Hoarseness

Differentials

• Laryngitis (viral, bacterial, or reflux-related) – viral laryngitis is most common; bacterial laryngitis is rare but may involve secondary bacterial infection

• Vocal cord nodules, polyps, cysts – typically due to phonotrauma, common in professional voice users

• Vocal cord paralysis (e.g., due to recurrent laryngeal nerve damage from thyroid surgery, lung cancer, or trauma) – left recurrent laryngeal nerve is more commonly affected due to its longer course

• Smoking, excessive voice use (e.g., singers, teachers) – chronic irritation leads to vocal cord oedema or dysplasia

• Systemic illnesses such as rheumatoid arthritis or sarcoidosis – can cause cricoarytenoid arthritis leading to hoarseness

• Neurological disorders (e.g., Parkinson’s disease, stroke) – may present with hypophonia or breathy voice

Symptoms

• Changes in voice quality, vocal fatigue, throat discomfort – may indicate structural or functional voice disorders

• Possible associated cough, sore throat, or dysphonia – reflux-related hoarseness often presents with chronic throat clearing and postnasal drip sensation

Investigations

• Laryngoscopy: Direct visualisation of vocal cords for lesions, inflammation, or paralysis; required for persistent or red flag cases

• Thyroid Function Tests: To exclude hypothyroidism as a cause of hoarseness

• CT or MRI: If mass or recurrent laryngeal nerve involvement is suspected; imaging is not recommended before laryngoscopy unless red flags are present

• Flexible nasoendoscopy: Used in primary care to assess for structural abnormalities; may help differentiate functional from organic causes

Red Flags

• Significant smoking history – increased risk of malignancy

• 45 years + unexplained hoarseness persisting >3 weeks – requires urgent referral for malignancy exclusion

• Dysphagia/odynophagia – may indicate oesophageal or laryngeal malignancy

• Neck mass – concerning for metastatic lymphadenopathy

• Haemoptysis (lung cancer) – consider bronchogenic carcinoma affecting the recurrent laryngeal nerve

• Fevers, weight loss, night sweats – systemic symptoms concerning for malignancy or granulomatous disease

• Stridor – suggests airway compromise, requiring urgent ENT referral

• Persistent otalgia (may indicate nasopharyngeal carcinoma) – referred pain from cranial nerve involvement

History - General

• Duration, gradual or sudden onset – sudden onset suggests traumatic or neurological causes, while gradual onset may indicate neoplastic or inflammatory conditions

• Associated symptoms: cough, sore throat, reflux, dysphagia – reflux is a common cause and may present without heartburn

Examination

• Goitre – may suggest compressive thyroid pathology affecting recurrent laryngeal nerve

• Cervical lymphadenopathy – may indicate malignancy, TB, or sarcoidosis

• Stridor – high-pitched inspiratory sound, indicates airway obstruction

• Oral cavity for signs of candida – common in inhaled corticosteroid use

• CN findings (e.g., cranial nerve palsies) – consider neurological causes like brainstem stroke

• Vocal quality, tone, and pitch – assess for breathiness, strain, or tremor

• Base of tongue/tonsils for masses or lesions – oropharyngeal malignancies may cause referred hoarseness

• Clubbing (lung cancer) – may suggest underlying malignancy

• Reduced AE (if respiratory-related cause suspected) – pleural effusion or lung mass can cause hoarseness via phrenic nerve involvement

Treatment

• Refer if >45 years and unexplained persistent hoarseness >3 weeks OR if red flags present

• Trial reflux management: proton pump inhibitors (PPI) or lifestyle modifications for suspected reflux-related hoarseness (e.g., elevate head of bed, avoid late-night meals, reduce caffeine, alcohol, smoking)

• If cause identified: treat underlying condition and review in 6–8 weeks

• Voice rest and speech therapy for phonotrauma-related cases – whispering should be avoided as it increases vocal strain

• Adequate hydration and vocal hygiene – steam inhalation or humidifiers may help reduce vocal cord irritation