Voice problems / hoarseness

Definition/Description

Dysphonia - an abnormal voice.

Hoarseness - change in quality of voice and difficulty in projecting the voice (with or without the need to clear the voice or throat regularly).

Features of a normal voice include: clarity, consistency, audibility, stamina, flexibility of pitch and is comfortable. A patient may complain of problems with any of these features.

Red Flag Symptoms

Persistent hoarse voice for more than six weeks with no history of URTI is a 2WW referral (exclude lung cancer)

Continuous hoarse voice rather than an intermittent hoarse voice.
Any signs of airway obstruction (such as stridor)
Dysphagia (difficulties swallowing) or odynophagia (painful swallowing)
Frequent associated cough with or without sickness / bringing up food boli
Haemoptysis
Consider the possible significance of risk factors, including:
- age – over 50 years
- smoking
- excess alcohol intake.

The recurrent laryngeal nerve extends deep into the chest, therefore a CXR would be indicated for probably most patients (certainly smokers; others if middle aged) before a referral to ensure no pathology there.

Guidelines on Management

Explore possible strain and overuse (public speaking, teaching, singing etc.).
Does resting the voice help?
Could this be laryngitis after an URTI (can last for 2-3 weeks)
Could this be dyspepsia or silent reflux (voice problems often worse in the morning, better during the day)
Particularly in asthmatic patients on steroid inhalers: think possible fungal infection in the upper airway
For localized or mild oral candidal infection, prescribe topical treatment for 7 days (and advise the person to continue treatment for 2 days after symptoms resolve).
- Offer miconazole oral gel first-line.
- Offer nystatin suspension if miconazole is unsuitable.
- For extensive or severe candidiasis, prescribe oral fluconazole 50 mg a day for 7 days.
Advise on prevention – brush teeth/ rinse mouth after inhaler use.

Less common other causes for voice changes or hoarseness: nerve palsy, hypothyroidism, Parkinsonism or medication side effects (e.g. antihypertensives – particularly ACEi, antihistamines, antidepressants, contraceptives etc) and others.

Good advice to give patients includes:

rest the voice as much as possible
avoid whispering (this actually strains the voice box more than normal use)
reduce or stop negative impacts on the voice box (smoking, alcohol, caffeine, dryness, spicy food etc.)
ensure sufficient regular voice lubrication (e.g. sips of clear fluid, sugar-free lozenges, simple steam inhalations)

Consider a trial of Peptac® +/- a PPI for one month in suspected possible (silent) reflux.

Referral Criteria/Information

Emergency or 2WR:

Acute stridor – refer immediately.
Continuous hoarse voice for more than two or three weeks, particularly if there are individual risk factors (age, smoking, alcohol excess etc.), as mentioned above.

Routine:

If conservative measures are ineffective and there is a possible need for a laryngoscopy and/or speech therapy.
If it is a low-risk but possibly anxious patient, the ENT primary care clinic (which is bookable via the on-call SHO) could provide a nasal endoscopy facility for quick reassurance.