Hoarseness (Dysphonia)

Red flags

Smoking; dysphagia; odynophagia or otalgia; stridor; haemoptysis; recent fevers; night sweats; unexplained weight loss.

Key facts

• In acute hoarseness, the diagnosis is usually obvious from history alone (e.g. URTI, vocal overuse).
• Think hypothyroidism if unusual hoarseness develops.
• Laryngeal cancer must be excluded if hoarseness persists >3 weeks in an adult.
• Intermittent hoarseness is almost always secondary to a benign disorder; constant or progressive hoarseness suggests malignancy.
• Non-malignant vocal cord lesions include polyps, vocal nodules, contact ulcers, and granulomas.
• In chronic hoarseness, the larynx must be visualised for diagnosis — common findings are screamer’s nodules in children and non-specific irritant laryngitis in adults.

Examination

Listen for stridor — if present, arrange urgent referral for direct visualisation. Decreased lung expansion/auscultation findings may indicate a restrictive lung pathology affecting air volume through the larynx (and hence voice). Examine the oral cavity and oropharynx for lesions affecting the resonance chamber; examine the tongue and tonsils. Cranial nerve exam — abnormality may indicate a central cause. Palpate the neck and thyroid.

Vocal cord nodules & benign tumours

Includes nodules (most common), polyps (second most common), cysts, and papules. Suspect in singers and children who scream, presenting with voice change.

Management: may respond well to conservative measures — voice rest and vocal therapy. Refractory cases can be removed by microlaryngeal surgery or laser therapy.