Hoarseness
Differential Diagnosis
Common Diagnoses
- Acute Viral Laryngitis
- Voice Overuse (Shouting, Screaming)
- Hypothyroidism
- Smoking
- Sinusitis
Occasional Diagnoses
- GORD in adults
- Benign Tumours: Singer’s Nodes, Polyps
- Crico-Arytenoid Rheumatoid Arthritis
- Functional (Hysterical) Aphonia
Rare Diagnoses
- Acute Epiglottitis
- Laryngeal Carcinoma
- Recurrent Laryngeal Nerve Palsy
- Physical Trauma (e.g. after Intubation)
- Chemical Inhalation Trauma
- Rare Inflammatory Lesions (e.g. TB, Syphilis)
Ready Reckoner
Key distinguishing features of the most common diagnoses
| Acute Laryngitis | Overuse | Hypothyroidism | Smoking | Sinusitis | |
|---|---|---|---|---|---|
| Recent Illness | Yes | No | Possible | No | Yes |
| Tired, Cold and Slowed Up | No | No | Yes | No | No |
| Fever and Malaise | Possible | No | No | No | Yes |
| Symptoms Chronic | No | Possible | Yes | Yes | No |
| Facial Pain and Catarrh | No | No | No | No | Yes |
Possible Investigations
Likely:None.
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.
Top Tips
- 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.
Red Flags
- 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.