Hoarseness and persistent voice change

Hoarseness (dysphonia) is an abnormal voice quality, pitch, loudness or effort, from impaired vocal fold vibration. Most acute cases are viral laryngitis and settle within 3 weeks. Persistent dysphonia needs laryngoscopy to exclude cancer and vocal fold paralysis.

Anatomy and physiology. Voice arises from vibration of the vocal folds driven by subglottic air pressure. The recurrent laryngeal nerve supplies all intrinsic muscles except the cricothyroid (superior laryngeal nerve). The left recurrent nerve loops under the aortic arch, so thoracic and mediastinal disease can cause left vocal fold paralysis.

Classification. Acute (under 3 weeks), persistent (over 3 weeks), and chronic (over 3 months). By cause: inflammatory, structural, neurogenic, neoplastic, functional, systemic and iatrogenic.

Key distinctions. Hoarseness with a smoker or heavy drinker, lasting over 3 weeks, needs laryngoscopy. Breathy weak voice suggests vocal fold paralysis. Voice that tires with use suggests muscle tension dysphonia or myasthenia.

History. Onset and duration, preceding upper respiratory infection, voice use (singing, shouting, teaching, calls), smoking, alcohol, reflux, asthma and inhaler use, dysphagia, odynophagia, aspiration, cough, breathlessness, stridor, neck mass, weight loss, haemoptysis, recent intubation or surgery (thyroid, neck, chest, cardiac, spine), trauma, neurological symptoms, thyroid disease, rheumatoid arthritis, and voice effect on work.

Drug history. Inhaled corticosteroids, ACE inhibitors (cough), anticoagulants (vocal fold haemorrhage), androgens, antihistamines and anticholinergics (dryness), bisphosphonates (oesophagitis), and amiodarone.

Examination. Voice (breathy, rough, strained, tremulous, falsetto), breathing (stridor), neck (mass, thyroid, nodes), chest, cranial nerves, tongue and palate, and signs of systemic disease. Flexible nasopharyngolaryngoscopy with or without stroboscopy to assess vocal fold mobility, mucosal waves, lesions, and arytenoid movement.

Red flags

• Hoarseness persisting over 3 weeks (especially with smoking or alcohol use)
• Stridor, dyspnoea, dysphagia, haemoptysis, otalgia or neck mass
• Unexplained weight loss
• Hoarseness after neck, thoracic or cardiac surgery, intubation or trauma
• Sudden onset with chest, neck or thoracic disease (aneurysm, tumour)
• Neurological signs, or fatigable voice with ptosis or diplopia
• Hoarseness with throat pain and fever in children (croup, epiglottitis)
• Immunosuppression

Special groups. Children: congenital anomalies, laryngeal papillomatosis, vocal nodules, croup. Pregnancy: reflux and oedema. Older adults: presbylarynx, neurological disease and cancer. Region specific: laryngeal tuberculosis and papillomatosis.

Inflammatory and infective

• Acute viral laryngitis, bacterial laryngitis, croup and epiglottitis
• Laryngopharyngeal reflux, chronic laryngitis from smoking and irritants
• Laryngeal candidiasis (inhaled corticosteroids), tuberculosis, syphilis, fungal infection
• Allergic laryngitis, angioedema
• Granulomatosis with polyangiitis, sarcoidosis, rheumatoid arthritis (cricoarytenoid arthritis), amyloidosis

Structural and benign lesions

• Vocal fold nodules, polyps, cysts, Reinke oedema
• Contact granuloma, vocal fold haemorrhage
• Laryngeal papillomatosis, laryngocele, sulcus vocalis, web, stenosis
• Presbylarynx (vocal fold atrophy)

Neurogenic

• Vocal fold paralysis (unilateral or bilateral): thyroid and neck surgery, thoracic surgery, intubation, lung and oesophageal cancer, aortic aneurysm, mediastinal nodes, skull base lesions, stroke, brainstem lesions, viral neuritis, idiopathic
• Parkinson disease, essential voice tremor, spasmodic dysphonia, myasthenia gravis, motor neuron disease, multiple sclerosis

Neoplastic

• Laryngeal squamous cell carcinoma and premalignant dysplasia and leukoplakia
• Hypopharyngeal, thyroid and oesophageal cancer, lung cancer, lymphoma, laryngeal sarcoma and other rare tumours

Functional and systemic

• Muscle tension dysphonia, psychogenic dysphonia (functional aphonia)
• Hypothyroidism, acromegaly, androgen effect, menopause, dehydration
• Vocal overuse and abuse

Reasoning. Acute hoarseness with a clear viral cause needs no investigation. Examine the larynx within 2 weeks for persistent hoarseness, and the same day for stridor, breathing difficulty or after surgery with airway concern.

First line. Flexible laryngoscopy or stroboscopy. Voice and swallow assessment by a speech and language therapist.

Targeted tests.

• CT or MRI from skull base to mediastinum (including thoracic inlet and aortic arch) for vocal fold paralysis without an obvious cause, and CT neck and chest for suspected cancer. Chest radiograph for lung and mediastinal disease.
• Biopsy under direct laryngoscopy for any suspicious lesion (leukoplakia, mass, ulcer).
• Thyroid stimulating hormone and free thyroxine. Full blood count, ESR and C reactive protein, and angiotensin converting enzyme, ANCA, rheumatoid factor when systemic disease is suspected.
• Acetylcholine receptor antibodies and repetitive nerve stimulation for suspected myasthenia gravis. Laryngeal electromyography to separate paralysis from fixation and to predict recovery.
• Swab or biopsy for candida, tuberculosis and fungal infection. Syphilis serology.
• Oesophagogastroduodenoscopy for dysphagia or alarm features with suspected reflux.
• Videofluoroscopy or fibreoptic endoscopic evaluation of swallowing for aspiration.

Limitations. Laryngeal signs of reflux are non-specific and common in asymptomatic adults. Stroboscopy needs expertise.

Airway compromise. Upright position, oxygen, urgent anaesthetic and ENT call, nebulised adrenaline 1 in 1,000, 5 mL (children 0.5 mL/kg, maximum 5 mL) in croup or oedema, dexamethasone 10 mg IV (children 0.15 to 0.6 mg/kg orally or IV, maximum 10 mg), heliox if available, and intubation or surgical airway if needed.

Acute laryngitis. Voice rest (relative), hydration, humidification, avoid whispering and throat clearing, smoking cessation, and treat the infection supportively. Antibiotics are not indicated for viral laryngitis. A short course of prednisolone 30 mg orally daily for 3 to 5 days may be used for professional voice users needing rapid recovery (evidence is limited).

Laryngopharyngeal reflux. Omeprazole 20 to 40 mg orally once daily before breakfast, increased to twice daily if needed, for 8 to 12 weeks, with alginate after meals, weight reduction, avoidance of late meals, alcohol, caffeine and smoking, and raising the head of the bed. Review at 8 to 12 weeks; evidence for acid suppression is limited, and failure of response needs ENT review.

Inhaled corticosteroid related dysphonia and candidiasis. Use a spacer, rinse the mouth after use, lower the dose where possible, and nystatin 100,000 units/mL, 1 mL four times daily for 7 days or fluconazole 50 to 100 mg orally daily for 7 to 14 days for candidiasis.

Benign vocal fold lesions. Voice therapy by a speech and language therapist as first line for nodules and muscle tension dysphonia. Microlaryngeal surgery for persistent polyps, cysts and haemorrhage after therapy, with post-operative voice rest. Reinke oedema: smoking cessation and surgery. Contact granuloma: voice therapy, reflux treatment, botulinum toxin or surgery.

Vocal fold paralysis. Voice therapy, observation for 6 to 12 months for recovery (idiopathic or post-viral), injection laryngoplasty (temporary with hyaluronic acid or carboxymethylcellulose) for early symptomatic relief or aspiration, medialisation thyroplasty or reinnervation for persistent paralysis, and treatment of the underlying cause. Bilateral paralysis with stridor: airway assessment, tracheostomy or posterior cordotomy by ENT.

Spasmodic dysphonia and essential voice tremor. Botulinum toxin injection into the thyroarytenoid muscles by ENT (typical start 1 to 2.5 units each side) and voice therapy.

Neoplasms. Urgent multidisciplinary head and neck cancer team: radiotherapy for early glottic cancer, transoral laser surgery, or total laryngectomy and chemoradiotherapy for advanced disease. Premalignant dysplasia: stop smoking, excision and surveillance.

Systemic causes. Hypothyroidism: levothyroxine 1.6 micrograms/kg orally daily (start at 25 to 50 micrograms in older adults and in heart disease). Myasthenia gravis: neurology referral. Rheumatoid arthritis: rheumatology. Tuberculosis: isoniazid 5 mg/kg (maximum 300 mg), rifampicin 10 mg/kg (maximum 600 mg), pyrazinamide 25 mg/kg (maximum 2 g) and ethambutol 15 mg/kg daily for 2 months, then isoniazid and rifampicin for 4 months, with pyridoxine 10 to 25 mg daily.

Functional dysphonia. Voice therapy and psychological support.

Voice hygiene. Hydration, avoiding shouting, throat clearing and smoking, humidification, and rest during illness.

Monitoring. Review at 3 weeks for acute hoarseness. Repeat laryngoscopy at 6 to 12 weeks after treatment of lesions, and every 3 to 6 months for dysplasia surveillance.

Referral and escalation. Immediate for stridor or airway compromise. ENT laryngoscopy within 2 weeks for hoarseness persisting over 3 weeks, and same week for hoarseness with red flags. Speech and language therapy for benign voice disorders. Cardiothoracic or oncology referral for mediastinal disease and aneurysm.

Admission criteria. Airway compromise, acute epiglottitis or croup with distress, suspected aortic aneurysm or mediastinal tumour with paralysis, and aspiration with pneumonia.

Discharge and safety netting. Return for noisy breathing, difficulty breathing, difficulty swallowing, coughing blood, neck swelling, weight loss, or hoarseness persisting beyond 3 weeks.