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Assessing patient with hoarse voice

GP Dr Alex Watson and ENT surgeon Mr Peter Robb advise on a common presentation

GP Dr Alex Watson and ENT surgeon Mr Peter Robb advise on a common presentation

History

You need to ascertain:
How long have they had a hoarse voice?
A hoarse voice for more than three weeks should always be taken more seriously.

Was there a sudden or gradual onset?
Sudden hoarseness may follow an obvious cause (such as vocal abuse).

Has the hoarseness been constant or intermittent?
Intermittent hoarseness may reflect more of an ‘irritable larynx' triggered by intermittent irritants (such as gastro-oesophageal reflux, stress).

Associated symptoms

In particular ask about:
•sore throat
•dysphagia or globus
•‘heartburn'/dyspepsia/‘waterbrash'
•respiratory symptoms such as cough, breathlessness, haemoptysis
•any other ear or nose symptoms.

What impact is it having on the patient's life?

For some individuals (such as singers), this can have a huge impact on their professional lives.
•Past medical history – for example, asthma, GORD, stress-related conditions such as anxiety and depression.
•Drug history – some drugs can exacerbate GORD (for example NSAIDs), while others can dry out the laryngeal mucosa (for example antihistamines). Oral antibiotics may cause candidiasis with hoarseness. Asthma inhalers may irritate the larynx and cause a gruff voice. Consider spacers and gargling after inhalers.
•Social history should include questions about occupation, hobbies, smoking and alcohol consumption.

Examination

Listen to them speak. A harsh, gravely, low-pitched quality usually indicates pathology affecting the vocal cords. A weak breathy voice is more typical of a vocal cord palsy, or in the elderly where the muscles in the larynx are not as strong as they used to be, resulting in incomplete closure of the vocal cords. Repeated throat clearing may be due to GORD or reflect a psychogenic cause.

Listen to them cough. This may help reveal a psychogenic cause – for example normal cough but little or no voice. A normal cough suggests good vocal cord movement.

A full ENT examination is essential in all cases. Do not forget to examine the neck for lymphadenopathy and thyroid pathology. Consider a complete respiratory examination if lung pathology is suspected.

Are any further investigations helpful?

•Left vocal cord palsy – CT scan skull base to mediastinum.
•Right vocal cord palsy – CT scan skull base and neck.
•Videolaryngostroboscopy and voice clinic assessment for functional voice problems.
•Thyroid function tests.

How should patients be managed?

Inflammatory

•Acute laryngitis: voice rest, steam inhalations, clear fluids. Occasionally, a single dose of steroids may be useful for the professional voice user.
•Chronic laryngitis: management usually involves lifestyle changes such as stopping smoking, voice use and retraining with a speech and language therapist.

Neoplastic

•Laryngeal papillomatosis: Usually requires repeated surgical treatment. Interferon, antivirals and acid suppression not yet proven to be helpful.
•Laryngeal carcinoma: early disease has a high cure rate with external beam radiotherapy. Advanced disease generally requires surgical exclusion and voice restoration with a speaking valve.

Neurological

•Vocal cord palsy: treatment will depend on the causation. Treatment to bulk up the vocal cord or to lateralise a medially paralysed vocal cord may improve the strength of the voice but it will still sound gruff.

Systemic

Treating acid reflux or hypothyroidism will improve the voice

Vocal abuse

Best managed by a voice specialist speech and language therapist. Surgical exclusion of vocal cord nodules should be avoided.

Psychogenic

Usually responds well to speech and language therapy and identification and management of the underlying psychological factors.

Refer if...

• Persistent hoarseness for more than three weeks – this needs urgent outpatient review to rule out an early laryngeal cancer or vocal cord palsy due to lung cancer
• Stridor for emergency airway assessment
• Other voice changes needing confirmation of diagnosis

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