Hoarse voiceBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c522 (Published 07 April 2010) Cite this as: BMJ 2010;340:c522
- 1Department of Otolaryngology, Derbyshire Royal Infirmary, Derby DE1 2QY
- 2Elizabeth Avenue Group Practice, London N1 3BX
- Correspondence to: O Judd
- Accepted 4 December 2009
A 38 year old woman who is a teacher presents with a three week history of hoarse voice after a common cold. It is intermittent, with normal voice in between. She reports a sensation of having phlegm in the throat that constantly needs to be cleared.
What you should cover
Hoarseness has a prevalence of 6% in the general population, rising to 11% for professional voice users (30% of the workforce). Most episodes are benign and resolve with vocal hygiene (see box). Laryngeal cancer is an important, but rare, cause of hoarseness (5/100 000 in males and 1/100 000 in females). Most patients with laryngeal cancer have risk factors, mainly smoking, high alcohol intake, and increasing age (72% of cancers occur over the age of 60). Heavy smoking and drinking are synergistic risk factors, and together increase risk 80-fold.
Vocal hygiene advice for patients
Cigarette smoke, dry atmospheres, dust, fumes
Alcohol, caffeine, decongestant drugs
Throat lozenges—they can dry out your throat
Gargling with aspirin
Fatigue, lack of sleep, and eating late at night
Shouting, whispering, screaming, singing, straining your voice
Prolonged periods of speaking without rest
Repetitive throat clearing and coughing
Resting your voice
Yawning and humming to relax your voice box
Sleeping for longer
Good hydration—minimum of six glasses of water a day
Regular steam inhalation (without additives such as menthol)
Humidifying your environment—place a bowl of water near a radiator
To remedy habitual throat clearing: resist the temptation to clear your throat; instead, sip ice cold, carbonated water every time you feel the need to clear your throat or cough, for at least four days and four nights
Intermittent symptoms are less worrying than progressive hoarseness.
Red flags are: persistent hoarseness lasting more than three weeks, difficulty or pain on swallowing, haemoptysis, earache with normal otoscopy, weight loss, and heavy smoking or alcohol intake.
Associated symptoms of throat clearing, globus phenomenon (a sensation of a lump in the throat), and cough are common; they are usually benign, multifactorial in aetiology, and resolve with good vocal hygiene.
Hoarseness after prolonged use of the voice, or strain, suggests a benign cause.
Ask about gastro-oesophageal reflux disease. Consider using the reflux symptom index (RSI) questionnaire; it is quick to use in general practice, validated, and useful.
“One airway” atopic disease may be contributory, especially if there is chronic nasal congestion and mouth breathing. Ask about asthma, rhinitis, and inhaled steroids.
Hoarseness often follows viral upper respiratory tract illness.
Rarely, associated symptoms of intrathoracic malignancy (for example, lung cancer invading the left recurrent laryngeal nerve causing unilateral vocal cord palsy), hypothyroidism, or neurological disease (parkinsonism, myasthenia, motor neurone disease) are present.
Explore the patient’s fears; many are worried about cancer.
Weigh the patient and compare against records.
Examine the neck and thyroid. Red flags are lumps and lymphadenopathy.
Examine the mouth for candidiasis.
Respiratory and neurological examination, if indicated.
What you should do
NICE advises an urgent chest x ray for hoarseness persisting more than three weeks, especially if the patient is a heavy drinker or smoker aged over 50. If the x ray is positive, refer urgently for suspected lung cancer. If negative, refer urgently for suspected head and neck cancer.
Red flag symptoms or signs should prompt urgent referral for suspected head and neck cancer.
Stopping smoking and reducing alcohol consumption is of paramount importance.
Advise vocal hygiene in every case. Consider providing this in a leaflet to aid compliance and save time during the consultation (for example, print out the box).
Treat any possible contributing conditions; optimise treatment of asthma or rhinitis, and treat oral candidiasis related to inhaled steroids and advise on prevention.
Trial of a proton pump inhibitor or liquid alginate may be reasonable in patients with symptoms of gastro-oesophageal reflux disease (RSI >13), but meta-analysis has not shown that proton pump inhibitors are efficacious for laryngeal symptoms presumed secondary to the disease.
Antibiotics are ineffective for hoarseness after upper respiratory tract infection.
Consider routine referral to ear, nose, and throat specialists for non-persistent, recurrent cases that do not meet criteria for urgent referral and fail to resolve with treatment in primary care. The team will examine the vocal cords with a nasal endoscope to identify causes such as cord polyps, nodules, granulomata, and oedema (Reinke’s oedema). Many centres provide a voice clinic in conjunction with speech and language therapists.
For the clinician
Hoarseness—article written for doctors on PatientUK website (www.patient.co.uk/showdoc/40000966)
Resources and where to find voice clinics—British Voice Association (www.british-voice-association.com)
Rubin JS, Sataloff RT, Korovin GS. Diagnosis and treatment of voice disorders. 3rd ed. San Diego: Plural Publishing, 2006
Belafsky PC, Postma GN, Koufman JA. Validity and reliability of the reflux symptom index (RSI). J Voice 2002;16:274-7, doi:10.1016/S0892-1997(02)00097-8
Cite this as: BMJ 2010;340:c522
This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.
We thank Iona Heath and Daniel Toeg for their comments on the manuscript.
Competing interests: None declared.
Provenance and peer review: Not commissioned; externally peer reviewed.