What is the best course of treatment for chronic hoarseness?

Management of Chronic Hoarseness

All patients with chronic hoarseness (lasting more than 4 weeks) require laryngoscopy to visualize the vocal folds, and this should be performed immediately—regardless of duration—if any red flag features are present. 1, 2

Immediate Laryngoscopy Required (Do Not Wait)

Perform or refer for laryngoscopy immediately if ANY of the following are present:

• History of tobacco or alcohol use (2-3 fold increased cancer risk) 1, 3, 4
• Concomitant neck mass 1, 3
• Hemoptysis, dysphagia, odynophagia, or otalgia 1, 3
• Unexplained weight loss 1, 3
• Progressive worsening of hoarseness 1, 3
• Neurologic symptoms (stroke, Parkinson's, multiple sclerosis) 1, 3
• Airway compromise or stridor 1, 3, 2
• Recent neck surgery (thyroid, cervical spine, carotid endarterectomy) 1, 3
• Recent prolonged intubation (>4 days causes laryngeal injury in 94% of patients) 1, 3
• Professional voice users (singers, teachers, clergy, lawyers) whose work is impaired 1, 3, 2
• Immunocompromised status 1, 3
• Hoarseness in a neonate 1, 3

The most dangerous clinical error is failing to recognize hoarseness as a presenting symptom of head and neck cancer, particularly in smokers, as delayed diagnosis results in higher staging and reduced survival. 4

Timeline for Laryngoscopy in Uncomplicated Cases

Laryngoscopy must be performed if hoarseness persists beyond 4 weeks, as viral laryngitis typically resolves within 1-3 weeks. 1, 3, 2 The 2018 updated guideline shortened the timeframe from 3 months to 4 weeks based on evidence that earlier visualization improves outcomes and reduces costs. 1 Delaying otolaryngology referral beyond 3 months more than doubles healthcare costs ($271 to $711). 1

What NOT to Do Before Laryngoscopy

Do not prescribe the following empirically without visualizing the larynx first:

• Antibiotics (no evidence of benefit) 2, 5, 6
• Corticosteroids (no evidence of benefit) 2, 5
• Proton pump inhibitors (high-quality evidence shows no better than placebo for laryngopharyngeal reflux) 2, 7

These treatments delay diagnosis of serious pathology and are not evidence-based for undifferentiated hoarseness. 2, 5

Targeted History to Obtain

Medication review:

• Inhaled corticosteroids (cause dose-dependent mucosal irritation and fungal laryngitis in asthma/COPD patients) 1, 3, 4
• ACE inhibitors (cause chronic cough) 1, 4
• Antihistamines, diuretics, anticholinergics (drying effect on mucosa) 1, 4
• Anticoagulants (can cause vocal fold hematoma) 1

Occupational voice demands:

• Over 50% of teachers have hoarseness from vocal overuse, with 20% missing work as a result 1, 4
• Professional voice users require lower threshold for intervention due to impact on livelihood 1, 3, 2, 4

Age-specific considerations:

• Children: 77% of hoarse children have vocal fold nodules that may persist into adolescence if untreated 1, 4
• Older adults: Vocal fold atrophy (presbylarynx) is common and frequently undiagnosed by primary care providers 1, 4

Treatment After Laryngoscopy Establishes Diagnosis

Voice therapy is the first-line treatment for most benign vocal pathology (Level 1a evidence):

• Effective for functional dysphonia (muscle tension dysphonia) 1, 2, 5, 6
• Effective for vocal fold nodules and polyps 1, 2, 5, 6, 7
• Should be performed by specialized speech-language pathologist 2, 4, 6

Surgery is indicated for:

• Suspected malignancy 2, 4, 5
• Benign lesions unresponsive to voice therapy 2, 4, 5, 6
• Vocal fold paralysis with glottal insufficiency 2, 4
• Papillomatosis (surgery is treatment of choice) 7

Vocal hygiene education should be provided to all patients, though evidence for individual components is limited. 6, 7

Common Pitfalls to Avoid

• Waiting 3 months for laryngoscopy in persistent hoarseness (outdated recommendation; current guideline is 4 weeks) 1, 2
• Treating empirically with PPIs, antibiotics, or steroids without visualization 2, 5, 7
• Ordering CT or MRI before laryngoscopy (laryngoscopy must come first to guide further imaging) 2, 8
• Failing to recognize that 90% of hoarse patients initially present to primary care, making primary care physicians the critical gatekeepers for timely referral 1
• Overlooking occupational voice demands when developing treatment plans 2

Imaging Role (Only After Laryngoscopy)

If laryngoscopy reveals vocal fold paralysis or mass lesion, CT neck with contrast is the imaging of choice to evaluate laryngeal tumors and identify the etiology of vocal fold paralysis. 8 For left vocal fold paralysis, imaging must extend to the aortopulmonary window to cover the left recurrent laryngeal nerve's origin. 8