Hoarseness in Adults

Steven A. House; Eric L. Fisher

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Dec 1, 2017 Issue

Hoarseness in Adults

STEVEN A. HOUSE, MD, and ERIC L. FISHER, MD, University of Louisville School of Medicine, Louisville, Kentucky

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

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
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	29–31
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 recommendation	Evidence rating	References
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	29–31
Vocal hygiene education is effective for treating patients with hoarseness.	B	29, 32

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BEST PRACTICES IN OTOLARYNGOLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

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Do not perform

The Authors

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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.

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