🩺 Hoarseness

Hoarseness, or dysphonia, refers to an abnormal change in voice quality, often described as breathy, strained, or raspy. It is a common symptom resulting from any condition that interferes with vocal cord vibration or apposition. While most cases are benign and self-limiting (such as viral laryngitis), persistent hoarseness is a primary indicator of laryngeal malignancy or underlying systemic disease. Management in the UK is heavily dictated by NICE suspected cancer guidelines (NG12).

Inquire about the duration (crucial for 2-week wait criteria), onset, and whether the hoarseness is constant or intermittent. Ask about associated 'red flag' symptoms like dysphagia, odynophagia, weight loss, or an unexplained neck lump. Explore irritants such as tobacco use, alcohol intake, and occupational voice strain (e.g., teachers or singers). Clarify symptoms of laryngopharyngeal reflux (heartburn, water brash) or recent viral upper respiratory tract infections. A history of previous neck surgery (thyroid/carotid) or intubation is clinically significant.

Perform a thorough neck examination to palpate for lymphadenopathy or thyroid masses. A bedside oropharyngeal exam is often unremarkable but look for signs of oral candidiasis or reflux-related pharyngeal erythema. Definitive diagnosis requires flexible nasal endoscopy (FNE) to directly visualise the vocal cords for nodules, polyps, cysts, or suspicious lesions. Assess cord mobility; unilateral immobility indicates recurrent laryngeal nerve pathology. Check for stigmata of systemic disease, such as a goitre or signs of acromegaly.

Common causes include viral laryngitis, voice misuse (leading to vocal nodules), and laryngopharyngeal reflux (LPR). Benign growths like vocal cord polyps or Reinke's oedema are frequent in smokers. Serious differentials include squamous cell carcinoma of the larynx and recurrent laryngeal nerve palsy (secondary to lung cancer or thyroid surgery). Less common causes include systemic diseases like hypothyroidism (myxoedema of the cords), sarcoidosis, or rheumatoid arthritis affecting the cricoarytenoid joints.

Persistent hoarseness for >3 weeks in patients >45 years; unexplained neck lump; dysphagia or odynophagia; persistent unilateral earache (referred pain); unexplained weight loss; haemoptysis or stridor (the latter being a medical emergency).

The primary investigation is flexible nasal endoscopy (FNE) performed in an ENT clinic to visualize the larynx. If a suspicious mass or cord palsy is identified, CT imaging from the skull base to the diaphragm (CT neck/chest) is indicated to trace the course of the recurrent laryngeal nerve. Reflux may be investigated via a trial of proton pump inhibitors or 24-hour pH monitoring. If an autoimmune cause is suspected, screen with inflammatory markers, though this is rare. Biopsy under general anaesthesia (microlaryngoscopy) is required if malignancy is suspected.

The '2-week rule' is paramount: any patient aged 45+ with persistent hoarseness (>3 weeks) without an obvious cause requires urgent ENT referral. Chronic laryngitis is most commonly caused by gastro-oesophageal reflux (LPR) or tobacco use. Reinke's oedema is a specific form of chronic cord swelling almost exclusively seen in female smokers. In unilateral vocal cord palsy, always consider a mediastinal or thyroid malignancy involving the recurrent laryngeal nerve (especially the left side due to its longer course around the aortic arch).

Links to the ENT and Oncology sections of the MLA Content Map. Emphasises the importance of the NICE NG12 suspected cancer pathway. Students must distinguish between acute inflammatory conditions and chronic pathologies requiring specialist referral. Understanding the anatomy of the recurrent laryngeal nerve is high-yield for clinical exams and explains why chest pathology can cause voice changes.