Viral URTI: acute laryngitis
Non-specific irritative laryngitis (Reinke oedema)
Vocal abuse (shouting, screaming, etc.)
Nodules and polyps of cords
Presbyphonia in elderly: ‘tired’ voice
Serious disorders not to be missed
larynx, lung, including recurrent laryngeal nerve palsy, oesophagus, thyroid
Imminent airway obstruction (e.g. acute epiglottis, croup)
Rare other severe infections (e.g. TB, diphtheria)
Benign tumours of vocal cords (e.g. polyps, ‘singer’s nodules’, papillomas)
Gastro-oesophageal reflux → pharyngolaryngitis
Physical trauma (e.g. post-intubation), haematoma
Fungal infections (e.g. Candida with steroid inhalation, immunocompromised)
Allergy (e.g. angioedema)
Systemic autoimmune disorders (e.g. SLE, Wegener granulomatosis)
drugs: antipsychotics, anabolic steroids
smoking → non-specific laryngitis
Is the patient trying to tell me something?
Note the nature and duration of the voice change. Enquire about corticosteroid inhalations, excessive or unaccustomed voice straining, especially singing, recent surgery, possible reflux, smoking or exposure to environmental pollutants. Elicit associated respiratory or general symptoms such as cough and weight loss.
Palpate the neck for enlargement of the thyroid gland or cervical nodes
Perform a simple oropharyngeal examination except if epiglottitis is suspected
Check for signs of hypothyroidism, such as coarse dry hair and skin, slow pulse and mental slowing
Perform indirect laryngoscopy if skilled in the procedure
thyroid function tests
chest X-ray if it is possibly due to lung carcinoma with recurrent laryngeal nerve palsy
indirect laryngoscopy (the gag reflex may preclude this)
a special CT scan to detect suspected neoplasia or laryngeal trauma.
Acute hoarseness rarely causes any diagnostic problem or concern but the chronic cases are often cause for concern.
Remember that intubation causes transient hoarseness.
Consider gastro-oesophageal reflux disease in the elderly.