Hoarseness

Background

• Hoarseness is one of the voice-related changes known as dysphonia, and is characterized as a coarse, raspy, rough, strained, or strangled voice.
• It particularly affects persons with high vocal demands (such as teachers, coaches, and singers), older adults (especially those with age-related laryngeal changes, such as atrophy), and children who have younger siblings, are often in noisy environments, participate in sports, or who otherwise use their voice frequently and/or at high volume.
• The reported lifetime prevalence of hoarseness is 30%. Though a common presentation in primary care settings, only about 6% seek medical treatment.
• Voice overuse is the most common cause of chronic hoarseness and typically has a self-limited clinical course. The condition may also be due to inflammation or irritants or underlying conditions (such as physical lesions or neoplasia, neurological or psychiatric conditions, and systemic diseases and disorders).

Evaluation

• An acute onset of hoarseness with a symptom duration of less than 2 weeks and an apparent benign cause does not require further evaluation. If symptom duration exceeds 2 weeks with no improvement, it is crucial to assess for potential causes (which range widely from simple inflammatory processes or medication side effects to serious systemic conditions such as malignancy).
• Warning signs suggesting a possible serious condition:
  • In most patients - progression without fluctuation; history of smoking (≥ 10 pack-years); heavy alcohol consumption; hemoptysis; neck mass or enlarged cervical lymph nodes; otalgia; dysphagia; odynophagia or unilateral throat pain; stridor, dyspnea, or other signs of airway obstruction; and fevers, night sweats, or unexplained weight loss.
  • In children in particular - aphonia; pain or dysphagia; stridor, shortness of breath, and other possible signs of breathing problems; signs of airway obstruction, feeding problems, and failure to thrive.
• Perform laryngoscopy in adults with warning signs and in most children and infants.
• Additional testing may include:
  • Consider referral for a biopsy or imaging studies (such as computed tomography or magnetic resonance imaging) if clinically indicated and laryngoscopy is nondiagnostic.
  • Consider videostroboscopy (using strobe lighting during laryngoscopy) to further visualize mucosal vibration disorders (such as scar or sulcus) if conventional laryngoscopy is inconclusive.
  • Consider referral for speech-language pathology to aid in evaluation of the perceptual, acoustic, and aerodynamic character of hoarseness, if the exam and imaging are insufficient for a diagnosis.
• Additional considerations for hoarseness in children include:
  • Elicit detailed history from child, if possible, and parent or caregiver.
  • Consider use of pediatric assessment tools to aid diagnosis and evaluate the impact of hoarseness on child's quality of life.
  • Perform (or refer for) transnasal or transoral laryngoscopy to confirm diagnosis. If awake assessment cannot be performed, consider:
    • Laryngoscopy with anesthesia.
    • Microlaryngoscopy, though assessment of functional characteristics is not possible.

Management

• The initial management of acute hoarseness may include:
  • voice rest (especially whispering avoidance) and vocal hygiene (including avoidance of irritants, use of a humidifier, control of voice volume, and limited intake of large or spicy meals);
  • do not routinely prescribe antibiotics, corticosteroids, or antireflux medications (prior to visualization of the larynx for gastroesophageal reflux disease [GERD] or laryngopharyngeal reflux [LPR]) (Strong recommendation);
  • advise voice therapy in patients with impaired vocal quality of life (Strong recommendation); success requires active participation and cooperation that may be challenging for some children and/or their caregivers.
• Cause-specific management may include:
  • treatment for GERD after visualization of the larynx
  • reduction or discontinuation of inhaled corticosteroids
  • topical antifungal medication for thrush
  • treatment of other medical conditions
  • surgical intervention for dysplastic or malignant lesions, airway obstruction, or benign lesions nonresponsive to conservative management
    • in children, surgery for benign lesions is typically avoided (if possible) unless they are ideal surgical candidates
    • if performed, surgery in children should follow the principles used in the adult population
• Refer patients with spasmodic dysphonia and other types of laryngeal dysphonia for botulinum toxin injections (Strong recommendation).