How should I evaluate and manage voice hoarseness, and when is referral to an otolaryngologist indicated?

Evaluation and Management of Voice Hoarseness

Initial Assessment: When to Refer Immediately

Perform laryngoscopy immediately (same-day or next-day) if any red flag is present, regardless of symptom duration. 1, 2, 3

Red flags requiring urgent laryngoscopy include:

• History of tobacco or alcohol use – increases head and neck cancer risk 2-3 fold 1, 2, 3
• Concomitant neck mass, hemoptysis, dysphagia, odynophagia, or otalgia 1, 2, 3
• Recent neck, chest, or cardiac surgery – 50% of anterior cervical spine surgery patients and 17-31% of cardiac surgery patients develop postoperative hoarseness 2, 3
• Recent endotracheal intubation – vocal fold granulomas can develop within 4 weeks of extubation 1
• Respiratory distress, stridor, or airway compromise – constitutes an emergency 2, 3
• Unexplained weight loss or progressive worsening 1, 2, 3
• Professional voice users (teachers, singers, clergy) – over 50% of teachers experience hoarseness, and their livelihood depends on voice function 1, 2, 3
• Immunocompromised status 2, 3

Timing of Laryngoscopy for Non-Urgent Cases

Perform or refer for laryngoscopy within 4 weeks if hoarseness persists, and no patient should wait longer than 3 months for laryngeal examination. 1, 2, 3

• Viral laryngitis typically resolves within 7-10 days; observation is appropriate for acute hoarseness with upper respiratory symptoms (rhinitis, fever >101.5°F) 2
• Delaying laryngoscopy beyond 3 months more than doubles healthcare costs ($271 to $711) and significantly worsens outcomes for malignancy – higher disease stage and poorer survival 2, 3, 4
• 52% of laryngeal cancer patients thought their hoarseness was harmless and delayed seeking care; 40% waited ≥3 months before seeking attention 2, 3
• 16.7% of vocal fold cancer patients only sought treatment after encouragement from family members 2, 3

Critical History Elements

Obtain a targeted voice-specific history focusing on:

• Onset pattern – abrupt versus gradual, relation to infection or intubation 2, 3
• Voice characteristics – breathy voice suggests vocal fold paralysis; strained voice with pitch breaks suggests spasmodic dysphonia 2
• Constancy – whether voice is ever normal, fatigue with use 2, 3
• Associated symptoms – pain with talking, changes in pitch or range 2, 3
• Occupational impact – work attendance affected, voice demands 2, 3

Medication Review

Identify medications that may cause hoarseness:

• Inhaled corticosteroids – cause dose-dependent mucosal irritation and fungal laryngitis 1, 2, 3
• ACE inhibitors – produce chronic cough contributing to hoarseness 2
• Antihistamines, diuretics, anticholinergics – dry laryngeal mucosa 2
• Anticoagulants (warfarin), thrombolytics, phosphodiesterase-5 inhibitors – may precipitate vocal fold hematoma 2
• Bisphosphonates – associated with chemical laryngitis 2

What NOT to Do Before Laryngoscopy

The American Academy of Otolaryngology-Head and Neck Surgery makes strong recommendations against empiric treatment without visualization of the larynx. 1, 2, 3

• Do NOT prescribe antibiotics – systematic reviews demonstrate no benefit for acute laryngitis, as the majority of cases are viral 1, 2, 5, 6
• Do NOT prescribe corticosteroids – no high-quality trials support routine use; potential adverse effects include hypertension, diabetes, osteoporosis, and infection 1, 2
• Do NOT prescribe anti-reflux medications based on symptoms alone without laryngoscopy – empiric PPI therapy is not recommended 1, 2, 3
• Do NOT order CT or MRI before laryngoscopy – imaging should only follow direct visualization to evaluate specific identified pathology 1, 3, 4

Critical pitfall: 56% of primary care diagnoses change after specialist laryngoscopy, meaning empiric treatment delays accurate diagnosis and risks missing laryngeal cancer or vocal fold paralysis 3, 4

Laryngoscopy Technique and Findings

Acceptable laryngoscopy techniques include:

• Transnasal flexible fiberoptic laryngoscopy 2
• Transoral rigid endoscopy 2
• Stroboscopy for detailed mucosal wave assessment 2

During laryngoscopy, assess:

• Vocal fold mobility – to identify paralysis 2, 3
• Mucosal lesions – nodules, polyps, masses 2
• Structural abnormalities – edema, inflammation 2
• Dynamic function – closure pattern during phonation 2

When to Order Imaging (After Laryngoscopy)

CT with contrast is the imaging of choice, but only after laryngoscopy identifies specific pathology requiring further evaluation. 4, 7

Indications for imaging after laryngoscopy:

• Vocal fold paralysis identified – requires imaging from skull base to thoracic inlet (aorticopulmonary window for left-sided paralysis) to evaluate the entire recurrent laryngeal nerve path 3, 4, 7
• Laryngeal tumor visualized – to assess extent and staging 4, 7
• Unexplained findings requiring anatomic evaluation 2

Treatment Based on Laryngoscopy Findings

Voice Therapy (First-Line for Most Benign Conditions)

Voice therapy has Level 1a evidence for effectiveness in functional or benign organic dysphonia and should be advocated for patients with hoarseness that reduces quality of life. 1, 2, 5

• Improves voice quality in nonorganic dysphonia 2, 3
• Treats benign pathologic vocal fold lesions (nodules, polyps) 2, 5
• Document and communicate laryngoscopy findings to the speech-language pathologist before initiating therapy 1, 2
• 77% of hoarse children have vocal fold nodules that may persist into adolescence if not properly treated 1

Vocal Hygiene Counseling

Counsel all patients on:

• Voice rest – avoid whispering, which strains vocal folds 2, 6
• Adequate hydration 2, 3
• Avoidance of tobacco smoke – decreases risk of hoarseness 2, 3
• Avoidance of irritants – chemicals, smoke particulates, pollution 2

Surgical Intervention

Surgery is indicated for suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. 1, 6

Botulinum Toxin

Offer botulinum toxin injections for dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. 1

Special Populations

• Older adults – vocal fold atrophy with resulting hoarseness is frequently undiagnosed; neurologic disorders (stroke, Parkinson's) are more common 1
• Children – 15-24% prevalence of chronic hoarseness; 77% have vocal fold nodules 1
• Infants – hoarseness recognized by abnormal cry; consider birth trauma, Arnold-Chiari malformation, posterior fossa mass, or mediastinal pathology 1
• Tobacco smokers – increased frequency of polypoid vocal fold lesions and head/neck cancer; requires expedient assessment for malignancy 1

Documentation and Follow-Up

Document resolution, improvement, or worsening of symptoms after treatment or observation. 1, 2, 3

Referral Communication

When referring to otolaryngology:

• Explicitly state all red flags present (e.g., hoarseness, neck pain, jaw pain, globus, concern for malignancy) 3
• Request expedited laryngoscopy within days, not weeks 2, 3
• Include all risk factors and symptom duration 3