Hoarseness
This guideline applies to adults aged 16 years and over.
Introduction
Hoarseness (dysphonia) is when the voice impairs communication, in terms of altered quality, pitch, volume or effort. Aetiology can include inflammation, autoimmune, malignancy, benign lesions, neurological, structural, muscle tension imbalance or ageing.
Benign lesions (i.e. nodules, polyps, oedema etc.) may have an acute onset following a trigger such as coughing bouts or screaming.
Muscle tension imbalance is an umbrella term for conditions including:
- Voice strain (muscle tension dysphonia) – episodic and variable altered voice, worse on use, associated with vocal fatigue and effortful voice production. Often occurs with throat discomfort. Risk factors include using voice for work and high life stress.
- Psychogenic aphonia – complete loss of voice.
- Puberphonia – failure of male voice maturity at puberty.
Presbyphonia is age-related hoarseness, due to vocal cord atrophy. It is a common presentation with an incidence 25% of patients aged over 65 years old, and is particularly prevalent in elderly patients attending the RCHT ENT out-patient clinic. If a patient attends primary care for a reason unrelated to their voice, consider carefully before referring to ENT.
Red Flag Features
Hoarseness in the context of:
- Unexplained, persistent hoarseness (more than 3 weeks) in adult aged 45yr or over
- Recent trauma to neck
- Stridor / breathing difficulties
- Difficulty swallowing
- Referred otalgia
- Unexplained lymphadenopathy
Key Features of Assessment
- Duration and onset (sudden or gradual)
- Pattern e.g. worse at end of day
- Triggers e.g. change in voice use
- Smoking and alcohol
- Occupation
- Associated symptoms, i.e. coryza, sore throat, cough, reflux, haemoptysis, breathlessness, weight loss, fever
- Identify/exclude red flags
Examine mouth, throat and neck +/- respiratory and/or neurological examinations if appropriate.
Investigations
Arrange CXR if risk factors for and/or clinical concern about malignancy – lung cancer can present with hoarseness due to recurrent laryngeal nerve palsy.
Management
1. Avoid routinely prescribing antibiotics.
2. Provide patient information leaflet on voice hygiene.
3. Advise self-refer to Healthy Cornwallfor smoking cessation support, if appropriate.
4. Tailor treatment according to suspected underlying condition:
See links to:
Referral
Emergency admission
- Recent neck trauma and/or stridor or breathing difficulties.
Arrange admission to the Emergency Department
Suspected cancer (2WW) Referral
- Unexplained, persistent hoarseness (more than 3 weeks) in adult aged 45yr or over.
Refer via Suspected Cancer (2WW) ENT and Thyroid Referral Form
Urgent ENT Referral
Patient not meeting 2WW criteria and:
- Using their voice for work
- Currently not working due to hoarse voice
- Sudden onset aphonia (complete loss of voice)
- High psychological distress associated with hoarse voice
- Hoarseness that fails to improve with 4 weeks of self-management in context of a recent URTI
ENT will liaise with SLT. The length of time these patients wait to see SLT positively correlates with the length of rehabilitation – so early referral is key.
Urgent Throat Symptoms Clinic
- Longstanding (over 1 year) intermittent non-progressive hoarseness
Refer for an urgent throat symptoms assessment via Suspected Cancer (2WW) ENT and Thyroid Referral Form. ENT will aim to see within 4 weeks.
Presbyphonia is a common finding in the elderly. If a patient attends primary care for a reason unrelated to their voice, consider carefully before referring to ENT.
Routine ENT Referral
- Not meeting 2WW criteria with hoarseness that fails to improve with 4 weeks of self-management in low-risk patient with no obvious underlying cause.
Routine Speech and Language Therapy (SLT) Referral
- Patients with symptoms relating to voice / laryngeal pathology must have been seen by ENT within the last 12 months.
- See Adult SLT guideline for referral information.
Advice and Guidance
If diagnostic uncertainty, seek ENT Advice and Guidance.
Supporting Information
For professionals:
For patients:
RCHT – Voice Changes (Patient Info Leaflet)
The British Voice Association – Reflux and your voice
References
Pub Med – Lansoprazole for persistent throat symptoms in secondary care
Page Review Information
Review date |
15/03/2024 |
Next review date |
15/03/2026 |
Specialty Lead GP |
Dr Laura Vines |
Contributors |
Mr Venkat Reddy, ENT Consultant Surgeon Jennifer Lloyd, SLT Clinical Lead |