Hoarseness

Background: Hoarseness is a change in the voice that can be intermittent or persistent. Intermittent hoarseness (where there are periods of normal voice between periods of hoarseness) there is unlikely to be any pathological findings on examination and are often referred onwards to speech and language therapy. Persistent hoarseness is more commonly associated with pathology and persistent hoarseness for >3 weeks is considered a red flag symptom for ENT and should be referred as urgent suspected cancer.

All patients aged 35 and over with persistent hoarseness (where their voice is never normal) for >3 weeks should be referred as urgent suspected cancer. 

How to assess:

Consider patients occupation and hobbies. Voice overuse is common in teachers, fitness instructors, call centre workers, singers

How to manage:

Post-viral – intermittent voice change can persist for several months after an upper respiratory tract infection. Advise simple voice care.

Asthma – patients should be advised oral rinses / gargles after use of inhalers to minimise the risk of laryngeal candida. Oral fluconazole can be considered if laryngeal candida is suspected (does not typically respond to oral nystatin)

Reflux – empirical management of antireflux treatment if patient symptomatic

Elderly voice (presbyphonia) – consider in elderly patients who are non-smokers. This is related to loss of vocal cord bulk associated with ageing. This may gradually worse over time

Referral guidance:

All patients with intermittent hoarseness should be referred to ENT on a routine basis

All patients aged 35 and over with persistent hoarseness (where their voice is never normal) for >3 weeks should be referred to ENT as urgent suspected cancer. See the lung cancer section for guidance regarding chest x-rays and respiratory referral.