What are the management options for hoarseness of voice?

Management of Hoarseness of Voice

Voice therapy is the first-line treatment for hoarseness that reduces quality of life, with Level 1a evidence demonstrating effectiveness for both functional and organic vocal disturbances. 1, 2

Immediate Assessment: Red Flags Requiring Urgent Laryngoscopy

Perform laryngoscopy immediately if any of the following are present: 2

• Tobacco or alcohol use history
• Hemoptysis, dysphagia, odynophagia, or otalgia
• Respiratory distress, stridor, or airway compromise
• Concomitant neck mass or unexplained weight loss
• Recent neck/chest surgery, endotracheal intubation, or neck radiation
• Professional voice users or immunocompromised patients

Timing of Laryngoscopy for Non-Urgent Cases

Laryngoscopy must be performed if hoarseness persists beyond 4 weeks without a clear benign cause. 2, 3 No patient should wait longer than 3 months for laryngeal examination, as delays more than double healthcare costs and risk missing critical diagnoses like laryngeal cancer or vocal fold paralysis. 2

What NOT to Do Before Laryngoscopy

The American Academy of Otolaryngology-Head and Neck Surgery makes strong recommendations against the following empiric treatments: 1, 4, 2

• Do not prescribe antibiotics - Most cases are viral; antibiotics provide no benefit and contribute to resistance patterns 1, 4
• Do not prescribe corticosteroids - No clinical trials demonstrate efficacy, and even short-term use carries documented adverse events including sleep disturbances, mood disorders, gastrointestinal issues, and metabolic effects 4
• Do not prescribe anti-reflux medications unless concurrent signs/symptoms of gastroesophageal reflux disease are present 1, 2

Exception for Corticosteroids

Prednisone may be considered only in professional voice users with confirmed allergic laryngitis who are acutely dependent on their voice, but this requires: 4

• Laryngoscopy to confirm the diagnosis first
• Shared decision-making discussing limited evidence and documented risks
• Standard dosing: prednisolone 50 mg daily for 3 days 4

Treatment Algorithm Based on Laryngoscopy Findings

For Functional or Benign Organic Dysphonia

Advocate for voice therapy - This has the strongest evidence base (Level 1a) for improving voice quality in: 1, 2, 5

• Nonorganic dysphonia
• Benign pathologic vocal cord lesions (nodules, polyps)
• Functional vocal disturbances

Voice therapy typically consists of 1-2 sessions weekly for 4-8 weeks. 6 Document and communicate laryngoscopy findings to the speech-language pathologist before initiating therapy. 1, 2

For Vocal Process Granuloma (Post-Surgical)

First-line treatment includes: 6

• Proton pump inhibitor therapy: omeprazole 40 mg twice daily or esomeprazole 40 mg twice daily for minimum 8-12 weeks
• Voice therapy with certified speech-language pathologist focusing on reducing vocal fold contact at the granuloma site
• Spontaneous remission occurs in 81% of cases with observation alone, typically within 30.6 weeks 6

For Reflux-Associated Laryngitis

Anti-reflux medications may be prescribed only if there are concurrent signs or symptoms of gastroesophageal reflux disease. 1, 2 However, evidence for proton pump inhibitors in laryngopharyngeal reflux is poor, with high-quality studies showing they are no more effective than placebo. 7

Conservative Management and Vocal Hygiene

Counsel all patients on: 2, 3

• Voice rest (avoid whispering, which is more traumatic than normal speech)
• Adequate hydration 1
• Avoidance of tobacco smoke (primary or secondhand) - decreases risk of hoarseness 1, 2
• Avoidance of irritants such as chemicals, smoke particulates, and pollution 1

Medication Review

Identify medications that may contribute to hoarseness: 2

• Inhaled corticosteroids (cause vocal fold edema and thickness) 1
• ACE inhibitors
• Antihistamines
• Anticoagulants

Surgical Management Indications

Surgery is indicated for: 3, 5

• Laryngeal or vocal fold dysplasia or malignancy
• Airway obstruction
• Benign pathology resistant to conservative treatment
• Papillomatosis (surgery is treatment of choice) 7

Both CO₂ laser and microdissection are equally acceptable for surgical resection of common benign vocal fold lesions. 7

Common Pitfalls to Avoid

• Delaying laryngoscopy beyond 3 months - This significantly increases costs and risks missing serious diagnoses 2
• Empiric treatment without visualization - May delay appropriate diagnosis and treatment 4
• Assuming patients recognize severity - 40% of vocal fold cancer patients waited 3 months before seeking attention, and 52% of laryngeal cancer patients thought their hoarseness was harmless 2
• Ignoring proxy input - Family members may recognize voice changes before the patient does, particularly in geriatric or malignancy cases 2

Documentation Requirements

Document: 2

• Resolution, improvement, or worsening of symptoms after treatment or observation
• Laryngoscopy findings communicated to speech-language pathologist before voice therapy initiation