What are the best medications for treating hoarseness?

Best Medications for Hoarseness

Do not routinely prescribe medications for hoarseness—antibiotics, corticosteroids, and antireflux medications should not be used empirically without laryngoscopic visualization of the larynx. 1

Strong Recommendations Against Empiric Medication Use

The American Academy of Otolaryngology-Head and Neck Surgery provides clear guidance against routine medication prescribing for hoarseness:

Antibiotics: Strong Recommendation Against

• Antibiotics should not be routinely prescribed to treat hoarseness under any circumstances. 1
• Acute laryngitis is self-limited, with improvement in 7-10 days even with placebo treatment. 1
• Cochrane reviews found no benefit of penicillin or erythromycin for acute upper respiratory infections causing hoarseness. 1
• The preponderance of harm (antibiotic resistance, adverse effects) over benefit makes this a strong recommendation against use. 1

Corticosteroids: Recommendation Against

• Clinicians should not routinely prescribe corticosteroids for patients with hoarseness prior to visualization of the larynx. 1
• Significant and serious side effects can occur with short- or long-term corticosteroid use. 1
• The only potential exception is for professional voice users acutely dependent on their voice with confirmed allergic laryngitis, but this requires laryngoscopic confirmation first. 1
• Pediatric croup with associated hoarseness may benefit from systemic steroids, but this is a specific diagnosis, not empiric treatment. 1

Antireflux Medications: Recommendation Against Empiric Use

• Clinicians should not prescribe antireflux medications to treat isolated hoarseness based on symptoms alone attributed to suspected GERD or LPR without visualization of the larynx. 1
• Randomized controlled trials show no benefit of PPIs (esomeprazole 40mg twice daily for 16 weeks) for hoarseness without GERD symptoms. 1
• PPIs carry significant risks including hip fractures in older adults, vitamin B12 deficiency, iron deficiency anemia, and increased pancreatitis risk. 1

When Medications May Be Appropriate (After Laryngoscopy)

Antireflux Therapy for Confirmed Chronic Laryngitis

• Clinicians may prescribe antireflux medication for patients with hoarseness AND laryngoscopic signs of chronic laryngitis (erythema, edema, redundant tissue, surface irregularities of the interarytenoid mucosa, arytenoid mucosa, posterior laryngeal mucosa, and/or vocal folds). 1
• This is an option, not a recommendation, based on observational studies with a relative balance of benefit and harm. 1
• Laryngoscopic findings must be documented before initiating therapy. 1

Botulinum Toxin for Specific Diagnoses

• Clinicians should offer botulinum toxin injections for treatment of hoarseness caused by spasmodic dysphonia and other types of laryngeal dystonia. 1
• This requires laryngoscopic diagnosis and is a recommendation for specific pathology, not empiric treatment. 1

Medication-Induced Hoarseness Recognition

Seven medication classes cause hoarseness through distinct mechanisms and require awareness, not treatment with additional medications: 1, 2

• Inhaled corticosteroids: Most common medication-related cause; produces dose-dependent mucosal irritation and fungal laryngitis. 1, 2
• ACE inhibitors: Cause hoarseness through chronic cough mechanism. 1, 2
• Anticoagulants/thrombolytics: Cause vocal fold hematoma. 1, 2
• Bisphosphonates: Cause chemical laryngitis. 1, 2
• Anticholinergics/antihistamines/diuretics: Produce drying effects on laryngeal mucosa. 1, 2
• Sex hormones (testosterone, Danocrine): Alter hormone production/utilization. 1, 2
• Antipsychotics: Cause laryngeal dystonia. 1, 2

Critical Management Algorithm

1. Perform laryngoscopy or refer for visualization when hoarseness persists >4 weeks or immediately if serious cause suspected (recent neck/chest surgery, intubation, neck mass, respiratory distress, tobacco abuse, professional voice user). 1

2. Do not prescribe antibiotics, corticosteroids, or antireflux medications before laryngoscopic visualization. 1

3. If medication-induced hoarseness suspected, perform laryngoscopy to exclude other serious pathology before attributing symptoms to medications. 2

4. If chronic laryngitis confirmed on laryngoscopy, consider antireflux therapy as an option. 1

5. Advocate for voice therapy as primary treatment for most causes of hoarseness amenable to conservative management. 1

Common Pitfalls to Avoid

• Never attribute hoarseness to medications without laryngoscopic confirmation, especially in smokers or patients with malignancy risk factors, as this delays cancer diagnosis. 2
• Do not use laryngoscopic findings alone to diagnose LPR—findings like posterior cobblestoning have poor sensitivity and specificity (<50%). 3
• Recognize that 40% of patients with vocal fold cancer waited three months before seeking attention, and empiric medication use further delays diagnosis. 1
• Professional voice users require immediate evaluation if hoarseness develops after medication initiation, not empiric treatment. 2