The most common cause of hoarseness seen in primary care practice is acute laryngitis, and its most important treatment is voice rest.
Indirect laryngoscopy must always be performed if the hoarseness is not associated with a cold or flu, and in all patients with hoarseness lasting for more than two weeks. If visibility is not sufficient in indirect laryngoscopy the patient should be referred to a specialist (phoniatrician or ENT specialist).
If dysphonia restricting the patient's working capacity or functional ability is prolonged, it is also advisable to refer the patient to a specialist for diagnosis, treatment and rehabilitation.
When assessing the risk of malignant tumour in the larynx, taking a smoking history is essential. Remember to document the smoking history in the referral.
In prolonged dysphonia, the voice is not necessarily qualitatively hoarse or particularly abnormal. Symptoms may include fatigue of the voice or throat irritation symptoms.
Hoarseness in children is an indication for consulting a phoniatrician or an ENT specialist because indirect laryngoscopy is difficult to perform.
Organic dysphonia
Acute laryngitis
The most common cause of hoarseness seen in primary care practice
There are typical symptoms of upper respiratory tract infection, sore throat, hoarseness, often also rhinitis, headache and mild fever.
The vocal chords are erythematous and swollen.
As the infection is usually viral, antimicrobial treatment is of no benefit Antibiotics for Acute Laryngitis in Adults. Antimicrobials may be indicated because of other infections, not because of laryngitis alone.
In viral laryngitis the most important treatment is voice rest and avoiding coughing, clearing the throat and whispering. Patients in professions with heavy vocal loading should have a sufficiently long sick leave of at least one week (unless other tasks can be arranged).-If hoarseness continues for 3-4 weeks and, particularly, if the vocal cords cannot be reliably examined, the patient should be referred to a phoniatrician or an ENT specialist.
Chronic laryngitis
Prolonged laryngitis may be due to, for example, the following:
smoking or other toxic irritation
prolonged respiratory tract infections
fungal or bacterial infection of the larynx
inhaled corticosteroids
mechanical irritation of the throat (severe cough or heavy vocal loading)
laryngeal reflux disease
possibly also allergic factors.
The vocal cords are erythematous, swollen, and sometimes dry or covered with crusts or mucus.
The treatment depends on the cause and should be based on the history as well as thorough laryngoscopy.
Therefore, if laryngitis is prolonged, an ENT specialist or phoniatrician should be consulted.
General guidance in vocal hygiene is important.
Smoking cessation
Avoidance of coughing and clearing of the throat
Avoidance of forceful use of the voice and whispering
Sufficient intake of water, steam inhalation (e.g. a steam inhalation pipe, picture 1)
Sufficient voice rest in connection with respiratory infections
A voice amplifier for patients in professions with heavy vocal loading
Always refer the patient to an ENT specialist or phoniatrician.
Vocal cord changes may be associated with functional dysphonia, for which voice therapy is needed.
Neurological dysphonia
Vocal cord paralysis
Damage to the recurrent laryngeal nerve (n. laryngeus recurrens) or external branch of the superior laryngeal nerve (n. laryngeus superior)
Damage to the recurrent laryngeal nerve
The vocal cord is paralysed or its motion limited.
The voice is at least initially hoarse, breathy and weak.
There may be mild swallowing problems and effort dyspnoea
Causes
A complication of surgery (thyroid, neck or thoracic cavity procedures)
Compression caused by a tumour anywhere along the nerve pathway (base of the skull, neck area, mediastinum)
Neuritis
Intubation
Certain neurological diseases
Certain heart diseases (left recurrent nerve compressed at the heart)
Idiopathic
Damage to the superior laryngeal nerve
Main symptom narrowed and lowered vocal range.
Examination using a mirror often reveals little about the patient's status
Treatment
Always refer the patient to a specialist (phoniatrician or ENT specialist) for further examinations and treatment.
Voice rest will not help.
Guidance provided by a voice therapist is often helpful for the function of the voice even though voice training cannot cure nerve damage.
Voice surgery in severe cases
Spasmodic dysphonia
A rare severe chronic voice disorder characterized by breaking and choking speech and tense and strained vocal quality. In another subtype the voice is whispery, weak and fades away at times.
A form of focal dystonia, where the motor disorder affects laryngeal muscles.
The patient should be referred to a phoniatrician.
Dysphonia associated with neurological diseases
Many neurological diseases (e.g. Parkinson's disease, amyotrophic lateral sclerosis, MS) involve problems in voice production.
The voice is leaky and quiet. The loudness, pitch or rhythm may be altered.
Voice therapy and communication aids may be used for treatment.
Dysphonia in the elderly
Dysphonia becomes more prevalent by age and may cause significant functional impairment.
Careful examination of the larynx is important to rule out malignant causes and other diseases.
Often the aetiology is, however, benign, age-related vocal cord bowing (presbyphonia).
The treatment of presbyphonia consists of voice therapy and, sometimes in serious cases, surgery.
Functional voice disorders
A group of voice disorders not explained by an organic cause
Organic causes should be excluded.
However, a functional voice disorder may occur simultaneously with an organic disorder; an organic voice disorder may cause a functional problem and vice versa.
The method of voice production may be uneconomic or the requirements for use of the voice excessive (e.g. often in professions with heavy vocal loading).
Typical symptoms include qualitative voice changes and voice fatigue, sometimes neck pain, a feeling of a lump in the throat and various throat irritation symptoms.
Underlying causes should be identified (excessive use of voice, a tense way of speaking, hobbies requiring use of the voice, bad acoustics in the working environment, such as background noise, high reverberation).
Treatment is based on voice therapy 2 including, for example, voice ergonomics, voice and laryngeal care and vocal training. Voice therapy is provided by specialized speech therapists.
Vocal cysts and other congenital structural defects
Vocal cord paralysis
Intubation damage
Functional disorders
Laryngitis
Vocal cord papilloma
Hearing should be tested in loud children with a hoarse voice.
If hoarseness continues, refer to a phoniatrician or an ENT specialist because indirect laryngoscopy is difficult to perform in children.
References
Persaud R, Garas G, Silva S et al. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Rep 2013;4(2):10. [PubMed]
Ruotsalainen J, Sellman J, Lehto L et al. Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Otolaryngol Head Neck Surg 2008;138(5):557-65. [PubMed]
Martins RH, Hidalgo Ribeiro CB, Fernandes de Mello BM et al. Dysphonia in children. J Voice 2012;26(5):674.e17-20. [PubMed]
Lyberg-Åhlander V, Rydell R, Fredlund P et al. Prevalence of voice disorders in the general population, based on the Stockholm public health cohort. J Voice 2019;33(6):900-905. [PubMed]