What are the likely causes and treatment options for hoarseness and dysphonia?

Hoarseness and Difficulty Speaking: Diagnosis and Treatment

Immediate Diagnostic Action

Laryngoscopy is mandatory within 4 weeks for persistent hoarseness, and certain red flags require same-day or next-day laryngeal visualization—do not treat empirically without seeing the vocal folds. 1, 2

Red Flags Requiring Immediate Laryngoscopy (Within Days)

• Tobacco or alcohol use history requires urgent evaluation, as smoking increases head and neck cancer risk 2-3 fold 1, 2, 3
• Concomitant neck mass, hemoptysis, dysphagia, odynophagia, or otalgia mandate immediate laryngoscopy 1, 2
• Recent neck/chest surgery or endotracheal intubation—up to 50% of anterior cervical spine surgery patients develop hoarseness, and 17-31% of cardiac surgery patients experience voice changes 1, 2
• Professional voice users (teachers, singers, performers) whose livelihood depends on voice cannot wait weeks for evaluation 1
• Respiratory distress, stridor, or airway compromise requires emergency assessment 1, 2
• Unexplained weight loss, immunocompromised status, or progressive worsening of symptoms 1, 2
• Hoarseness in a neonate or infant is a red flag requiring immediate otolaryngology consultation, as it may indicate birth trauma, Arnold-Chiari malformation, or mediastinal disease 4

Timeline for Laryngoscopy

• Most viral laryngitis resolves in 7-10 days, so observation is reasonable for acute hoarseness with concurrent upper respiratory symptoms (rhinitis, fever >101.5°F) 1
• Laryngoscopy is required at 4 weeks if hoarseness persists, and no patient should wait longer than 3 months 1, 2
• Delaying beyond 3 months more than doubles healthcare costs and significantly worsens outcomes for malignancy, leading to higher disease stage and poorer survival 1, 2
• 52% of laryngeal cancer patients thought their hoarseness was harmless and delayed seeking care, with 40% waiting 3 months before seeking attention 1, 2

Critical History and Physical Examination

Voice-Specific Questions to Ask

• Onset pattern: Was it abrupt or slowly progressive? Did it occur after upper respiratory infection or intubation? 1
• Voice characteristics: Is it constant or intermittent? Does it fatigue with use? Is there pain or effort when talking? 1
• Quality changes: Breathy voice suggests vocal fold paralysis or incomplete closure; strained voice with pitch breaks suggests spasmodic dysphonia 1
• Occupational impact: Does the patient need voice for work? Are they missing work due to hoarseness? 1

Medication Review (Critical Step)

• Inhaled corticosteroids cause dose-dependent mucosal irritation and fungal laryngitis 1, 3
• ACE inhibitors cause chronic cough that can lead to hoarseness 1
• Antihistamines, diuretics, anticholinergics cause mucosal drying 1, 3
• Anticoagulants (Coumadin), thrombolytics, phosphodiesterase-5 inhibitors can cause vocal fold hematoma 1
• Bisphosphonates cause chemical laryngitis 1

Physical Examination Focus

• Listen to the voice quality (perceptual evaluation) and observe for breathing or swallowing difficulties 1
• Palpate the neck for masses or lesions 1
• Consider proxy input from family members, as patients often minimize their symptoms—16.7% of vocal fold cancer patients only sought treatment after encouragement from others 1, 2

What NOT to Do Before Laryngoscopy

The American Academy of Otolaryngology-Head and Neck Surgery makes strong recommendations against empiric treatment without visualization: 1, 2, 5

• No antibiotics—systematic reviews show no benefit for acute laryngitis, and most hoarseness is viral 1, 5, 6
• No corticosteroids—no clinical trials demonstrate benefit for routine hoarseness, and side effects include hypertension, diabetes, osteoporosis, and infection 1, 2
• No anti-reflux medications unless concurrent GERD symptoms are present 2, 6
• 56% of primary care diagnoses change after specialist laryngoscopy, meaning empiric treatment delays accurate diagnosis and risks missing laryngeal cancer or vocal fold paralysis 2

Treatment Based on Laryngoscopy Findings

First-Line Treatment: Voice Therapy

Voice therapy has Level 1a evidence for effectiveness in functional or benign organic dysphonia and should be the first-line treatment for hoarseness that reduces quality of life. 2, 5, 6

• Voice therapy improves voice quality in nonorganic dysphonia and treats benign vocal fold lesions (nodules, polyps) 2, 5
• Laryngoscopy must be performed before prescribing voice therapy, and findings should be documented and communicated to the speech-language pathologist 2
• Over 50% of teachers experience dysphonia from voice overuse, and 20% miss work as a result 1

Vocal Hygiene Counseling (All Patients)

• Voice rest (avoid whispering, which is more traumatic than normal speech) 2, 6
• Adequate hydration to maintain mucosal moisture 2
• Avoidance of tobacco smoke and other irritants (chemicals, pollution) 2, 3

Surgical Management

• Surgery is indicated for laryngeal or vocal fold malignancy, airway obstruction, or benign pathology resistant to conservative treatment 5, 6
• Vocal fold paralysis may require medialization procedures for incomplete glottal closure 3

Pharmacologic Treatment (Limited Indications)

• Proton pump inhibitors are appropriate only for chronic laryngitis associated with documented gastroesophageal reflux 5, 6
• Systemic steroids may be considered in limited cases for allergic laryngitis in performers or pediatric croup with hoarseness, but routine use is unwarranted 1

Common Causes by Prevalence

• Acute laryngitis (viral): 42.1% of cases, typically resolves in 1-3 weeks 5
• Functional vocal disturbances: 30% of cases, often from voice overuse 5
• Benign tumors: 10.7-31% of cases 5
• Chronic laryngitis: 9.7% of cases 5
• Vocal cord paresis: 2.8-8% of cases 5
• Malignant tumors: 2.2-3% of cases 5

Critical Pitfall to Avoid

Do not assume hoarseness is benign based on duration alone—persistent symptoms beyond 1-3 weeks mandate evaluation to exclude malignancy or vocal fold paralysis, as delays in diagnosis lead to higher disease stage and worse prognosis. 1, 2