What is the differential diagnosis for a patient with a hoarse voice and throat dryness, considering their age, medical history, medication use, and smoking status?

Differential Diagnosis of Hoarse Voice

The differential diagnosis for hoarse voice must be systematically organized by acuity, risk factors, and underlying mechanism, with immediate attention to red flags that indicate malignancy, neurologic injury, or airway compromise. 1, 2

Acute Causes (Duration <3 weeks)

Viral laryngitis is the most common cause of acute hoarseness, typically self-resolving within 7-10 days without treatment. 1 Consider this diagnosis when:

• Associated upper respiratory symptoms present (rhinitis, fever >101.5°F, fatigue) 1
• Recent onset with no red flag features 1
• No history of tobacco use or other high-risk factors 1

Other acute etiologies include: 1

• Bacterial or fungal laryngeal infection 1
• Foreign body in larynx, trachea, or esophagus 1
• Neck or laryngeal trauma 1
• Vocal overuse or abuse (particularly in teachers, clergy, professional voice users) 1

Chronic Causes (Duration >3-4 weeks)

Benign Structural Lesions

• Vocal fold nodules (77% of hoarse children have nodules; common in voice overuse) 1
• Vocal fold polyps (increased frequency in tobacco smokers) 1
• Vocal fold atrophy (common in elderly, frequently undiagnosed) 1
• Laryngeal granulomas (44% develop within 4 weeks post-prolonged intubation) 1

Malignancy

Head and neck cancer must be excluded urgently in high-risk patients, as hoarseness in tobacco smokers is associated with increased frequency of polypoid lesions and malignancy. 1 Risk factors include:

• Tobacco use (strongest risk factor) 1
• Alcohol abuse (moderate to heavy use) 1
• Age >50 years 3
• Male sex 3
• Progressive worsening of symptoms 1, 2

Neurologic Causes

Vocal fold paralysis from recurrent laryngeal nerve injury causes include: 1

• Post-thyroid surgery (up to 2.1% incidence) 1
• Anterior cervical spine surgery (1.27-2.7% recurrent laryngeal nerve paralysis; up to 50% immediate hoarseness) 1
• Carotid endarterectomy (up to 6% nerve damage) 1
• Cardiac surgery (17-31% develop hoarseness) 1
• Prolonged intubation (>4 days: 94% have laryngeal injury; vocal fold immobility persists ≥4 weeks in some patients) 1

Other neurologic disorders: 1

• Stroke 1
• Parkinson's disease 1
• Multiple sclerosis 1
• Myasthenia gravis 1
• Amyotrophic lateral sclerosis 1

Medication-Induced Hoarseness

Key medications causing hoarseness include: 1

• Inhaled corticosteroids (dose-dependent mucosal irritation or fungal laryngitis in asthma/COPD patients) 1
• ACE inhibitors (chronic cough leading to voice changes) 1
• Antihistamines, diuretics, anticholinergics (drying effect on mucosa) 1
• Anticoagulants (Coumadin, thrombolytics, phosphodiesterase-5 inhibitors cause vocal fold hematoma) 1
• Bisphosphonates (chemical laryngitis) 1
• Antipsychotics (laryngeal dystonia) 1

Functional and Inflammatory

• Muscle tension dysphonia (voice overuse is the most common cause of chronic dysphonia; >50% of teachers affected) 1
• Laryngopharyngeal reflux 1, 4
• Chronic laryngitis (allergic, chemical, tobacco-related) 1

Endocrine and Systemic

• Hypothyroidism and other endocrinopathies 1
• Testosterone deficiency 1
• Sjögren's syndrome 1
• Menopause 1

Age-Specific Considerations

In infants: Abnormal cry warrants immediate otolaryngology consultation to evaluate for birth trauma, Arnold-Chiari malformation, posterior fossa mass, or mediastinal pathology. 1

In children: 15-24% prevalence of chronic hoarseness; 77% have vocal fold nodules that may persist into adolescence if untreated. 1

In elderly: Vocal fold atrophy is common and frequently undiagnosed; neurologic disorders (stroke, Parkinson's) are more prevalent. 1

Red Flags Requiring Expedited Laryngoscopy

Perform or refer for laryngoscopy immediately (regardless of duration) when: 1, 2

• Recent head, neck, or chest surgery 1, 2
• Recent endotracheal intubation 1, 2
• Concomitant neck mass 1, 2
• Respiratory distress or stridor 1, 2
• Tobacco or alcohol abuse history 1, 2
• Professional voice user 1, 2
• Hemoptysis 1, 2
• Dysphagia or odynophagia 1, 2
• Otalgia 1, 2
• Unexplained weight loss 1, 2
• Progressive worsening 1, 2

Critical Timing for Laryngoscopy

Laryngoscopy is mandatory when hoarseness fails to resolve within 4 weeks, or immediately if serious underlying cause suspected. 1, 2 The 4-week threshold is critical because:

• Most viral laryngitis resolves in 1-3 weeks 2
• Delaying beyond 3 months doubles healthcare costs and risks missing critical diagnoses 2
• 56% of primary care diagnoses change after specialist laryngoscopy 2

Common Pitfalls to Avoid

Never prescribe antibiotics, corticosteroids, or antireflux medications empirically before laryngeal visualization. 1, 2 This delays diagnosis and is not evidence-based. 1, 5

Do not order CT or MRI before laryngoscopy—imaging should only follow direct visualization to evaluate specific identified pathology. 2, 6

Do not dismiss hoarseness in smokers as "chronic laryngitis" without laryngoscopy, as this population has significantly elevated malignancy risk. 1