Voice impairment affects one third of the U.S. population. It is most common in teachers and older adults, although it can affect anyone. Hoarseness (dysphonia) is often caused by a benign condition; however, prompt evaluation is needed to detect a more serious etiology.

The American Academy of Otolaryngology–Head and Neck Surgery Foundation has released evidence-based guidelines for the evaluation and management of hoarseness. The goals of the guidelines are to improve diagnostic accuracy; reduce inappropriate medication and imaging use; and promote appropriate use of laryngoscopy, voice therapy, and surgery.

Each recommendation is assigned a grade based on quality of evidence: A = well-designed, randomized controlled trials (RCTs) or diagnostic studies performed in a population similar to the guidelines' target population; B = RCTs or diagnostic studies with minor limitations, or overwhelming consistent evidence from observational studies; C = observational case-control or cohort studies; D = expert opinion, case reports, reasoning from first principles (branch research or animal studies); X = exceptional situations where validating studies cannot be performed, and there is clear preponderance of benefit over harm.

Evaluation

DIAGNOSIS

Hoarseness should be diagnosed in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (grade C recommendation).

The diagnosis of hoarseness is based on clinical criteria that may be reported by the patient or proxy, identified by the physician, or both. No testing or additional evaluation is required. Hoarseness may be accompanied by discomfort with speaking, increased phonatory effort, weak voice, and altered voice quality (e.g., shakiness, breathiness, raspiness). Evaluation is needed in patients with significant voice change, or limited voice change but significant other symptoms.

The evaluation should include critically and objectively listening to the patient's voice; characterizing the severity of voice change and other symptoms; and obtaining a medical history, including medication use (Table 1). Quality of life may be affected because of communication problems (e.g., difficulty being heard) or decrements in physical, social, and emotional aspects of life. The input of the patient's proxies is important, especially for children and patients with cognitive impairment, because they may not recognize symptoms themselves.

MODIFYING FACTORS

Patients with hoarseness should be assessed using history and/or physical examination for factors that modify management (grade C recommendation).

Modifying factors are clues to the presence of underlying conditions that may alter the management course. These factors include recent surgery involving the neck or affecting the recurrent laryngeal nerve; recent endotracheal intubation; radiation therapy to the neck; history of tobacco use; and an occupation that requires vocal performance, such as singing. It is beneficial to identify factors early that could influence timing of diagnostic procedures, choice of interventions, or follow-up care.

LARYNGOSCOPY

Laryngoscopy may be performed at any time, although it is recommended when hoarseness does not resolve within three months of onset or if a serious underlying cause is suspected (grade C recommendation).

Visualizing the larynx and vocal folds is important in a patient presenting with hoarseness, especially if symptoms persist. Earlier evaluation may be performed if deemed appropriate and may facilitate management. Laryngoscopy may be used initially in a patient with hoarseness to identify complications after surgery or intubation, or to assess the larynx after trauma. Conditions that can be diagnosed with laryngoscopy include unilateral vocal fold paralysis, benign vocal fold lesions, laryngeal cancer, and laryngopharyngeal reflux.

Laryngoscopy should be performed in neonates with hoarseness (based on the sound of crying) to identify congenital anomalies that could affect breathing or swallowing. The procedure is indicated in all patients when symptoms do not improve after three months or if an etiology is suspected that may cause serious harm (e.g., shortening the patient's life, reducing professional viability or voice-related quality of life). Table 2 lists clues that may suggest a serious underlying condition.

IMAGING

Computed tomography or magnetic resonance imaging should not be performed in patients with primary hoarseness before visualizing the larynx (grade C recommendation).

Because hoarseness is often self-limited and has an etiology that can be detected with laryngoscopy, imaging should be reserved for the assessment of specific pathology after the larynx has been visualized.

Evidence supports the use of imaging studies after laryngoscopy to further evaluate vocal fold paralysis, or vocal fold or larynx lesions that may be malignant or obstruct the airway.

Medical Therapy

ANTIREFLUX THERAPY

Antireflux medications should not be prescribed for patients with hoarseness without gastroesophageal reflux disease (GERD) signs or symptoms (grade B recommendation). Antireflux medications may be used if there are signs or symptoms of chronic laryngitis (grade C recommendation).

Because of the known adverse effects and limited evidence of benefit, widespread empiric use of antireflux medications for hoarseness is discouraged in the absence of symptoms of GERD or laryngeal findings consistent with laryngitis. However, the use of these medications should not be limited in the management of properly diagnosed laryngitis.

The benefit of antireflux medications in persons with hoarseness but no symptoms of esophageal reflux or esophagitis is unclear. However, the therapy is effective in controlling GERD symptoms. Although short-term therapy is generally safe, prolonged (greater than three months) therapy with proton pump inhibitors or histamine H₂ antagonists is associated with significant risks. In patients with hoarseness and GERD, a trial of anti-reflux therapy may be initiated. However, if symptoms continue or worsen, therapy should be discontinued and laryngoscopy should be performed to assess for an alternative cause of hoarseness.

Laryngoscopy can help determine whether antireflux medications should be considered in patients with hoarseness. The therapy is an option for laryngeal inflammation that is detected on laryngoscopy (e.g., laryngitis identified with erythema, edema, redundant tissue, or surface irregularities). Further research is needed to explore which signs are most associated with treatment response and to determine the optimal examination techniques to detect these signs.

CORTICOSTEROIDS

Oral corticosteroids should not be routinely prescribed to treat hoarseness (grade B recommendation).

Although corticosteroids are commonly prescribed for hoarseness and acute laryngitis, routine use should be avoided because of the risk of serious adverse effects and lack of support for their effectiveness.

Oral corticosteroid therapy may be used for some indications after a specific and accurate diagnosis is achieved. Appropriate indications include recurrent croup with associated laryngitis in children and allergic laryngitis. The benefits of the therapy may also outweigh the risks in some patients who are dependent on their voice, such as singers and other performers.

ANTIMICROBIALS

Antibiotics should not be routinely prescribed to treat hoarseness (grade A recommendation).

The routine use of antimicrobials is unwarranted for hoarseness, because the condition is usually caused by acute laryngitis or upper respiratory tract infection, not a bacterial infection. Antibiotic use is also associated with adverse effects and societal implications such as bacterial resistance. Rarely, antibiotics are needed for laryngitis secondary to bacterial infection.

Voice Therapy

Laryngoscopy should be performed before initiating voice therapy, and results should be documented and communicated to the speech-language pathologist (grade C recommendation). Voice therapy should be advocated for patients with diagnosed hoarseness that reduces voice-related quality of life (grade A recommendation).

Although voice therapy is a well-established treatment for some voice disorders, therapy should be initiated only after a diagnosis is established to avoid possible delay in appropriate diagnosis and therapy. Significant evidence supports the benefits of laryngoscopy, specifically videostroboscopy, in planning voice therapy. Documentation of laryngoscopy results should include a detailed description of diagnosis and laryngeal pathology, a brief history of the problem, and possibly visual images.

Voice therapy focuses on the behavioral factors associated with hoarseness, and is effective for children older than two years and adults. Family education may also be helpful. Physicians should actively advocate for voice therapy when appropriate, including offering patient resources (e.g., brochures) and family education.

Invasive Therapy

SURGERY

Surgery should be advocated in patients with hoarseness and suspected laryngeal malignancy, benign laryngeal soft tissue lesions, or glottic insufficiency (grade B recommendation).

Surgery is not the primary treatment for most causes of hoarseness, although it may be indicated. Hoarseness may be the presenting sign of upper aerodigestive tract malignancy. Prompt biopsy is needed for suspicious lesions with increased vasculature, ulceration, or exophytic growth. Conservative therapy may be attempted before biopsy for some superficial white lesions.

Benign soft tissue lesions may affect voice-related quality of life. Surgery is an option if satisfactory results are not achieved with conservative measures and the voice may be improved with surgery. Surgery is also needed for recurrent respiratory papilloma.

Glottic insufficiency caused by weakness or soft tissue defects of the vocal folds can lead to weak, breathy hoarseness. Surgical management of the condition is primarily through static medialization of the vocal fold.

BOTULINUM TOXIN

Botulinum toxin injections should be prescribed for the treatment of hoarseness caused by spasmodic dysphonia (grade B recommendation).

Although botulinum toxin is not approved by the U.S. Food and Drug Administration for patients with adductor spasmodic dysphonia, multiple double-blind RCTs have shown the therapy to improve voice in these patients. The treatment has also been shown to improve dysphonia, mental health, and social functioning. Adverse effects are possible with botulinum toxin injections; however, the therapy has a good safety record.

PREVENTION

Patient with hoarseness may be educated about preventive measures (grade C recommendation).

Preventive measures may lower the risk of hoarseness, but studies are limited. Measures that may be beneficial include hydration, avoidance of irritants (e.g., smoke, chemicals), voice training, and amplification. Benefits of these measures should be weighed against the risk of hoarseness or voice problems in asymptomatic patients.