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Hoarseness is the term often used by patients to report a change in their voice quality. Dysphonia altered vocal quality, pitch , loudness or vocal effort that impairs communication as assessed by a clinician and /or affects the quality of life
Seen frequently in primary care Lifetime prevalence of 30 % Rates higher among females and among those > 70 yrs Significant treatment costs- can be comparable to those spent on treating chronic conditions as COPD , asthma, diabetes and allergic rhinitis Can have considerable impact for those affected ○ social isolation ○ depression and anxiety ○ missed work – lost wages ○ lifestyle changes People in vocations with high vocal demand -↑↑ed risk eg ○ singers and entertainers ○ legal professionals ○ teachers ○ call center workers ○ aerobic instructors ○ clergy ○ coaches
H/o URTI Chest infections Reflux Occupation Steroid inhaler use and all medications list Recent surgery ( head and neck ) intubation Recent excessive voice use ( eg screaming during a match ) Smoking and alcohol Is it constant or there are periods of normal voice Dysphonia due to mass lesions will be constant and unremitting Check about other head and neck complains as dyspnoea , stridor , dysphagia , odynophagia , otalgia , sore throat and pain when speaking -Odynophonia Check for neurological conditions as Parkinsons disease , essential tremor , brainstem lesions and stroke
Larynx cannot be visualized – needs specialized set up to allow for Mirror examination , flexible fibreoptic laryngoscopy to videostrobolaryngoscopy
Full head and neck examination Laryngeal function- Voice study eg quality , vocal effort strain , vocal fatigue Cough , swallowing Neurological examination Respiratory examination
CXR- to exclude lung cancer / metastases Bloods if systemic cause suspected Laryngoscopy ○ Fibreoptic laryngoscopy can be done without GA ie larynx can be examined while using the voice Videostroboscopy – allows evaluation of laryngeal structure and function , anatomy and voice physiology CT , MRI if vocal cord cancer suspected or neurological impairment
Smoking is the single largest risk factor for laryngeal cancer
ENT UK pathway-hoarse voice GP referral pathway
Often follows viral URTIs Intermittent symptoms are less worrying than progressive hoarseness When associated with cancer the dysphonia is constant , progressive and unremitting Presence of associated features as dysphagia , odynophagia , otalgia ( with normal ears ) , haemoptysis , weight loss -should alert the clinician to look for a suspected cancer Consider reflux – treat if other causes ruled out Evaluation can be challenging as extra-laryngeal conditions can also be responsible ○ consider lung or cardiac pathology Advice about importance of stopping smoking and alcohol Antibiotics have no role for hoarseness following URTIs
LINKS AND RESOURCES
PATIENT INFORMATION
A treasure of useful leaflets from The British Voice Association https://www.britishvoiceassociation.org.uk/free.htm
Useful information from The Voice Foundation https://voicefoundation.org/health-science/voice-disorders/voice-disorders/
Information on hoarse voice from British Laryngological Association http://www.britishlaryngological.org/patient-information/hoarse-voice
ENT UK– printable information about hoarse voice https://www.entuk.org/sites/default/files/files/ENT/About%20Hoarseness%206pp%20DL%20(09024)_7_16.pdf
A range of PILs from ENT UK including above can be found with this link https://www.entuk.org/patient-information-leaflets
RESOURCES FOR HEALTHCARE PROFESSIONALS
Hoarseness: An approach for the general practitioner by Lauren Cooper and Rachele A Quested from RACGP https://www.racgp.org.au/afp/2016/june/hoarseness-an-approach-for-the-general-practitioner/
Clinical Practice Guideline Hoarseness ( Dysphonia ) from American Academy of Otolaryngology- Head and Neck Surgery – a very useful link which has information for patients and physicians. Please also look at choosing wisely by opening the patient link https://www.entnet.org/content/clinical-practice-guideline-hoarseness-dysphonia
Another link of choosing wisely http://www.choosingwisely.org/societies/american-academy-of-otolaryngology-head-neck-surgery-foundation/
References
- Stachler, R. J., Francis, D. O., Schwartz, S. R., Damask, C. C., Digoy, G. P., Krouse, H. J., … Nnacheta, L. C. (2018). Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngology–Head and Neck Surgery, 158(1_suppl), S1–S42. https://doi.org/10.1177/0194599817751030
- Hoarseness in Adults Am Fam Physician . 2009 Aug 15 ;80 (4) : 363-370
- Hoarseness : An approach for the general practitioner RACGP Volume 45 No.6.June 2016 Pages 378-381
- Evaluation of hoarseness and dysphonia- epocrates accessed via https://online.epocrates.com/diseases/84512/Evaluation-of- hoarseness-and-dysphonia/Potential-Etiologies
- Ten Tips on managing hoarseness Pulse accessed via http://www.pulsetoday.co.uk/ten-tips-on-managing- hoarseness/11033307.article
- Diagnostic Evaluation and Management of Hoarseness Ted Mau Phd Head and Neck Surgery September 2010 Volume 94 , Issue 5 , Pages 945-960 https://www.ncbi.nlm.nih.gov/pubmed/20736105
- ENT GP referral guideline http://www.enherts-tr.nhs.uk/files/2012/12/ent-GP- Referral-guidelines.pdf
- Evaluation of Dysphonia Conns Current Therapy 2018
- Hoarse voice BMJ O Judd, specialist registrar in ENT1, I B Colvin, general practitioner 2 2010 ;340;c522 doi: https://doi.org/10.1136/bmj.c522
- Hoarseness Patient UK Reviewed by Dr Helen Huins | Last edited | https://patient.info/doctor/hoarseness-pro
- Assessment of hoarseness and dysphonia BMJ Best Practice https://bestpractice.bmj.com/topics/en-gb/845