What is the recommended management for an adult presenting with new‑onset hoarseness without red‑flag features?

Management of New-Onset Hoarseness Without Red Flags

For an adult with new-onset hoarseness and no red-flag features, observe with conservative management for up to 4 weeks, then perform or refer for laryngoscopy if symptoms persist or worsen. 1

Initial Assessment and History

Identify dysphonia by asking about altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life. 1 Key voice-specific questions include:

• Onset pattern: Abrupt versus gradual, relation to upper respiratory infection 2
• Temporal characteristics: Is the voice ever normal? Does it worsen with use? 2
• Associated symptoms: Pain with talking, changes in pitch or range, ability to project 2
• Occupational impact: Work attendance, professional voice demands 2

Conduct a targeted medication review for drugs that cause hoarseness:

• Inhaled corticosteroids: Cause dose-dependent mucosal irritation and fungal laryngitis 1, 2, 3
• ACE inhibitors: Produce chronic cough contributing to hoarseness 2, 3
• Antihistamines, diuretics, anticholinergics: Dry laryngeal mucosa 2, 3
• Anticoagulants: May precipitate vocal fold hematoma 2, 3

Conservative Management During Observation Period

For presumed viral laryngitis (which typically resolves within 1-3 weeks), recommend: 2, 3

• Voice rest: Avoid excessive talking and especially avoid whispering 1
• Adequate hydration: Maintain mucosal moisture 1, 2
• Avoidance of irritants: Tobacco smoke, chemicals, pollution 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

• Do not prescribe antibiotics: No evidence of benefit for acute laryngitis; most cases are viral 1, 2
• Do not prescribe corticosteroids: No high-quality evidence supports routine use; potential adverse effects include hypertension, diabetes, osteoporosis, and infection 1, 2
• Do not prescribe antireflux medications: Based on symptoms alone without laryngoscopy 1, 2
• Do not order CT or MRI: Imaging should not precede laryngeal visualization 1

Timing of Laryngoscopy

Perform or refer for laryngoscopy when hoarseness fails to resolve or improve within 4 weeks. 1, 2 This is a firm recommendation, not optional. 1

The rationale for the 4-week threshold:

• Viral laryngitis typically resolves within 1-3 weeks 2, 3
• Symptoms persisting beyond 3 weeks already exceed the expected viral course 2, 4
• No patient should wait longer than 3 months for laryngeal examination 2, 3
• Delaying beyond 3 months more than doubles healthcare costs (from $271 to $711) and worsens outcomes for malignancy 2, 3

Treatment After Laryngoscopy Establishes Diagnosis

Once laryngoscopy identifies the cause:

• Voice therapy is first-line treatment with Level 1a evidence for functional or benign organic dysphonia, including vocal fold nodules and polyps 1, 2, 3
• Document and communicate laryngoscopy findings to the speech-language pathologist before initiating voice therapy 1, 2
• Surgery is indicated for suspected malignancy, benign lesions unresponsive to conservative management, or glottic insufficiency 1, 3

Common Pitfalls to Avoid

• Do not assume hoarseness is benign based on duration alone: 52% of laryngeal cancer patients thought their hoarseness was harmless and delayed seeking care 2, 3
• Do not wait 3 months for laryngoscopy: Current guidelines recommend evaluation within 4 weeks, not 3 months 1, 3
• Do not treat empirically without visualization: 56% of primary care diagnoses change after specialist laryngoscopy, meaning empiric treatment delays accurate diagnosis 2
• Recognize that patients often minimize their dysphonia: 16.7% only sought treatment after encouragement from family members 2