What is the management for hoarseness?

Management of Hoarseness

The clinician should NOT routinely prescribe antibiotics, corticosteroids, or anti-reflux medications for hoarseness before visualizing the larynx, and should advocate for voice therapy in patients with hoarseness that reduces voice-related quality of life. 1

Initial Assessment and Red Flags

When evaluating hoarseness, immediately identify factors requiring expedited laryngoscopy rather than waiting:

• Perform immediate laryngoscopy (regardless of duration) if any of these red flags are present: 2, 3

  • History of tobacco or alcohol use
  • Concomitant neck mass
  • Hemoptysis, dysphagia, odynophagia, or otalgia
  • Respiratory distress, stridor, or airway compromise
  • Unexplained weight loss
  • Progressive worsening of symptoms
  • Recent neck/chest surgery, endotracheal intubation, or radiation to the neck
  • Professional voice users (singers, teachers, public speakers)
  • Immunocompromised status

• Obtain targeted history to identify modifying factors: 1, 2, 3

  • Duration of symptoms (viral laryngitis typically resolves in 1-3 weeks)
  • Inhaled corticosteroid use (can cause fungal laryngitis)
  • Recent anterior cervical spine, thyroid, carotid, or cardiac surgery
  • Occupational voice demands

Timing of Laryngoscopy

Laryngoscopy is required when hoarseness fails to resolve within 4 weeks, and no patient should wait longer than 3 months for laryngeal examination. 2, 3

• Laryngoscopy may be performed at any time as an option, even before 4 weeks 1
• If red flags are present, perform laryngoscopy immediately regardless of symptom duration 2, 3
• Refer to otolaryngology or a clinician who can visualize the larynx if you cannot perform laryngoscopy 1

Common pitfall: Delaying laryngoscopy beyond 3 months more than doubles healthcare costs and risks missing critical diagnoses like laryngeal cancer or vocal fold paralysis. 2

What NOT to Do Before Laryngoscopy

Do not empirically treat hoarseness without visualization: 1, 4

• No antibiotics: Acute laryngitis is typically viral; systematic reviews show no benefit from antibiotics 4, 5
• No corticosteroids: No clinical trials demonstrate efficacy for dysphonia, and even short-term use carries documented risks (sleep disturbances, mood disorders, metabolic effects, infection risk) 4
• No anti-reflux medications: Only consider if concurrent signs/symptoms of GERD are present 1, 6
• No imaging before laryngoscopy: CT or MRI should only follow direct visualization to evaluate specific identified pathology 2, 7

Common pitfall: 56% of primary care diagnoses change after specialist laryngoscopy, so avoid treating presumed "laryngitis" or "reflux" without confirming the diagnosis. 2

Treatment Based on Laryngoscopy Findings

For Functional or Benign Organic Dysphonia:

Voice therapy is the first-line treatment with Level 1a evidence for effectiveness. 4, 5, 6

• Voice therapy improves voice quality in nonorganic dysphonia and treats benign pathologic vocal cord lesions (nodules, polyps) 1, 5
• Counsel patients on vocal hygiene: voice rest (avoid whispering), adequate hydration, avoid irritants like tobacco smoke 1, 8
• Document and communicate laryngoscopy findings to the speech-language pathologist 4

For Specific Pathology:

• Vocal fold paralysis: Obtain imaging from skull base to thoracic inlet to evaluate the entire recurrent laryngeal nerve path 2, 7
• Laryngeal/vocal fold dysplasia or malignancy: Surgical management is indicated 8, 5
• Benign lesions resistant to conservative treatment: Consider surgery (CO₂ laser or microdissection) 5, 6
• Confirmed GERD with laryngeal signs: Anti-reflux medications may be prescribed as an option 1

Important caveat: The evidence for proton pump inhibitors in laryngopharyngeal reflux is poor, with high-quality studies showing they are no more effective than placebo. 6

Preventive Measures

• Educate patients about vocal hygiene and control measures, particularly those in high-risk occupations (teachers, singers, telemarketers) 1, 8
• Avoidance of tobacco smoke (primary or secondhand) decreases risk of hoarseness 1
• Document resolution, improvement, or worsening of symptoms after treatment or observation 2

Referral Communication

When referring to otolaryngology, explicitly state: 2

• All red flags present (hoarseness duration, tobacco/alcohol use, neck pain, dysphagia, etc.)
• Concern for possible malignancy or vocal fold paralysis
• Request expedited laryngoscopy within days if multiple red flags exist