Acute Hoarseness

Acute hoarseness is a change in voice quality, pitch or effort lasting less than 4 weeks. The commonest cause is acute viral laryngitis, with vocal fold inflammation and oedema.

• Other causes are voice overuse, vocal fold haemorrhage, laryngopharyngeal reflux, bacterial laryngitis, croup, trauma and, rarely, laryngeal cancer.
• Candida laryngitis follows inhaled corticosteroids and broad spectrum antibiotics.
• Smokers and heavy drinkers are at higher risk of serious disease.

Rough, breathy or weak voice, voice loss, throat discomfort, cough, and often a recent cold.

• Stridor, drooling or difficulty swallowing suggest airway disease.
• Differential diagnosis: viral laryngitis, croup, epiglottitis, vocal fold haemorrhage, vocal fold paralysis, laryngopharyngeal reflux, vocal nodules, candida laryngitis, laryngeal tuberculosis, diphtheria, laryngeal papilloma, laryngeal carcinoma, angioedema, hypothyroidism.
• Complications: airway obstruction, chronic dysphonia, vocal fold scarring, occupational disability.

Clinical assessment with attention to red flag features.

• Flexible laryngoscopy for hoarseness lasting more than 4 weeks, or earlier in smokers, after neck surgery or intubation, trauma, or with stridor, dysphagia or neck mass.
• Throat swab for group A streptococcus if exudate and fever; sputum for tuberculosis if chronic cough.
• Thyroid function test and chest radiograph in persistent cases.

Mostly supportive; avoid antibiotics unless bacterial infection is confirmed.

• Supportive: relative voice rest without whispering, humidified air, 2 litres of fluid daily, stop smoking, avoid throat clearing and shouting, vocal hygiene advice.
• Pharmacological: paracetamol 1 g every 6 hours; honey and warm drinks; prednisolone 30 to 40 mg daily for 3 to 5 days only for professional voice users with an urgent performance need and normal laryngoscopy; penicillin V 500 mg four times daily for 10 days for group A streptococcal infection; fluconazole 100 mg daily for 7 to 14 days for laryngeal candidiasis; omeprazole 20 mg twice daily for 8 weeks for reflux. Croup in children: dexamethasone 0.15 mg/kg orally once.
• Procedures: microlaryngoscopy and biopsy for suspicious lesions; strict silence for 7 days for vocal fold haemorrhage.
• Special groups: children with stridor need urgent airway assessment; pregnancy, avoid systemic steroids unless essential; singers, early referral to a voice clinic.
• Red flags: stridor, hoarseness beyond 4 weeks, haemoptysis, neck mass, dysphagia, weight loss, history of smoking and alcohol, post operative voice change.
• Follow-up: review at 2 to 4 weeks; laryngoscopy if unresolved.