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GPs & primary care team

Primary care management

Hoarseness is a very common referral to ENT; it is the most common presenting feature of laryngeal carcinoma. It is important to be aware however that between 2-18% of lung cancers also present with hoarseness, with the incidence of lung cancer being 4:1 when compared to all head and neck cancers.

Non neoplastic causes of chronic hoarseness

  • Chronic inflammation
  • Trauma
  • Infection
  • Laryngopharyngeal reflux (LPR)
  • Vocal overuse
  • Neuromuscular or Neurological: MS, Parkinsonism, Myasthenia Gravis, Motor Neuron Disease etc
  • Systemic: Rheumatoid Arthritis, Laryngeal Sarcoidosis, Amyloidosis, Granulomatosis with polyangitis

Important aspects to the history in primary care

  • The key question is “can the voice be normal at any point” – if so then this is a routine referral
  • Rule out other red flag symptoms (haemoptysis, referred unilateral otalgia,)
  • Assess if any red flag respiratory symptoms potentially indicating a lung primary or metastasis
  • Smoking and alcohol history
  • PMH of asthma with inhaled corticosteroids or untreated reflux disease

Ascertain the onset and fluctuation/ fatigability of the symptoms

  • Hoarseness first thing in the morning is likely to be reflux related
  • Worsening throughout the day maybe neurological
  • Progressive constant symptoms more likely to be sinister pathology
  • Intermittent hoarseness is most likely to be of benign pathology

Physical examination

  • Assess vocal quality, cough and swallow
  • Examination of the neck and identify any lymphadenopathy
  • Respiratory and neurological examination (tongue movement/palate lift/gag reflex) dependant on history and findings.

Throat care advice in general practice

  • Avoid exposure to irritants – cigarette smoke, caffeine, alcohol, spicy or acidic foods
  • Vocal overuse as well as repetitive throat clearing should be discouraged.
  • A trial of PPI and Gaviscon advance TDS should be consider if symptoms of laryngopharyngeal reflux ONLY after strict lifestyle and dietary advice (download & explain to patient Silent Reflux Advice)

Referral to secondary care

Emergency

  • Evidence of airway obstruction in relation to hoarseness (on call ENT team Ninewells bleep 4496).

Urgent

  • Persistent (constant) unexplained hoarseness 2 week; consider cancer referral to head & neck in high risk patients – Request CXR.

Patient information

Evidence/guidance

Hoarse voice - red flag symptoms - GPonline

Editorial Information

Next review date: 10/01/2027