Red flag symptoms: Hoarse voice

By Dr Suneeta Kochhar on the 2 September 2016

An overview of the red flags of hoarse voice, inlcuding recognising potential causes such as trauma, infection or vocal overuse and conducting a clinical evaluation.

Smoking status must be assessed in any patient with a hoarse voice (ISTOCK)

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Red flag symptoms

Persistent hoarseness (>3 weeks)
Dysphagia
Odynophagia
Haemoptysis
Otalgia with normal otoscopy
Weight loss
Excessive alcohol intake
Smoking history

Hoarseness may be described as abnormal vocal quality, which may cause a weak or strained voice or a voice with a change in pitch. It is a common symptom that often self-limits and is often caused by URTI or vocal overuse.¹

Acute laryngitis is usually accompanied with other symptoms that may point to the underlying aetiology. For example, hoarse voice presenting with rhinitis and sinusitis may suggest upper respiratory allergy.

Hoarseness has a prevalence of 6% in the general population and 11% in professional voice users.1 Chronic hoarse voice may be related to smoking, chronic vocal overuse, laryngopharyngeal reflux and inhaled corticosteroid use.²

However, a hoarse voice may be the presenting complaint of squamous cell carcinoma of the larynx, particularly if there are risk factors such as increasing age, smoking, excessive alcohol intake and/or gastro-oesophageal reflux disease present. Heavy smoking and excessive alcohol intake are synergistic risk factors.¹

Squamous cell carcinoma of the larynx is a rare cause of hoarseness, at five in 100,000 in males and one in 100,000 in females.¹

Vagus or recurrent laryngeal nerve injury is an important cause of hoarseness. Thyroid or cardiothoracic surgery may injure the recurrent laryngeal nerve, resulting in unilateral vocal cord paralysis.

Moreover, lung cancer with mediastinal spread may also cause injury to the recurrent laryngeal nerve.² Direct trauma may be caused by endotracheal intubation and a recent surgical history may be suggestive.

Other neurological causes of a hoarse voice include Parkinson's disease, MS and myasthenia gravis.² Other clinical features may be suggestive of these diagnoses.

Systemic causes of a hoarse voice include hypothyroidism and acromegaly. Furthermore, rheumatoid arthritis may affect the cricoarytenoid joints.2 Less commonly, sarcoidosis and amyloidosis may cause hoarseness.²

Causes of hoarseness

Neoplasia
Inflammation
Trauma
Infection
Laryngopharyngeal reflux
Vocal overuse
Neuromuscular
Neurological: MS, Parkinson's disease, vagus or recurrent laryngeal nerve injury
Systemic: hypothyroidism, sarcoidosis, acromegaly

Clinical evaluation

In a patient presenting with hoarse voice, it is important to clarify what they feel has changed in their voice, that is, how the quality of their voice has changed.

It is helpful to assess the onset of the hoarseness, its duration and whether there is any fluctuation or fatiguability in the symptoms.²

For example, hoarseness that worsens as the day progresses may be suggestive of myasthenia gravis, whereas hoarseness that is worse at the beginning of the day may be suggestive of laryngopharyngeal reflux. In addition, progressive symptoms may be indicative of more serious pathology.²

In the acute setting, hoarseness is likely to be related to vocal overuse, injury, or inflammatory or infectious causes. Occupation may be relevant in the case of vocal overuse. Possible triggers may include exposure to allergens or irritants.

Alcohol intake and smoking status should be assessed. A medical history of asthma, as well as inhaled corticosteroid use, may be relevant.²

Specific questions in the history include asking about cough, dysphagia, heartburn, haemoptysis, odynophagia, otalgia, weight loss, rhinorrhoea, wheezing and eye watering.

Throat clearing and globus phenomenon (the sensation of a lump in the throat) are usually benign symptoms, which may resolve with vocal hygiene.¹ Malignancy or laryngeal papillomatosis may cause symptoms of airway obstruction.

Physical examination involves assessing vocal quality, cough and swallowing.¹ Moreover, an examination of the head and neck should be carried out.

The presence of lymphadenopathy may be suggestive of infection or malignancy. There may be evidence of oral candidiasis. Assessment may involve respiratory and/or neurological examination.¹

Management

Vocal hygiene advice includes advising patients to avoid exposure to irritants and cigarette smoke. Vocal overuse, as well as repetitive throat clearing and coughing, should be discouraged.¹

Avoiding dehydration, reducing caffeine intake, voice rest and steam inhalation may be helpful, depending on the underlying aetiology.¹ Advising patients about alcohol consumption may be relevant.

If hoarseness is persistent with no obvious cause, direct or indirect laryngoscopy may be appropriate.

Other options include a trial of PPI therapy, altering inhaled medication if relevant or optimising therapy in those conditions known to cause hoarse voice, if appropriate.² If there is no improvement in symptoms, laryngoscopy is indicated.

NICE guidance advises that a referral for suspected head and neck cancer should be made for people aged 45 and over with persistent unexplained hoarseness or an unexplained neck lump to rule out laryngeal cancer.³