular aneurysm of the distal aortic arch, measuring 4.5 cm in diameter


  • 1 What is the differential diagnosis of hoarseness?

  • 2 How did the abnormality seen on the computed tomogram lead to the patient’s symptoms?

  • 3 How can the problems be managed?


1 What is the differential diagnosis of hoarseness?

Short answer

Hoarseness (dysphonia) can be caused by infections such as viral laryngitis, benign laryngeal lesions, laryngeal cancer, vocal cord paralysis, gastro-oesophageal reflux disease, neurological disease, hypothyroidism, and functional voice disorders.

Long answer

Hoarseness (dysphonia) may be acute or chronic (lasting more than three weeks) and has a wide variety of causes. The most common acute cause is localised infection, usually self limiting laryngitis in association with a viral upper respiratory tract infection. It may also be present in tonsillitis, candidiasis, or less commonly in life threatening epiglottitis or supraglottitis. Patients with hoarseness that persists for more than three weeks, …

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