Hoarseness
Hoarseness (dysphonia) is a change in voice quality that can result from a wide range of conditions from benign self-limiting laryngitis to laryngeal carcinoma, requiring investigation if persisting beyond 3 weeks.
Key Facts
Hoarseness (dysphonia) is an alteration in voice quality, pitch, or volume; affects approximately 1% of the population at any time Most common cause: acute viral laryngitis (self-limiting); most important cause to exclude: laryngeal carcinoma NICE NG12: refer urgently (2-week wait) for laryngoscopy if hoarseness >3 weeks, particularly in smokers/ex-smokers >45 years Functional dysphonia is a common cause of chronic hoarseness with a structurally normal larynx — diagnosed by speech therapy assessment Vocal cord palsy causes breathy voice; investigate with CT from skull base to diaphragm to identify cause along course of vagus/recurrent laryngeal nerve Laryngopharyngeal reflux is a common cause of chronic hoarseness, throat clearing, and globus — treat with PPI (omeprazole 20mg BD for 2-3 months) Speech and language therapy is the first-line treatment for most benign causes of chronic hoarseness Key history: smoking, alcohol, voice use, reflux symptoms, previous neck/chest surgery, intubation history
Overview
Key Facts
Hoarseness is one of the most common ENT symptoms, with a wide differential diagnosis ranging from benign self-limiting conditions to life-threatening malignancy. Any patient with hoarseness persisting beyond 3 weeks requires visualisation of the larynx to exclude serious pathology.
Epidemiology
- Point prevalence: approximately 1% of the population
- Lifetime prevalence: 30% experience at least one episode of significant hoarseness
- More common in professional voice users (teachers, singers)
- Laryngeal cancer: approximately 2,400 cases/year in the UK; M:F ratio 4:1
Aetiology
- Inflammatory: acute viral laryngitis (most common overall), chronic laryngitis, laryngopharyngeal reflux
- Structural: vocal cord nodules, polyps, cysts, Reinke oedema, papillomatosis, laryngeal carcinoma
- Neurological: vocal cord palsy (recurrent laryngeal nerve palsy — causes include lung cancer, thyroid surgery, aortic aneurysm, idiopathic)
- Functional: muscle tension dysphonia, psychogenic aphonia
- Systemic: hypothyroidism, RA (cricoarytenoid arthritis), amyloidosis
- Iatrogenic: post-intubation granuloma, post-thyroidectomy RLN injury, inhaled corticosteroid effect
Pathophysiology
- Normal voice production requires: adequate subglottic air pressure, regular vocal cord vibration, and normal resonance
- Any disruption to vocal cord structure, mass, tension, or mobility causes hoarseness
- Mass lesions (nodules, polyps, tumours) increase vocal cord mass and alter vibration
- Vocal cord palsy prevents full cord adduction, causing breathy voice and air escape
- Oedema (Reinke oedema, reflux) deepens the voice due to increased cord mass
Clinical Presentation
History Points
- Duration and onset (acute vs chronic)
- Character of voice change (rough, breathy, strained, weak)
- Associated symptoms: sore throat, dysphagia, odynophagia, otalgia, stridor, cough, haemoptysis, weight loss
- Voice demands: professional voice user
- Smoking and alcohol history (strong risk factors for laryngeal cancer)
- Reflux symptoms: heartburn, throat clearing, globus, chronic cough
- Previous surgery: thyroidectomy, cardiac, thoracic, anterior cervical spine
- Previous intubation
- Medications: inhaled corticosteroids, ACE inhibitors (cough)
Examination
- Voice quality assessment
- Neck palpation: thyroid, lymphadenopathy
- Oral cavity and oropharynx inspection
- Indirect laryngoscopy or fibreoptic nasendoscopy
Red Flags
- Hoarseness >3 weeks (NICE NG12)
- Smoker/ex-smoker >45 years
- Dysphagia or odynophagia
- Haemoptysis
- Stridor
- Weight loss
- Neck lump
- Otalgia (referred pain from larynx via Arnold's nerve)
Differential Diagnosis
| Diagnosis | Key Features | Investigation |
|---|---|---|
| Acute viral laryngitis | Short history, URTI, self-limiting | Clinical |
| Laryngeal carcinoma | Smoker, progressive, weight loss, dysphagia | FNL, CT, biopsy |
| Vocal cord nodules | Bilateral, voice abuse, young female/child | FNL, stroboscopy |
| Vocal cord palsy | Breathy voice, aspiration; investigate RLN | FNL, CT skull base to diaphragm |
| Laryngopharyngeal reflux | Throat clearing, globus, chronic cough | PPI trial, 24h pH |
| Functional dysphonia | Normal larynx, psychosocial factors | FNL, SLT assessment |
| Reinke oedema | Deep voice, smoker, bilateral polypoid cords | FNL |
| Hypothyroidism | Coarse voice, fatigue, weight gain, constipation | TFTs |
Diagnosis / Investigation
Bedside
- GRBAS voice assessment
- Neck examination (lymph nodes, thyroid)
- Fibreoptic nasendoscopy (FNL): essential for all hoarseness >3 weeks
Bloods
- TFTs (exclude hypothyroidism)
- FBC if anaemia/malignancy suspected
Imaging
- CT neck and chest (skull base to diaphragm): for vocal cord palsy (identify cause along nerve course)
- CT with contrast: for laryngeal masses and staging
- MRI: for soft tissue detail of laryngeal/hypopharyngeal lesions
- CXR: if vocal cord palsy (exclude left hilar mass)
Special Tests
- Stroboscopy: detailed assessment of vocal cord vibration pattern
- Direct laryngoscopy and biopsy (under GA): for suspicious lesions
- Laryngeal EMG: for vocal cord palsy (prognostication)
- 24h pH/impedance monitoring: for laryngopharyngeal reflux
- SALT assessment: for functional voice disorders
Management
Non-pharmacological
- Voice rest and vocal hygiene: reduce voice use, avoid whispering (increases cord tension)
- Hydration
- Avoid irritants (smoking, alcohol)
- Speech and language therapy (SALT): first-line for functional dysphonia, vocal cord nodules, muscle tension dysphonia
Pharmacological
- PPI trial for suspected laryngopharyngeal reflux: omeprazole 20mg BD for 2-3 months
- Topical antifungal if inhaled corticosteroid-related candidiasis
- Levothyroxine if hypothyroidism confirmed
- Treat underlying cause (cancer, infection, reflux)
Surgical
- Microlaryngoscopy and excision: for vocal cord polyps, cysts, papillomatosis, suspicious lesions/biopsy
- Medialization thyroplasty: for permanent unilateral vocal cord palsy (implant pushes paralysed cord medially)
- Injection laryngoplasty: temporary medialization with hyaluronic acid or autologous fat for vocal cord palsy
- Laryngeal framework surgery: for bilateral cord palsy (tracheostomy may be needed if airway compromise)
- Treatment of malignancy: radiotherapy (early glottic), surgery (partial/total laryngectomy), chemoradiotherapy
Referral Criteria
- 2-week wait ENT referral: hoarseness >3 weeks (NICE NG12)
- Routine ENT: chronic voice change, globus, frequent throat clearing
- Emergency: stridor, airway compromise
- SALT referral: for voice rehabilitation
Prognosis
- Acute laryngitis: resolves within 7-10 days
- Vocal cord nodules: >80% resolve with speech therapy
- Vocal cord palsy: spontaneous recovery in 50-60% of idiopathic cases within 6-12 months
- Early glottic carcinoma (T1): >90% 5-year survival with radiotherapy
- Functional dysphonia: responds well to SALT; prognosis good
- Reinke oedema: improves with smoking cessation; surgery if persistent
- Post-thyroidectomy RLN palsy: temporary in 5-10%, permanent in 1-2%
Other Relevant Information
Approach to Hoarseness >3 Weeks
| Step | Action |
|---|---|
| 1 | History: smoking, alcohol, voice use, reflux, surgery, meds |
| 2 | Neck examination |
| 3 | Fibreoptic nasendoscopy |
| 4 | If normal: PPI trial, SALT referral |
| 5 | If abnormal: biopsy, CT/MRI, MDT |
Key Causes of Vocal Cord Palsy and Investigation
| Cause | % | Key Investigation |
|---|---|---|
| Iatrogenic (surgery) | 30-40% | Surgical history |
| Malignancy (lung, thyroid) | 20-30% | CT chest/neck |
| Idiopathic | 20-30% | Diagnosis of exclusion |
| Neurological (MS, stroke) | 5% | MRI brain |
| Aortic aneurysm | Rare | CT chest |