What is the assessment and treatment approach for a patient with chronic hoarseness?

Assessment and Treatment of Chronic Hoarseness

All patients with chronic hoarseness lasting more than 4 weeks require laryngoscopy to visualize the vocal folds, and this must be performed immediately if any red flag features are present. 1

Initial Clinical Assessment

Diagnosis and Recognition

• Diagnose hoarseness (dysphonia) when a patient presents with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life 2
• Consider input from family members or proxies, as 40% of patients with vocal fold cancer waited three months before seeking attention, and 16.7% only sought treatment after encouragement from others 2
• This is critical because patients may not recognize the severity of their own voice changes, particularly in cases of malignancy 2

Obtain Targeted History

Voice-specific questions to ask: 2

• Onset pattern (sudden vs. gradual)
• Whether voice is ever normal
• Presence of pain with talking
• Voice deterioration or fatigue with use
• Increased effort required to speak
• Changes in pitch, range, or ability to project
• Running out of air when talking

Red flag symptoms requiring immediate laryngoscopy: 1, 3

• Hemoptysis, dysphagia, odynophagia, or otalgia
• Unexplained weight loss or night sweats
• Progressive worsening of hoarseness
• Airway compromise or stridor
• Concomitant neck mass
• Neurologic symptoms

Critical medication review: 2, 1

• Inhaled corticosteroids (mucosal irritation, fungal laryngitis)
• ACE inhibitors (chronic cough)
• Antihistamines, diuretics, anticholinergics (mucosal drying)
• Anticoagulants, thrombolytics (vocal fold hematoma risk)
• Testosterone or anabolic steroids (hormone-related voice changes)
• Antipsychotics (laryngeal dystonia)

Relevant medical and surgical history: 2

• Tobacco or alcohol use (2-3 fold increased cancer risk) 1
• Recent neck surgery (anterior cervical spine, thyroid, carotid procedures)
• Recent prolonged intubation
• Occupational voice demands (teachers have >50% prevalence of hoarseness) 1
• History of stroke, Parkinson's disease, or other neurologic conditions 2

Timeline for Laryngoscopy

The 4-week rule is critical: 1, 3

• Laryngoscopy must be performed if hoarseness persists beyond 4 weeks, as viral laryngitis typically resolves within 1-3 weeks 1
• No patient should wait longer than 3 months for laryngeal examination, as delaying beyond 3 months more than doubles healthcare costs from $271 to $711 1
• This represents an update from older recommendations that suggested waiting 3 months 1

Immediate laryngoscopy is required for: 1, 4, 3

• Any patient with tobacco or alcohol use history
• Any red flag symptoms listed above
• Professional voice users (singers, teachers, public speakers)
• Immunocompromised patients
• Recent neck surgery or prolonged intubation
• Hoarseness in neonates

What NOT to Do Before Laryngoscopy

Avoid empiric treatment without visualization: 2, 3

• Do not prescribe antibiotics routinely, as systematic reviews show no benefit for acute laryngitis or upper respiratory infections, with documented adverse events 2
• Do not prescribe corticosteroids empirically (may be considered in specific cases only) 2
• Do not prescribe proton pump inhibitors empirically unless concurrent GERD symptoms are present 3
• Do not order CT or MRI before laryngoscopy—laryngoscopy must come first to guide further imaging 1

This approach is critical because empiric treatment delays diagnosis of serious pathology including malignancy 1, 3

Treatment After Laryngoscopy Establishes Diagnosis

Voice Therapy (First-Line for Most Benign Pathology)

Voice therapy should be advocated for patients with hoarseness that reduces voice-related quality of life. 2

• Voice therapy has Level 1a evidence supporting effectiveness for functional dysphonia, vocal fold nodules, and polyps 1, 3
• Laryngoscopy must be performed before prescribing voice therapy, and results must be documented and communicated to the speech-language pathologist 2
• This is mandated because failure to visualize the larynx can lead to inappropriate therapy or delay in diagnosis of pathology not amenable to voice therapy 2

Vocal hygiene measures to counsel patients: 3

• Voice rest (avoid whispering, which can be more traumatic than normal speech)
• Adequate hydration
• Avoidance of irritants like tobacco smoke
• Proper voice technique for occupational demands

Surgical Intervention

Surgery is indicated for: 1, 3

• Suspected malignancy
• Benign lesions unresponsive to voice therapy
• Vocal fold paralysis with glottal insufficiency
• Papillomatosis
• Airway obstruction

Common Pitfalls to Avoid

• Waiting 3 months for laryngoscopy is outdated—current guidelines recommend evaluation within 4 weeks 1
• 90% of hoarse patients initially present to primary care, making primary care physicians critical gatekeepers for timely referral 1
• Failing to recognize occupational voice demands when developing treatment plans leads to inadequate management 1
• Overlooking medication-induced hoarseness, particularly from inhaled corticosteroids in asthma/COPD patients 4
• Missing the 52% of laryngeal cancer patients who thought their hoarseness was harmless and delayed seeking care 2

Age-Specific Considerations

• Children: Vocal fold nodules may persist into adolescence if untreated 1
• Older adults: Vocal fold atrophy is common and frequently undiagnosed 1
• Geriatric patients: May require proxy input for assessment in approximately 25% of cases 2