What are the common causes of loss of voice and the recommended treatment?

Loss of Voice: Causes and Treatment

Voice therapy with a certified speech-language pathologist is the first-line treatment for most causes of chronic hoarseness, while laryngoscopy should be performed within 4 weeks if symptoms persist or immediately if red flags are present. 1, 2

Common Causes of Voice Loss

Self-Limited Conditions

• Acute laryngitis from upper respiratory infection is the most common cause (42.1% of cases), typically resolving in 7-10 days regardless of treatment 3, 4
• Associated symptoms include rhinitis, fever >101.5°F, and fatigue 3

Chronic Conditions Requiring Intervention

• Muscle tension dysphonia (10-40% of voice center caseloads) results from excessive laryngeal musculoskeletal tension 3, 1
• Vocal overuse/abuse affects >50% of teachers and 20% miss work as a result 3
• Benign vocal fold lesions (10.7-31% of cases) include nodules, polyps, cysts, and Reinke's edema 4
• Chronic laryngitis (9.7% of cases) may be related to gastroesophageal reflux, inhaled corticosteroids, or tobacco use 3, 4
• Vocal fold paralysis (2.8-8% of cases) from nerve injury 4

Medication-Induced Hoarseness

Several medications directly cause voice changes 3:

• Inhaled corticosteroids: dose-dependent mucosal irritation and fungal laryngitis
• ACE inhibitors: chronic cough affecting voice
• Antihistamines, diuretics, anticholinergics: drying effect on mucosa
• Anticoagulants (Coumadin), thrombolytics, phosphodiesterase-5 inhibitors: vocal fold hematoma risk
• Bisphosphonates: chemical laryngitis

Red Flag Causes Requiring Urgent Evaluation

Laryngeal malignancy (2.2-3% of cases) is more common in patients over 60 with tobacco use (28% malignancy rate after excluding self-limited disease) 1, 4

When to Perform Laryngoscopy

Immediate Laryngoscopy Required 3, 1

• History of tobacco or alcohol use
• Concomitant neck mass or lymphadenopathy
• Recent surgical procedures (head, neck, chest, or cardiac surgery)
• Recent endotracheal intubation (94% develop laryngeal injury if intubated >4 days) 1
• Hemoptysis, dysphagia, odynophagia, or otalgia
• Respiratory distress or stridor
• Unexplained weight loss
• Progressive worsening of symptoms
• Professional voice users (teachers, singers, attorneys)
• Neonates with hoarseness

Laryngoscopy Within 4 Weeks 1, 2, 5

Any hoarseness persisting beyond 4 weeks requires direct laryngeal visualization, as empirical treatment without laryngoscopy is not recommended 1

Treatment Algorithm

Conservative Management (First-Line for Most Patients)

Voice therapy is the primary treatment for functional dysphonia, muscle tension dysphonia, and benign vocal fold lesions 3, 1:

• More effective than vocal hygiene alone 1
• Effective across all ages (children to elderly) 3
• Addresses behavioral and muscular issues contributing to dysphonia 1
• Lee Silverman Voice Therapy method specifically for Parkinson's disease 3

Vocal hygiene measures should be implemented concurrently 1:

• Adequate hydration
• Voice rest (avoid whispering, which strains vocal folds more than normal speech) 6
• Avoidance of tobacco and alcohol
• Treatment of underlying conditions (reflux, allergies)

When Surgery Is Indicated 3, 1

Surgery should only be pursued after adequate trial of conservative management fails, except for specific conditions 1:

1. Suspected malignancy: Immediate surgical biopsy with histopathologic evaluation 3
2. Benign soft tissue lesions refractory to conservative therapy: Only when satisfactory voice cannot be achieved conservatively 3, 1
3. Glottic insufficiency: Surgical medialization (vocal fold injection or laryngoplasty) combined with voice therapy 3, 1
4. Laryngeal dystonia: May require botulinum toxin injections combined with voice therapy 3

Pharmacologic Therapy (Limited Indications)

Proton pump inhibitors only for documented gastroesophageal reflux with laryngitis 6, 4

Empirical treatment with antibiotics, corticosteroids, or proton pump inhibitors is NOT recommended without laryngoscopic diagnosis 1, 6, 5

Critical Pitfalls to Avoid

• Never treat hoarseness empirically beyond 2-4 weeks without laryngoscopy, as this delays diagnosis of serious conditions including malignancy 1, 6
• Do not proceed directly to surgery for benign lesions without adequate conservative management trial, as failure to address underlying behavioral causes leads to recurrence 3, 1
• In children, vocal nodules typically resolve with development; surgery has limited role and voice therapy is primary treatment 1
• Delaying biopsy in high-risk patients (age >60, tobacco use) results in higher cancer staging and reduced survival 1
• Whispering is more traumatic to vocal folds than normal speech and should be avoided during voice rest 6

Special Populations

Children: 77% with hoarseness have vocal nodules; voice therapy is primary treatment with surgery rarely indicated 1

Elderly: Presbylarynx (age-related changes) is common; 47% experience voice disorder in lifetime 3

Post-surgical patients: Cardiac surgery causes vocal cord injury in 1.4% (left nerve more commonly affected); anterior cervical spine surgery causes hoarseness in up to 50% immediately post-op 3, 1