Hoarseness

Probability diagnosis

Viral URTI: acute laryngitis

Non-specific irritative laryngitis (Reinke oedema)

Vocal abuse (shouting, screaming, etc.)

Smoking

Nodules and polyps of cords

Presbyphonia in elderly: ‘tired’ voice

Hypothyroidism

Acute tonsillitis

Serious disorders not to be missed

Cancer:

• larynx, lung, including recurrent laryngeal nerve palsy, oesophagus, thyroid

Imminent airway obstruction (e.g. acute epiglottis, croup)

Rare other severe infections (e.g. TB, diphtheria)

Foreign body

Motor neurone disease

Myasthenia gravis

Pitfalls (often missed)

Toxic fumes

Vocal abuse

Benign tumours of vocal cords (e.g. polyps, ‘singer’s nodules’, papillomas)

Gastro-oesophageal reflux → pharyngolaryngitis

Goitre

Dystonia

Physical trauma (e.g. post-intubation), haematoma

Fungal infections (e.g. Candida with steroid inhalation, immunocompromised)

Allergy (e.g. angioedema)

Leucoplakia

Systemic autoimmune disorders (e.g. SLE, Wegener granulomatosis)

Masquerades

Consider:

• drugs: antipsychotics, anabolic steroids

• smoking → non-specific laryngitis

• hypothyroidism, acromegaly

Is the patient trying to tell me something?

Consider:

• functional aphonia

• functional stridor

Key history

Note the nature and duration of the voice change. Enquire about corticosteroid inhalations, excessive or unaccustomed voice straining, especially singing, recent surgery, possible reflux, smoking or exposure to environmental pollutants. Elicit associated respiratory or general symptoms such as cough and weight loss.

Key examination

• Palpate the neck for enlargement of the thyroid gland or cervical nodes

• Perform a simple oropharyngeal examination except if epiglottitis is suspected

• Check for signs of hypothyroidism, such as coarse dry hair and skin, slow pulse and mental slowing

• Perform indirect laryngoscopy if skilled in the procedure

Key investigations

Consider:

• thyroid function tests

• chest X-ray if it is possibly due to lung carcinoma with recurrent laryngeal nerve palsy

• indirect laryngoscopy (the gag reflex may preclude this)

• a special CT scan to detect suspected neoplasia or laryngeal trauma.

Diagnostic tips

• Acute hoarseness rarely causes any diagnostic problem or concern but the chronic cases are often cause for concern.

• Remember that intubation causes transient hoarseness.

• Consider gastro-oesophageal reflux disease in the elderly.