One-liner#

Most hoarseness is acute laryngitis (viral, self-limited); persistent hoarseness >3 weeks requires laryngoscopy to rule out malignancy and identify treatable causes (vocal cord lesions, reflux, neurologic).

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Stridor or respiratory distress (airway compromise)
• Rapid onset with dysphagia and drooling (epiglottitis, deep space infection)
• Hoarseness after intubation with stridor (laryngeal injury)
• Hemoptysis with hoarseness (malignancy, TB)
• Severe dysphagia with aspiration

Key history#

Duration—critical for management:

• Acute (<3 weeks): Usually viral laryngitis; watchful waiting appropriate
• Persistent (>3 weeks): Requires laryngoscopy to rule out malignancy

Voice use and abuse:

• Occupation: teacher, singer, call center, coach, clergy
• Recent voice strain: yelling, singing, prolonged speaking
• Vocal hygiene: hydration, throat clearing habits

Associated symptoms:

• URI symptoms: suggests viral laryngitis
• Heartburn, regurgitation, throat clearing: suggests LPR (laryngopharyngeal reflux)
• Dysphagia, odynophagia: concerning for mass or structural lesion
• Weight loss, hemoptysis: concerning for malignancy
• Neck mass: thyroid, lymphadenopathy, laryngeal cancer
• Neurologic symptoms: weakness, diplopia, dysphagia (suggests neurologic cause)

Risk factors for laryngeal cancer:

• Smoking (strongest risk factor)
• Alcohol use (synergistic with smoking)
• Age >50
• Male sex
• HPV (oropharyngeal cancer)

Relevant history:

• Prior intubation or neck surgery (vocal cord injury)
• Thyroid surgery (recurrent laryngeal nerve injury)
• Lung cancer, aortic aneurysm (recurrent laryngeal nerve compression)
• Neurologic disease: Parkinson’s, stroke, ALS, myasthenia gravis
• Autoimmune disease: rheumatoid arthritis (cricoarytenoid arthritis)

Medications:

• Inhaled corticosteroids (laryngeal candidiasis, dysphonia)
• ACE inhibitors (cough leading to voice strain)
• Antihistamines, anticholinergics (mucosal drying)

Focused exam#

• Voice quality: Breathy (incomplete cord closure), strained (muscle tension), rough (mass or edema)
• Neck: Thyroid nodules, lymphadenopathy, masses, surgical scars
• Oropharynx: Lesions, tonsillar asymmetry, pooling of secretions
• Nasal: Post-nasal drip, signs of rhinitis
• Pulmonary: Wheezing, stridor, signs of lung disease
• Neurologic: Cranial nerves (especially IX, X, XII), signs of Parkinson’s, bulbar weakness

What you cannot see in office:

• Larynx requires visualization with laryngoscopy (ENT)
• Do NOT delay ENT referral for persistent hoarseness—you cannot rule out malignancy without laryngoscopy

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

The 3-week rule:

• Hoarseness <3 weeks with clear viral prodrome: watchful waiting appropriate
• Hoarseness >3 weeks: MUST have laryngoscopy to rule out malignancy

Laryngoscopy (ENT performs):

• Gold standard for evaluating hoarseness
• Visualizes vocal cords, larynx, hypopharynx
• Can identify: nodules, polyps, cancer, paralysis, edema, lesions
• Cannot be done in primary care office—requires ENT referral

When to order imaging:

• CT neck with contrast: palpable neck mass, suspected malignancy, vocal cord paralysis without clear cause
• CT chest: vocal cord paralysis (look for lung apex mass compressing recurrent laryngeal nerve)
• MRI: suspected skull base lesion, neurologic cause

When to order labs:

• Not routinely indicated
• Consider TSH if thyroid abnormality suspected
• Consider CBC, ESR if systemic disease suspected

When NOT to order workup:

• Acute hoarseness <3 weeks with viral URI symptoms
• Clear cause identified (voice strain, recent intubation)

Initial management#

Acute laryngitis (<3 weeks):

• Voice rest (not complete silence—whisper is actually worse)
• Hydration (8+ glasses water daily)
• Humidification
• Avoid irritants (smoking, alcohol, caffeine)
• Treat underlying cause (URI, allergies)
• No antibiotics (viral cause)

Suspected LPR:

• PPI trial: twice daily dosing (before breakfast and dinner) x 2-3 months
• Lifestyle modifications: avoid eating 3 hours before bed, elevate head of bed, avoid triggers
• Response may take 2-3 months

Persistent hoarseness (>3 weeks):

• ENT referral for laryngoscopy—do not delay
• Do not assume benign cause without visualization

Management by diagnosis#

Acute laryngitis#

Education:

• Viral infection of the voice box; usually follows a cold
• Voice will return to normal in 1-2 weeks
• Complete voice rest is not necessary—just avoid straining
• Whispering is actually harder on your voice than speaking softly

Treatment:

What NOT to do:

• No antibiotics (viral cause)
• No steroids for routine acute laryngitis
• No decongestants (dry out vocal cords)

Exception—professional voice users with urgent need:

• Singer, actor, or speaker with imminent performance may benefit from short-course steroids
• Prednisone 40-60 mg x 1-3 days can reduce vocal cord edema
• Use sparingly; does not treat underlying cause
• Counsel on voice rest after performance
• This is a temporizing measure, not routine treatment

Follow-up: No routine follow-up. Return if not improving after 3 weeks.

Laryngopharyngeal reflux (LPR)#

Education:

• Acid from the stomach can reach the throat and voice box, causing irritation
• Different from typical heartburn—you may not feel burning
• Treatment takes 2-3 months to work; be patient
• Lifestyle changes are as important as medication

Treatment:

Lifestyle modifications:

• No eating 3 hours before bed
• Elevate head of bed 6 inches (blocks under headboard, not just pillows)
• Avoid triggers: caffeine, alcohol, chocolate, fatty foods, acidic foods
• Weight loss if overweight
• Stop smoking

Follow-up: 2-3 months to assess response. If no improvement, ENT referral for laryngoscopy to confirm diagnosis.

Vocal cord nodules/polyps#

Recognition: Voice overuse (teachers, singers, coaches); gradual onset; voice fatigue; breathy or rough voice quality.

PCP role:

• Recognize pattern and refer to ENT
• Laryngoscopy confirms diagnosis
• Voice therapy is first-line treatment

Treatment (ENT/speech pathology):

• Voice therapy with speech-language pathologist (first-line)
• Vocal hygiene education
• Surgery for lesions not responding to therapy

Follow-up: ENT manages; PCP supports vocal hygiene and addresses contributing factors (reflux, allergies).

Vocal cord paralysis#

Recognition: Breathy, weak voice; aspiration (choking on liquids); may follow thyroid/chest surgery or have no clear cause.

PCP role:

• Recognize and refer to ENT urgently
• If no surgical history, order CT chest (lung apex mass can compress recurrent laryngeal nerve)
• Evaluate for aspiration risk

Causes to consider:

• Iatrogenic: thyroid surgery, carotid endarterectomy, anterior cervical spine surgery, chest surgery
• Malignancy: lung cancer (especially left-sided), thyroid cancer, esophageal cancer
• Neurologic: stroke, Parkinson’s, ALS, skull base lesion
• Idiopathic (viral): often recovers spontaneously over months

Treatment (ENT):

• Voice therapy
• Injection medialization (temporary or permanent)
• Surgical medialization (thyroplasty) for permanent paralysis

Laryngeal cancer#

Recognition: Persistent hoarseness >3 weeks in smoker/drinker; age >50; dysphagia; hemoptysis; weight loss; neck mass.

PCP role:

• Recognize red flags and refer URGENTLY to ENT
• Do not delay for imaging—ENT will scope and order appropriate workup
• Smoking cessation counseling

Referral: URGENT ENT (within 2 weeks). Laryngoscopy with biopsy; CT neck with contrast; staging workup.

Muscle tension dysphonia#

Recognition: Strained, effortful voice; often stress-related; no organic lesion on laryngoscopy; neck muscle tension.

Key distinction from organic causes:

• Laryngoscopy shows normal vocal cord structure and movement
• Voice may be normal with certain tasks (laughing, coughing) but abnormal with speech
• Often associated with stress, anxiety, or voice overuse
• Responds to voice therapy, not surgery

PCP role:

• Recognize pattern and refer to ENT for laryngoscopy (to rule out organic cause)
• Address contributing factors: stress, anxiety, voice overuse
• Support voice therapy recommendations

Treatment (speech-language pathologist):

• Voice therapy is primary treatment
• Relaxation techniques
• Laryngeal massage
• Addressing underlying stress/anxiety

Inhaled corticosteroid dysphonia#

Education:

• Inhaled steroids can irritate the voice box and cause hoarseness
• Proper technique reduces this side effect
• Rinsing your mouth after using the inhaler helps

Management:

• Rinse mouth and gargle after each ICS use
• Use spacer device with MDI
• Consider switching to different ICS formulation
• Consider dose reduction if asthma/COPD well-controlled
• If thrush present: treat with nystatin or fluconazole

Follow-up: 2-4 weeks after intervention. If persistent, ENT referral to rule out other causes.

Follow-up#

• Acute laryngitis: No routine follow-up; return if >3 weeks
• LPR: 2-3 months on PPI therapy; ENT if no improvement
• Persistent hoarseness (>3 weeks): ENT referral—do not manage without laryngoscopy
• Post-ENT evaluation: Per ENT recommendations

Return precautions (all patients):

• Hoarseness lasting more than 3 weeks
• Difficulty breathing or noisy breathing
• Difficulty swallowing or choking on food/liquids
• Coughing up blood
• Neck lump or swelling
• Unintentional weight loss

Patient instructions#

• Most hoarseness is caused by a viral infection and gets better in 1-2 weeks.
• Rest your voice: speak softly, avoid yelling, and limit talking when possible. Whispering is actually harder on your voice than speaking softly.
• Drink plenty of water (8+ glasses a day) to keep your vocal cords lubricated.
• Use a humidifier, especially at night.
• Avoid smoking, alcohol, and caffeine—these irritate your voice box.
• If you use an inhaler, rinse your mouth and gargle after each use.
• If your hoarseness lasts more than 3 weeks, you need to see a specialist to look at your vocal cords—don’t ignore it.
• Call or return immediately if you have trouble breathing, difficulty swallowing, cough up blood, or notice a lump in your neck.

Smartphrase snippets#

Acute laryngitis: Hoarseness x [X] days following URI symptoms. No red flags (no dysphagia, no hemoptysis, no weight loss, no neck mass). Consistent with acute viral laryngitis. Discussed voice rest, hydration, and humidification. No antibiotics indicated. Return if not resolved in 3 weeks for ENT referral.

Persistent hoarseness, ENT referral: Hoarseness x [X] weeks (>3 weeks). Given duration, referred to ENT for laryngoscopy to evaluate vocal cords and rule out malignancy. [Risk factors: smoking, alcohol, age]. Patient counseled on importance of evaluation.

Suspected LPR: Chronic hoarseness with throat clearing and globus sensation. No classic heartburn. Suspect laryngopharyngeal reflux. Started omeprazole 20 mg BID x 2-3 months. Discussed lifestyle modifications (no eating before bed, elevate HOB, avoid triggers). Follow-up in 2-3 months; ENT referral if no improvement.

ICS-related dysphonia: Hoarseness since starting [ICS name]. Exam shows [oral thrush / no thrush]. Counseled on proper technique: use spacer, rinse mouth after use. [Treating thrush with nystatin]. Will reassess in 2-4 weeks; ENT referral if persistent.

Coding/billing notes#

• Document duration of hoarseness (critical for determining need for laryngoscopy)
• Document risk factors for malignancy (smoking, alcohol, age)
• Document red flag assessment (no dysphagia, no hemoptysis, no weight loss, no neck mass)
• If referring to ENT, document indication (>3 weeks duration, concern for malignancy, etc.)
• For LPR, document symptoms and PPI trial plan