What is the appropriate management for a patient with hoarseness?

Management of Hoarseness

Perform laryngoscopy immediately if red flags are present, or within 4 weeks if hoarseness persists without red flags—do not wait 3 months, as this doubles healthcare costs and risks missing critical diagnoses like laryngeal cancer. 1, 2, 3

Immediate Laryngoscopy Required (Red Flags)

Visualize the larynx immediately or refer urgently if any of the following are present:

• Tobacco or alcohol use history (increases cancer risk 2-3 fold and polypoid lesions) 4, 1, 3
• Concomitant neck mass 4, 1, 2
• Hemoptysis, dysphagia, odynophagia, or otalgia 4, 1, 2
• Airway compromise, stridor, or respiratory distress 4, 2, 3
• Unexplained weight loss 4, 1, 2
• Progressive worsening of symptoms 1, 2, 3
• Neurologic symptoms (suggests central or peripheral nerve involvement) 4, 2, 3
• Recent neck/chest surgery or prolonged intubation (risk of recurrent laryngeal nerve injury) 4, 1, 2
• Recent radiation to the neck (causes hoarseness in 8% of cases) 1, 2
• Professional voice users (singers, teachers, performers—lower threshold for intervention) 2, 3
• Immunocompromised status 4, 2, 3
• Hoarseness in a neonate 4, 3

Timeline for Laryngoscopy Without Red Flags

Laryngoscopy must be performed if hoarseness persists beyond 4 weeks, as viral laryngitis typically resolves within 1-3 weeks. 1, 3 The outdated recommendation of waiting 3 months is no longer appropriate—delaying beyond 3 months increases costs from $271 to $711 and risks missing serious pathology. 3

Critical History to Obtain

Before laryngoscopy, gather targeted information:

• Medication review: Inhaled corticosteroids (cause direct irritation or fungal laryngitis), ACE inhibitors (chronic cough), antihistamines, diuretics, anticholinergics (mucosal drying), anticoagulants (vocal fold hematoma risk) 4, 1, 2, 3
• Occupational voice demands: Over 50% of teachers develop hoarseness from vocal overuse 3
• GERD symptoms: Heartburn, regurgitation, throat clearing 4
• Voice characteristics: Onset pattern, whether voice is ever normal, pain with talking, changes in pitch or projection 2
• Relevant medical history: Stroke, Parkinson's disease, other neurologic conditions 2

What NOT to Do Before Laryngoscopy

Do not empirically treat hoarseness without visualization of the larynx. 4, 2

• Do not prescribe antibiotics (no benefit for acute laryngitis or upper respiratory infections; strong recommendation against) 4, 2
• Do not prescribe corticosteroids (only indicated for croup; acute laryngitis is self-limited in 7-10 days) 4, 2
• Do not prescribe anti-reflux medications unless concurrent GERD symptoms or laryngoscopic evidence of chronic laryngitis is present (randomized trials show no benefit for empiric PPI therapy, plus risk of hip fractures, vitamin B12 deficiency, iron deficiency anemia) 4, 2
• Do not order CT or MRI before laryngoscopy—laryngoscopy must come first to guide further imaging 3, 5

Treatment After Laryngoscopy Establishes Diagnosis

Voice Therapy (First-Line for Most Benign Pathology)

Advocate for voice therapy for patients with hoarseness that reduces voice-related quality of life—this has Level 1a evidence for effectiveness. 4, 2, 3

• Voice therapy improves voice quality in functional dysphonia, vocal fold nodules, and polyps 4, 2, 3
• Laryngoscopy must be performed before prescribing voice therapy, and results must be documented and communicated to the speech-language pathologist 4, 2
• Approaches include hygienic (eliminating harmful behaviors), symptomatic (modifying pitch/loudness/quality), and physiologic methods 4

Vocal Hygiene Counseling

Counsel all patients on:

• Voice rest 2
• Adequate hydration 1, 2
• Avoidance of tobacco smoke (decreases hoarseness risk) 1, 2
• Avoidance of irritants (chemicals, smoke particulates, pollution) 2

Surgery (Specific Indications Only)

Advocate for surgery in patients with: 4

1. Suspected laryngeal malignancy (surgical biopsy required for histopathologic confirmation; highly suspicious lesions with increased vasculature, ulceration, or exophytic growth require prompt biopsy) 4
2. Benign soft tissue lesions unresponsive to voice therapy (vocal nodules, polyps, Reinke's edema, cysts, granulomas) 4, 3
3. Glottic insufficiency (vocal fold paralysis/paresis causing weak, breathy voice with poor cough and reduced airway protection) 4
4. Papillomatosis 3

Anti-Reflux Medications (Limited Role)

May prescribe anti-reflux medications only if laryngoscopy shows signs of chronic laryngitis (erythema, edema, redundant tissue, surface irregularities of inter-arytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, or vocal folds). 4 However, a randomized trial of esomeprazole 40 mg twice daily for 16 weeks showed no benefit over placebo for laryngeal symptoms. 4

Common Pitfalls to Avoid

• Waiting 3 months for laryngoscopy is outdated—current guidelines recommend 4 weeks maximum 1, 3
• Treating empirically without visualization delays diagnosis of serious pathology 2, 3
• Failing to recognize that 90% of hoarse patients initially present to primary care—primary care physicians are critical gatekeepers for timely referral 3
• Overlooking occupational voice demands when developing treatment plans 3
• Missing that 40% of vocal fold cancer patients waited 3 months before seeking attention, and 16.7% only sought treatment after encouragement from others 2

Age-Specific Considerations

• Infants: Abnormal cry may be only sign; consider birth trauma, Arnold-Chiari malformation, posterior fossa mass, or mediastinal pathology 4
• Children: Vocal fold nodules may persist into adolescence if untreated; children under 2 years may not participate effectively in voice therapy 4, 3
• Older adults: Vocal fold atrophy is common and frequently undiagnosed; up to 30% have glottic insufficiency 4, 3