Hoarse Voice

General rule: consider referral in the following circumstances

Any hoarse voice that persists for longer than 10 days in an individual with significant smoking history = malignancy until proven otherwise.
Otherwise, hoarse voice that persists beyond 3 weeks. Consider earlier referral if the person uses voice a lot (eg teacher, professional singer)

Causes: Primary Intralaryngeal

Acute Laryngitis
- Viral/Bacterial Laryngitis
- Acute Epiglottitis
- Croup
- Bacterial Tracheitis
Chronic Laryngitis
- Foreign Body Ingestion
- Voice Abuse/singing (most common cause)
- Irritants
  - Gastroesophageal Reflux (Reflux Laryngitis)
  - Alcohol Abuse
  - Tobacco smoke exposure (or other environmental irritants)
- Laryngeal growths
  - Laryngeal Neoplasm (esp. Squamous Cell Carcinoma or premalignant dysplasia)
  - Laryngeal Polyp (or laryngeal papillomatosis) or Nodules
  - Reinke Edema (polypoid chorditis, cysts or pseudocysts)
  - Traumatic Granuloma from intubation

Causes: Secondary Intralaryngeal

Intrinsic Laryngeal Muscle Weakness
- Hypothyroidism
- Myasthenia Gravis
- Bulbar palsy (severe Dysphagia also present)
- Multiple Sclerosis
- Age-related voice atrophy
- Parkinsonism
- Cerebrovascular Accident
Cricoarytenoid joint Arthritis or fixation
- Rheumatoid Arthritis/Gout/Systemic Lupus Erythematosus (SLE)
- Acromegaly
- Sarcoidosis
- Trauma (e.g. Intubation)

Causes: Laryngeal Nerve Damage (left recurrent laryngeal nerve)

Surgical Procedures (Thyroid, neck, chest)
- Vagus Nerve or recurrent laryngeal nerve injury
Malignancies
- Thyroid Cancer
- Esophageal Cancer
- Lung Cancer
Neuropathy
- Diabetic Neuropathy
- Viral Neuropathy

Causes: Functional Hoarseness (no organic cause)

Management

Consider Laryngoscopy if Hoarseness persists despite empiric management/Laryngoscopy Indications
- More than 4 weeks of Hoarseness despite specific management trials (see below)
- More than 2 weeks of symptoms and risk factors for Laryngeal Cancer
  - Tobacco Abuse
  - Alcohol Abuse
  - Gastroesophageal Reflux disease (esp. if longstanding or with Dysphagia)
  - Hemoptysis
General measures: Vocal Hygiene
- Voice rest (do not whisper!)
- Avoid Tobacco, Alcohol and other irritants
- Consider humidifier
- Avoid raising voice volume

Laryngitis

Most causes of laryngitis are viral.
Consider bacterial if there is dysphonia associated with pain on swallowing and phonating: give antibiotics.
Treatment is with voice restriction (NOT rest – leads to atrophy of glottic muscles):
- Restricted voice usage in terms of volume and length
- No whispering (actually causes more strain on the vocal cords)

Structural lesions

If suspected, these need referral for endoscopy.
Vocal nodules are usually due to voice abuse.
- They improve with voice therapy (referral to speech pathologist).
Other lesions (tumours, polyps, cysts etc.) need surgical intervention.

Age-related voice change

The muscles surrounding the vocal cords get weaker and atrophy with age: can lead to weak, breathy voice. Treatment is speech pathology.