Hoarseness in Adults

 

Am Fam Physician. 2017 Dec 1;96(11):720-728.

Author disclosure: No relevant financial affiliations.

Hoarseness is a common presentation in primary care practices. Combined with other voice-related changes, it falls under the umbrella diagnosis of dysphonia. Hoarseness has a number of causes, ranging from simple inflammatory processes to less common psychiatric disorders to more serious systemic, neurologic, or cancerous conditions. Medication-induced hoarseness is common and should be considered. The initial evaluation begins with a targeted history and physical examination, while also looking for signs of potential systemic etiologies. Treatment should begin with voice rest, especially avoidance of whispering, and conservative management directed toward a presumptive cause. For example, proton pump inhibitors are appropriate for hoarseness due to reflux, and proper vocal hygiene is recommended for vocal abuse–related indications. In the absence of a clear indication, antibiotics, oral corticosteroids, and proton pump inhibitors should not be used for the empiric treatment of hoarseness. Direct visualization of the larynx and vocal folds, commonly mislabeled as vocal cords, should be performed within three months if an etiology has not been determined or if conservative management has been ineffective. Patients who experience symptoms lasting longer than two weeks and who have risk factors for dysplasia (e.g., tobacco use, heavy alcohol use, hemoptysis) may require earlier laryngoscopic evaluation. Voice therapy is effective for improving voice quality in patients with dysphonia if conservative measures are unsuccessful, and it can also be helpful for prophylaxis in high-risk individuals (e.g., vocalists, public speakers). Surgical management is indicated for laryngeal or vocal fold dysplasia or malignancy, airway obstruction, or benign pathology resistant to conservative treatment.

Hoarseness is a common symptom in adults, with a lifetime prevalence of 30% and a point prevalence of 7% for adults 65 years and younger. Most never seek treatment, with only 6% of patients presenting to a health care professional.1 However, hoarseness still constitutes a common out-patient concern and can significantly impact patients' voice-related quality of life and limit their productivity.2

 Enlarge     Print

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Examination of the larynx by direct or indirect laryngoscopy should be performed on patients with hoarseness lasting longer than two weeks without an apparent benign etiology.

C

3

In the absence of signs and symptoms suggestive of an underlying cause, antibiotics, oral corticosteroids, and proton pump inhibitors should not be used for the empiric treatment of laryngitis/hoarseness.

C

3

If laryngopharyngeal or gastroesophageal reflux is suspected, consider a trial of a high-dose proton pump inhibitor for three to four months.

C

26

Voice therapy is effective for improving voice quality and vocal performance in patients with nonorganic dysphonia.

A

20

Voice therapy is effective for treating benign vocal fold nodules, polyps, cysts, and granulomas.

B

2931

Vocal hygiene education is effective for treating patients with hoarseness.

B

29, 32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Examination of the larynx by direct or indirect laryngoscopy should be performed on patients with hoarseness lasting longer than two weeks without an apparent benign etiology.

C

3

In the absence of signs and symptoms suggestive of an underlying cause, antibiotics, oral corticosteroids, and proton pump inhibitors should not be used for the empiric treatment of laryngitis/hoarseness.

C

3

If laryngopharyngeal or gastroesophageal reflux is suspected, consider a trial of a high-dose proton pump inhibitor for three to four months.

C

26

Voice therapy is effective for improving voice quality and vocal performance in patients with nonorganic dysphonia.

A

20

Voice therapy is effective for treating benign vocal fold nodules, polyps, cysts, and granulomas.

B

2931

Vocal hygiene education is effective for treating patients with hoarseness.

B

29, 32


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

 Enlarge     Print

BEST PRACTICES IN OTOLARYNGOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not perform

The Authors

show all author info

STEVEN A. HOUSE, MD, FAAFP, is a professor in the Department of Family and Geriatric Medicine at the University of Louisville (Ky.) School of Medicine, and director of the University of Louisville/Glasgow (Ky.) Family Medicine Residency Program....

ERIC L. FISHER, MD, is an assistant professor in the Department of Family and Geriatric Medicine at the University of Louisville School of Medicine, and assistant medical director at the University of Louisville/Glasgow Family Medicine Residency Program.

Address correspondence to Steven A. House, MD, University of Louisville/Glasgow Family Medicine Residency Program, 1325 North Race St., Glasgow, KY 42141 (e-mail: shouse@tjsamson.org). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Roy N, et al. Voice disorders in the general population: prevalence, risk factors, and occupational impact. Laryngoscope. 2005;115(11):1988–1995....

2. Ramig LO, Verdolini K. Treatment efficacy: voice disorders. J Speech Lang Hear Res. 1998;41(1):S101–S116.

3. Schwartz SR, Cohen SM, Dailey SH, et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009;141(3 suppl 2):S1–S31.

4. Feierabend RH, Malik SN. Hoarseness in adults. Am Fam Physician. 2009;80(4):363–370.

5. Dworkin JP. Laryngitis: types, causes, and treatments. Otolaryngol Clin North Am. 2008;41(2):419–436, ix.

6. Adams NP, et al. Fluticasone versus placebo for chronic asthma in adults and children. Cochrane Database Syst Rev. 2008;(4):CD003135.

7. Bhutta MF, Rance M, Gillett D, Weighill JS. Alendronate-induced chemical laryngitis. J Laryngol Otol. 2005;119(1):46–47.

8. Dicpinigaitis PV. Angiotensin-converting enzyme inhibitor-induced cough: ACCP evidence-based clinical practice guidelines. Chest. 2006;129(1 suppl):169S–173S.

9. Galván CA, Guarderas JC. Practical considerations for dysphonia caused by inhaled corticosteroids. Mayo Clin Proc. 2012;87(9):901–904.

10. Zhukhovitskaya A, et al. Gender and age in benign vocal fold lesions. Laryngoscope. 2015;125(1):191–196.

11. Andrus JG, Shapshay SM. Contemporary management of laryngeal papilloma in adults and children. Otolaryngol Clin North Am. 2006;39(1):135–158.

12. Havas T, Lowinger D, Priestley J. Unilateral vocal fold paralysis: causes, options and outcomes. Aust N Z J Surg. 1999;69(7):509–513.

13. Rosenthal LH, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope. 2007;117(10):1864–1870.

14. Altieri A, et al. Alcohol consumption and risk of laryngeal cancer. Oral Oncol. 2005;41(10):956–965.

15. Qadeer MA, et al. Gastroesophageal reflux and laryngeal cancer: causation or association? A critical review. Am J Otolaryngol. 2006;27(2):119–128.

16. Sulica L. The natural history of idiopathic unilateral vocal fold paralysis: evidence and problems. Laryngoscope. 2008;118(7):1303–1307.

17. Davids T, Klein AM, Johns MM III. Current dysphonia trends in patients over the age of 65: is vocal atrophy becoming more prevalent? Laryngoscope. 2012;122(2):332–335.

18. Persaud R, et al. An evidence-based review of botulinum toxin (Botox) applications in non-cosmetic head and neck conditions. JRSM Short Rep. 2013;4(2):10.

19. Altman KW, Atkinson C, Lazarus C. Current and emerging concepts in muscle tension dysphonia: a 30-month review. J Voice. 2005;19(2):261–267.

20. Ruotsalainen J, Sellman J, Lehto L, Verbeek J. Systematic review of the treatment of functional dysphonia and prevention of voice disorders. Otolaryngol Head Neck Surg. 2008;138(5):557–565.

21. Bartels H, et al. Laryngeal amyloidosis: localized versus systemic disease and update on diagnosis and therapy. Ann Otol Rhinol Laryngol. 2004;113(9):741–748.

22. Chang JI, Bevans SE, Schwartz SR. Otolaryngology clinic of North America: evidence-based practice: management of hoarseness/dysphonia. Otolaryngol Clin North Am. 2012;45(5):1109–1126.

23. Sulica L. Laryngoscopy, stroboscopy and other tools for the evaluation of voice disorders. Otolaryngol Clin North Am. 2013;46(1):21–30.

24. Cohen SM, Dinan MA, Kim J, Roy N. Otolaryngology utilization of speech-language pathology services for voice disorders. Laryngoscope. 2016;126(4):906–912.

25. Ansaranta M. Hoarseness and dysphonia. Essential Evidence Plus. Updated August 15, 2014. https://www.essentialevidenceplus.com/content/ebmg_ebm/876 [login required]. Accessed March 25, 2016.

26. Campagnolo AM, Priston J, Thoen RH, Medeiros T, Assunção AR. Laryngopharyngeal reflux: diagnosis, treatment, and latest research. Int Arch Otorhinolaryngol. 2014;18(2):184–191.

27. King JM. Hoarseness. Essential Evidence Plus. Updated November 15, 2016. https://www.essentialevidenceplus.com/content/eee/101 [login required]. Accessed May 9, 2017.

28. Ishizuka T, Hisada T, Aoki H, et al. Gender and age risks for hoarseness and dysphonia with use of a dry powder fluticasone propionate inhaler in asthma. Allergy Asthma Proc. 2007;28(5):550–556.

29. Yun YS, Kim MB, Son YI. The effect of vocal hygiene education for patients with vocal polyp. Otolaryngol Head Neck Surg. 2007;137(4):569–575.

30. Cohen SM, Garrett CG. Utility of voice therapy in the management of vocal fold polyps and cysts. Otolaryngol Head Neck Surg. 2007;136(5):742–746.

31. Leonard R, Kendall K. Effects of voice therapy on vocal process granuloma: a phonoscopic approach. Am J Otolaryngol. 2005;26(2):101–107.

32. Chan RW. Does the voice improve with vocal hygiene education? A study of some instrumental voice measures in a group of kindergarten teachers. J Voice. 1994;8(3):279–291.

33. Truong DD, Bhidayasiri R. Botulinum toxin therapy of laryngeal muscle hyperactivity syndromes: comparing different botulinum toxin preparations. Eur J Neurol. 2006;13(suppl 1):36–41.

34. Siu J, Tam S, Fung K. A comparison of outcomes in interventions for unilateral vocal fold paralysis: a systematic review. Laryngoscope. 2016;126(7):1616–1624.

35. Rosen CA, Anderson D, Murry T. Evaluating hoarseness: keeping your patient's voice healthy. Am Fam Physician. 1998;57(11):2775–2782.

 

 

Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Related Content


MOST RECENT ISSUE


Dec 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article