Hoarseness

Diagnosis/Definition

• The term “hoarseness” is used as a general description of a non-specific change in vocal intensity or quality.
  Initial Diagnosis and Management
• History: Many times the etiology for a change in voice can be determined from a good history. Initially, the goal is to differentiate among traumatic, inflammatory, infectious, neurologic and neoplastic causes. Specific historical points should include the duration, persistence, and severity of the symptoms, recent neck or laryngeal trauma (e.g. general endotracheal anesthesia), associated URI symptoms, and alcohol/tobacco use. Also important is a thorough past medical history including connective tissue disorders, thyroid disorders, GERD, neurologic diseases, and psychiatric problems. Infections causing “hoarseness” will typically resolve over the course of 2 weeks. Many times an infection can worsen an existing inflammatory problem (e.g. GERD) causing persistent symptoms for greater than 2 weeks.
• Physical Examination: A thorough head and neck exam is indicated. Effort should be placed on identifying any evidence of infection and/or mass lesion in the pharynx or larynx. Presence of a neck mass typically signifies a malignancy.
• Ancillary Tests: If a traumatic etiology is suspected, a CT of the neck might be indicated to R/O a laryngeal fracture. In the acute setting the C-spine must be cleared.
• Initial Management: If there is a low suspicion for a neoplastic or traumatic etiology and/or there is a high likelihood of an infectious/inflammatory etiology, the following management strategy can be used:

• Voice rest
• Increased fluid intake
• Humidification of inhaled air
• Oral/inhaled steroid treatment and/or antibiotics when appropriate
• Treatment of GERD (See GERD referral guidelines)
• Treatment of SINUSITIS (See Sinusitis referral guidelines)
• Treatment for other underlying etiologies such as hypothyroidism, diabetes mellitus and rheumatoid disease should be undertaken.

Ongoing Management and Objectives

The goal for ongoing management is to document improvement in voice quality and to treat any underlying medical disorders.

Indications for Specialty Care Referral

All cases of hoarseness that persist for greater than two weeks despite medical therapy should be referred to Otolaryngology for evaluation.

All cases with a suspected neoplastic or traumatic etiology should be discussed with an ENT provider and referred within 72 hours to Otolaryngology for evaluation.

Criteria for Return to Primary Care

The patient will be followed by primary care after a definitive diagnosis has been made and appropriate therapy has been rendered, or the problem has resolved.