Hoarseness may start suddenly and last a few days (acute), or arise gradually and continue for weeks or months (chronic). The history will clarify this and point the way forward in management. Acute hoarseness rarely causes any diagnostic problem or concern; the less common chronic case raises more worrying possibilities and usually requires referral.
- Acute Viral Laryngitis
- Voice Overuse (Shouting, Screaming)
- Benign Tumours: Singer’s Nodes, Polyps
- Crico-Arytenoid Rheumatoid Arthritis
- Functional (Hysterical) Aphonia
- Acute Epiglottitis
- Laryngeal Carcinoma
- Recurrent Laryngeal Nerve Palsy
- Physical Trauma (e.g. after Intubation)
- Chemical Inhalation Trauma
- Rare Inflammatory Lesions (e.g. TB, Syphilis)
Key distinguishing features of the most common diagnoses
|Tired, Cold and Slowed Up||No||No||Yes||No||No|
|Fever and Malaise||Possible||No||No||No||Yes|
|Facial Pain and Catarrh||No||No||No||No||Yes|
Possible: TFT, CXR, direct or indirect laryngoscopy.
Small Print: Throat swab.
- TFT: In chronic hoarseness to exclude hypothyroidism.
- CXR: To check for thoracic lesions causing recurrent laryngeal nerve palsy.
- Indirect laryngoscopy: Useful for a GP with the necessary skills; most will refer to an ENT specialist.
- Direct laryngoscopy: Using a flexible fibre-optic endoscope. This is a specialist investigation allowing close-up views and biopsy of suspicious lesions.
- Throat swab: Useful, very rarely, if hoarseness is associated with a persisting pharyngitis.
- In acute laryngitis, don’t forget to tell the patient to rest the voice, and remember that occupational factors are important – use of voice (e.g. by telephonists) or working in smoky environment (e.g. a pub) will aggravate and prolong symptoms, causing diagnostic confusion.
- If you suspect a malignancy, arrange an urgent CXR immediately prior to referral. The referral can then be made to the correct specialist (chest rather than ENT) if a lung lesion is present, thus expediting appropriate management.
- Don’t forget transient hoarseness caused by intubation – GPs are seeing this increasingly often as patients spend less post-operative time in hospital.
- Every adult patient with persistent, unexplained hoarseness has carcinoma of the larynx until proved otherwise.
- GORD is a common cause in the elderly, but beware of making this diagnosis without specialist investigation first.
- Epiglottitis is rare but if you suspect it in any patient, admit immediately – and don’t examine the throat.
- Hypothyroidism is easily overlooked – prompt diagnosis can save unnecessary anxiety and investigation.