Hoarseness of Voice Algorithm

Safety

Red Flags — Laryngeal Cancer & Airway Risk

Done

In patients aged 45 years or over, consider suspected cancer pathway referral for persistent, unexplained hoarseness (NICE NG12, updated April 2026). In practice, hoarseness persisting beyond approximately 3 weeks, or failing to follow the expected recovery pattern after an upper respiratory infection, should prompt reassessment — "persistent" means beyond the period expected for a self-limiting condition (3 weeks is a rule of thumb, not the NICE wording). Do not delay referral by repeated empirical treatment. Younger adults with persistent unexplained dysphonia still need ENT assessment on clinical judgement, particularly with smoking, alcohol excess, progressive symptoms, unilateral otalgia, dysphagia, weight loss, neck mass or abnormal examination.

Persistent hoarseness (in practice >~3 weeks) Aged 45 and over, unexplained → consider suspected cancer pathway referral, head and neck (NICE NG12, updated April 2026). Younger adults with no clear benign cause → urgent ENT laryngoscopy on clinical judgement (not an NG12 criterion). Do not treat empirically and re-review.

Stridor + hoarseness Bilateral vocal cord palsy, large laryngeal tumour, epiglottitis. Stridor, particularly with dyspnoea, increased work of breathing, hypoxia, drooling, tripod positioning, reduced consciousness or sudden inability to phonate = threatened airway: keep the patient upright and calm, avoid throat examination or unnecessary procedures, give oxygen if needed and call 999. Stridor without distress is still an emergency — same-day emergency ENT assessment now via the on-call ENT team, with a very low threshold for 999 transfer.

Hoarseness + dysphagia + weight loss Laryngeal / hypopharyngeal / oesophageal cancer → suspected cancer pathway referral (unexplained dysphagia at any age, NICE NG12); hoarseness with dysphagia, weight loss, odynophagia, persistent unilateral otalgia, haemoptysis, neck mass or aspiration → refer on the pathway matching the dominant clinical syndrome (head and neck or upper GI).

Hoarseness + haemoptysis Laryngeal / lung cancer → haemoptysis at 40 or over meets the NICE lung cancer suspected-cancer criterion on its own (hoarseness not required); head and neck pathway as well if laryngeal features.

Unilateral vocal cord palsy Caused by mediastinal / apical lung tumour compressing recurrent laryngeal nerve (Pancoast) → prompt ENT for laryngeal examination; urgent CXR. An unexplained vocal-fold palsy requires urgent investigation for a lesion along the recurrent laryngeal nerve, including thoracic and thyroid causes (CT arranged by secondary care).

Sudden neurological symptoms or rapidly progressive neck swelling Sudden dysarthria/speech disturbance → 999 (stroke pathway). Rapidly progressive neck swelling, aspiration or severe dysphagia → urgent same-day assessment

Neck mass + hoarseness Cervical lymph node metastasis from laryngeal cancer, thyroid cancer compressing RLN → head and neck suspected cancer pathway referral

Epiglottitis (children/adults) Drooling + stridor + hoarse voice + fever + tripod position → 999. Do NOT examine throat or lie the patient flat (airway collapse risk). Keep calm and upright, O2 if needed, 999.

Hoarseness after thyroid/chest surgery RLN injury — unilateral palsy without airway compromise → prompt ENT referral. Bilateral palsy, stridor, aspiration or significant dysphagia → same-day ENT discussion/urgent assessment; 999 if respiratory compromise

NICE NG12 (updated April 2026): consider a suspected cancer pathway referral for laryngeal cancer in people aged 45 and over with persistent unexplained hoarseness or an unexplained lump in the neck; NICE does not specify a duration — in practice, hoarseness persisting beyond about 3 weeks is treated as persistent. Earlier-stage laryngeal cancer has a better prognosis. Recurrent laryngeal nerve palsy from a mediastinal mass is a critical presentation — a CXR showing an apical lung mass (Pancoast tumour) in a hoarse smoker needs urgent lung cancer pathway referral. Epiglottitis in children (H. influenzae type b — now rare due to Hib vaccine) and adults (Streptococcus, Staph) can progress to complete airway obstruction — do NOT examine the oropharynx or lie the patient flat, keep the patient calm and upright, and call 999.

Diagnose

History — Duration, Quality & Context

Done

Duration

<3 weeks after URTI → likely acute laryngitis (self-limiting). Persistent (in practice ≥~3 weeks) and unexplained → consider suspected cancer pathway if aged 45 and over (NICE NG12); ENT assessment on clinical judgement if younger. Onset sudden or gradual; intermittent or constant. Progressive over weeks–months → malignancy or progressive neurological cause.

Voice quality

Rough/gravelly (laryngitis, vocal cord nodules) vs weak/breathy (vocal cord palsy, paralysis) vs strained/effortful (spasmodic dysphonia, muscle tension dysphonia) vs quiet/monotone (Parkinson's — hypophonia) vs intermittent. Distinguish dysphonia (voice quality) from dysarthria (articulation) and dysphagia (swallowing)

Occupation / voice use

Singers, teachers, call centre workers, clergy — professional voice users at high risk of vocal cord nodules, polyps, contact granuloma. High vocal demand = lower threshold for ENT referral.

Smoking and alcohol

Most important risk factors for laryngeal cancer. Pack-year history (1 pack/day for 1 year = 1 pack-year); ask about vaping. Anyone aged 45 and over with persistent unexplained hoarseness should be considered for the NG12 laryngeal pathway; a younger smoker with persistent hoarseness still needs urgent ENT assessment.

Reflux symptoms

Ask about typical GORD symptoms (heartburn, acid regurgitation). Do not assume throat symptoms (throat clearing, globus, cough, morning hoarseness) are caused by reflux — they may reflect laryngeal hypersensitivity, functional dysphonia, rhinitis, medication effects or voice overuse.

Preceding illness

Post-viral (parainfluenza, COVID — post-viral dysphonia lasts weeks). Post-anaesthetic intubation (trauma to vocal cords). After neck/thoracic surgery (RLN injury).

Associated symptoms

Dysphagia, odynophagia, aspiration, unilateral otalgia, haemoptysis, neck lump, weight loss. Neurological symptoms: dysarthria, dysphagia, limb weakness, bradykinesia, tremor; breathlessness at rest or when supine with bulbar symptoms

Medicines

Inhaled corticosteroids and other potentially causative medicines

Laryngopharyngeal reflux (LPR) is commonly blamed for throat symptoms, but the diagnosis is nonspecific — do not diagnose it solely from throat clearing, globus, cough, morning hoarseness or posterior laryngeal erythema. Hypophonia (abnormally quiet, monotone voice) is a specific feature of Parkinson's disease — it results from reduced respiratory drive and vocal fold hypomobility. Lee Silverman Voice Treatment (LSVT LOUD) is an established intensive voice-treatment programme for Parkinson's disease; access and suitability vary and other speech-and-language interventions may be used.

Diagnose

Differential Diagnosis

Done

Acute laryngitis

Post-URTI, voice abuse. Hoarse + sore throat + viral prodrome. Usually self-limiting, though it may take several weeks. Relative voice rest + hydration. No antibiotics needed. Persistent or progressive symptoms → reassess rather than repeat symptomatic prescriptions.

Laryngeal cancer

Smoker + alcohol, older age, persistent or progressive hoarseness, ± otalgia (referred pain), ± neck mass. Squamous cell carcinoma. Suspected cancer pathway referral for nasendoscopy.

Vocal cord nodules / polyps

Voice abuse (teachers, singers). Bilateral nodules (hourglass pattern on phonation) or unilateral polyp. Breathy/rough voice. Voice therapy ± surgical excision.

Vocal cord palsy

Unilateral: breathy, weak voice (paralysed cord fails to adduct). Causes: idiopathic (viral), thyroid surgery RLN injury, mediastinal mass (lung cancer, lymphoma, aortic aneurysm), thyroid cancer. Bilateral: stridor + respiratory distress.

Laryngopharyngeal reflux (LPR)

Nonspecific diagnosis — do not diagnose from throat clearing, globus, cough, morning hoarseness or posterior laryngeal erythema alone. Lifestyle advice; time-limited PPI trial only with typical reflux symptoms or a clear GORD indication.

Hypothyroidism

Husky/croaky voice + myxoedema facies, weight gain, bradycardia, cold intolerance. TFTs diagnostic. Levothyroxine reverses voice change.

Functional dysphonia

Muscle tension dysphonia — strained/effortful voice, neck muscle tightness, no organic laryngeal pathology. Linked to stress/anxiety. Voice therapy after laryngeal assessment has excluded structural disease.

Neurological

Parkinson's (hypophonia — quiet monotone), MND (spastic/flaccid dysarthria), MS (scanning speech), stroke (dysarthria). Sudden dysarthria → 999 (stroke pathway); progressive dysarthria with dysphagia → urgent neurological assessment; breathlessness at rest or supine with progressive bulbar symptoms → immediate assessment (NICE NG127). A persistent quiet, hoarse or wobbly voice needs ENT assessment first to exclude structural disease before considering laryngeal dystonia or a functional diagnosis

Vocal cord palsy from a mediastinal mass (particularly left-sided, as the left recurrent laryngeal nerve loops under the aortic arch) is a critical diagnosis — causes include lung cancer, lymphoma, aortic aneurysm, and mediastinal fibrosis. If vocal-fold palsy is confirmed without an obvious cause, secondary care investigates the course of the recurrent laryngeal nerve (thyroid, neck, mediastinum, lung apex); an urgent CXR is reasonable while awaiting this. Hypothyroidism-related voice change (due to myxoedematous infiltration of the laryngeal mucosa and TA muscle weakness) is completely reversible with levothyroxine replacement — TSH (with reflex FT4 per local protocol) is worth checking when hypothyroidism is clinically suspected. Functional dysphonia (muscle tension dysphonia) responds to voice therapy with a speech and language therapist, but persistent dysphonia should have laryngeal assessment rather than voice therapy as a substitute.

Diagnose

Targeted Examination

Done

Voice quality assessment

Listen carefully: breathy/weak (palsy), rough/gravelly (nodules, laryngitis), strained/effortful (muscle tension), quiet/monotone (Parkinson's). Document quality clearly, ability to sustain phonation, cough strength and swallowing safety.

Neck

Thyroid size + consistency (goitre compressing larynx, thyroid cancer invading RLN), cervical lymphadenopathy (metastatic head and neck cancer — level 2/3), tracheal deviation

Indirect laryngoscopy

Laryngeal mirror (rarely available in GP) or flexible nasendoscopy (ENT). Flexible laryngoscopy is not usually available in general practice and should not be replaced by repeated empirical treatment. In primary care: inspect oral cavity and oropharynx where safe (not in suspected epiglottitis or threatened airway).

Neurological

Parkinsonism features (rigidity, bradykinesia, hypomimia), tongue fasciculations (MND), facial weakness, soft palate movement (unilateral palsy = upper motor neurone), gag reflex

Respiratory

Stridor (inspiratory — supraglottic obstruction; biphasic — glottic), SpO2 and respiratory rate if clinically indicated, respiratory examination. Stridor with distress, hypoxia, drooling or tripod positioning = 999; stridor without distress is still an emergency — same-day emergency ENT assessment now via the on-call ENT team, with a very low threshold for 999 transfer.

General

Weight loss (malignancy, MND), lymphadenopathy, cachexia, clubbing (lung cancer), cushingoid features (steroid-induced myopathy of laryngeal muscles)

Thyroid cancer presenting as hoarseness (RLN invasion) is one of the most important diagnoses not to miss — it indicates a locally advanced tumour. Examine the neck, thyroid and cervical lymph nodes in hoarseness presentations. A hard, irregular, non-tender thyroid mass in a hoarse patient is a thyroid suspected cancer pathway referral. Oropharyngeal inspection with a torch is limited in primary care (the hypopharynx and larynx cannot be seen) and should not be attempted in suspected upper-airway obstruction.

Refer

Referral Pathways

Done

999

Threatened airway — stridor with respiratory distress, hypoxia, drooling, tripod positioning, reduced consciousness or sudden inability to phonate; suspected epiglottitis with systemic illness; bilateral vocal cord palsy with stridor or respiratory compromise (otherwise same-day urgent ENT); severe acute airway obstruction

Suspected cancer · head & neck

Consider for persistent unexplained hoarseness aged 45 and over (NICE NG12, updated April 2026). Unexplained neck lump. Hoarseness with concerning associated symptoms (weight loss, dysphagia, neck mass), irrespective of age, per the local pathway and suspected cancer referral criteria.

Suspected cancer · lung

Haemoptysis aged ≥40 (hoarseness not required). Abnormal CXR. Hoarseness plus respiratory/systemic symptoms. Suspected apical or mediastinal lesion, e.g. Pancoast tumour (shoulder pain + arm symptoms + Horner's + hoarseness). Vocal-fold palsy without an identified cause. A normal CXR does not exclude lung cancer — if clinical suspicion remains high, still refer.

Urgent ENT

A breathy, weak voice, ineffective cough, aspiration or suspected vocal-fold immobility warrants prompt ENT referral for laryngeal examination (timescale per local pathway). Persistent unexplained dysphonia in a younger patient. Progressive dysphonia. Professional voice user with significant occupational impairment. Post-intubation or post-neck/thoracic surgery voice change — prompt ENT; same-day discussion if bilateral palsy, stridor, aspiration or significant dysphagia. Persistent symptoms despite an apparent benign diagnosis.

Routine ENT / voice clinic

Professional voice users with persistent dysphonia, substantial occupational impact, recurrent episodes or suspected vocal-fold lesions → early referral to an ENT voice clinic or voice-specialist service (earlier where the voice is essential for employment or symptoms are progressive). Suspected vocal cord nodules/polyps. Functional dysphonia where voice therapy not locally available via SALT.

SALT — voice therapy

Functional dysphonia (muscle tension dysphonia), Parkinson's hypophonia (LSVT LOUD), vocal cord nodules (voice hygiene programme before surgery). Voice therapy should follow or accompany laryngeal assessment rather than substitute for it when symptoms are persistent.

NICE NG12 (updated April 2026) asks you to consider a suspected cancer pathway referral for people aged 45 and over with persistent unexplained hoarseness; the 3-week threshold is a practical rule of thumb — do not delay referral with repeated empirical treatment (PPIs, antibiotics, or voice rest). Professional voice users (singers, actors, teachers) should have a lower threshold for ENT voice-clinic referral where the voice is essential for employment or symptoms are progressive.

Diagnose

Investigations

Done

CXR (when indicated)

Urgent chest X-ray when there are respiratory or systemic features suggesting lung cancer (cough, dyspnoea, chest pain, weight loss, abnormal chest examination), haemoptysis, smoking history with persistent hoarseness (particularly older adults), symptoms suggesting an apical or mediastinal lesion, or suspected vocal-fold palsy without an identified cause. Not mandatory for every adult with persistent hoarseness. A normal CXR does not exclude laryngeal cancer, lung cancer or a mediastinal lesion; do not delay ENT or suspected-cancer referral while awaiting imaging.

Bloods

Only when clinically indicated: TSH (reflex FT4 per local protocol) if hypothyroidism is clinically suspected (NICE NG145) · FBC + CRP only where infection, anaemia, inflammatory disease or systemic illness is suspected · other tests directed by history and examination. No routine calcium for uncomplicated hoarseness

Flexible nasendoscopy

Key diagnostic assessment — normally undertaken by ENT/voice services. Views entire larynx in office. Identifies vocal cord lesions, movement abnormalities, subglottic lesions, post-cricoid pathology.

CT neck/chest

Ordered by ENT/oncology after endoscopic diagnosis for staging, or when vocal cord palsy found with no identified cause — requested by secondary care per local ENT/respiratory pathways, not a routine GP investigation.

NOT in primary care

Laryngoscopy is not possible in primary care. Do not prescribe antibiotics for hoarseness empirically and delay referral. Do not repeat courses of PPI without ENT review in persistent cases.

NICE NG12 recommends urgent CXR for relevant lung-cancer symptoms and signs rather than a blanket CXR for all hoarseness. Where indicated, CXR can identify lung cancer (including Pancoast), mediastinal lymphadenopathy (lymphoma), and aortic aneurysm (RLN stretch). A normal CXR does not exclude these conditions — secondary care arranges CT if clinical suspicion remains high. Thyroid function tests are worth checking when hypothyroidism is clinically suspected (NICE NG145), not at every presentation.

Treat

GP-Initiated Management

Done

Acute laryngitis (<3 weeks)

Voice rest + hydration

Viral — no routine antibiotics. Relative voice rest; avoid shouting, prolonged talking and whispering (whispering may increase laryngeal effort in some patients). Adequate fluids; avoid smoking and alcohol. Simple analgesia if appropriate — paracetamol dose adjusted for age, weight, liver disease, alcohol excess and frailty, within the maximum daily dose and avoiding duplicate combination products. Do not advise steam inhalation from bowls of hot water (uncertain benefit, scalding risk) — avoid very dry environments instead. May take several weeks to resolve; persistent or progressive symptoms → reassess, not repeat prescriptions. Clear review plan.

Suspected GORD with typical symptoms

Lifestyle ± time-limited PPI trial

Do not diagnose LPR solely from throat clearing, globus, cough, morning hoarseness or posterior laryngeal erythema. Ask about heartburn and acid regurgitation. Consider a time-limited PPI trial only when typical reflux symptoms are present or there is a clear GORD indication — full-dose PPI for 4–8 weeks per local formulary (NICE CG184), review response and step down to the lowest effective dose or stop. A large UK trial found no benefit from twice-daily PPI for persistent throat symptoms (BTS chronic cough statement advises against routine PPI for upper-airway symptoms). Persistent dysphonia must not be managed with repeated PPI courses instead of laryngeal assessment.

Hypothyroidism

Levothyroxine (dose per NICE NG145)

Voice change fully reversible with euthyroidism. Allow 3–6 months to assess full vocal recovery. Aim for a TSH within the reference range (NICE NG145). Steroid inhaler dysphonia — rinse mouth after use, spacer device, review whether the inhaled steroid dose remains necessary.

Steroid inhalerCheck inhaler technique; use a spacer with a metered-dose inhaler; rinse, gargle and spit after every dose; check for oral candidiasis (diagnose clinically and treat per local formulary and current product information); review whether the inhaled steroid dose remains necessary. Switching to a dry-powder inhaler does not reliably reduce dysphonia and may worsen local deposition in some patients.

Parkinson'sLSVT LOUD (Lee Silverman Voice Treatment) — intensive speech therapy, 4 sessions/week × 4 weeks. An established intensive voice-treatment programme for Parkinson's disease; access and suitability vary, and other speech-and-language interventions may be used.

Functional dysphoniaAfter ENT assessment has excluded structural disease: voice therapy with SALT — laryngeal massage, resonant voice therapy, reducing muscle tension. Psychological therapy (CBT) if anxiety-driven. No surgery — surgical treatment worsens functional dysphonia.

Next steps: see GORD and acid reflux · Hypothyroidism · Smoking cessation · Parkinson's disease

Routine high-dose PPI is not supported for isolated throat or voice symptoms — NICE CG184 supports a full-dose PPI for 4–8 weeks for GORD with step-down to the lowest effective dose, not indefinite high-dose treatment. Whispering during acute laryngitis may increase laryngeal effort in some patients, so relaxed quiet speaking is preferred. Steroid inhaler dysphonia is common — a spacer device reduces oropharyngeal deposition, and technique and dose should be reviewed.

Lifestyle

Vocal Hygiene & Voice Health

Done

Smoking cessation The most important intervention — smoking is the number one risk factor for laryngeal cancer AND causes chronic laryngeal inflammation (smoker's laryngitis). Brief advice + NHS Stop Smoking referral at every consultation.

Hydration Vocal fold mucosa requires adequate hydration — adequate fluid intake. Avoid smoking and alcohol. Dry, heated indoor air worsens vocal cord dryness — humidifier in bedroom/office.

Voice rest After a vocal strain event — a short period of relative voice rest. Avoid shouting, excessive throat clearing (damages cords — try hard swallow instead), coughing repetitively, whispering.

Reflux lifestyle Weight reduction where appropriate, smoking cessation, reducing alcohol, avoiding meals for approximately 3 hours before bed, and raising the head of the bed if nocturnal reflux is present. Identify personal triggers rather than following a universal list of trigger foods.

Alcohol reduction Alcohol is an independent laryngeal cancer risk factor, causes mucosal inflammation, and can worsen reflux. UK CMO low-risk limit: no more than 14 units/week, spread over 3 or more days. Brief intervention + AUDIT-C at every consultation.

Professional voice care Teachers/singers: warm up voice before heavy use. Avoid speaking over background noise (projects laryngeal strain). Microphone use reduces vocal load. Voice amplification in classroom settings.

Steroid inhaler technique Rinse mouth, gargle and spit after every dose without fail. Use spacer with MDI. This prevents both candidiasis and dysphonia. Review inhaler technique at every asthma review.

Humidity Do not use steam inhalation from bowls of hot water — uncertain benefit and risk of scalding, particularly in children and older adults. Avoid very dry environments instead.

Vocal hygiene measures are a cornerstone of voice therapy programmes for benign voice disorders. Throat clearing causes direct vocal fold trauma with each event (the cords adduct forcefully) — it is a maintaining factor in LPR and functional dysphonia. Training patients to substitute a hard swallow (which clears the throat without direct cord contact) can reduce symptoms. Smoking cessation at any stage reduces laryngeal cancer risk.

Safety

Follow-Up & Safety-Netting

Done

Acute laryngitis

If not resolved at about 3 weeks or not following the expected recovery pattern → reassess; consider suspected cancer pathway referral at 45 and over (ENT on clinical judgement if younger). Do not prescribe repeated empirical courses instead of referral.

PPI trial (typical GORD) — 4–8 weeks

Review response; stop or step down if ineffective or no longer required. Persistent dysphonia → ENT for laryngeal assessment — do not let PPI treatment delay it. Never extend PPI indefinitely without review.

Referral tracking

Confirm hospital letter received. Patient to chase if no appointment within 2 weeks. Document referral date and expected response date in notes.

Post-ENT

If laryngeal cancer confirmed: MDT management, CNS allocated, GP provides: opiate analgesia, nutrition support, palliative care coordination, smoking cessation (ongoing benefit even post-diagnosis)

Vocal cord palsy follow-up

After treatment of cause — reassess at 6 months. Permanent palsy → ENT for vocal cord medialization (injection augmentation or thyroplasty) to improve voice and prevent aspiration.

999 safety-net

Stridor or breathing difficulty, inability to swallow saliva or drooling, sudden inability to vocalise, epiglottitis signs (drooling + tripod position + fever), sudden neurological symptoms (stroke pathway)

Same-day GP

Rapidly worsening voice, new neck swelling, new dysphagia or aspiration, haemoptysis, progressive neurological symptoms

Documentation

Duration and character of dysphonia, smoking and alcohol history, examination findings, referral route and urgency, investigation results, explicit safety-net advice, planned review date

In persistent hoarseness, avoid repeated empirical treatment without laryngeal assessment — repeated prescribing of antibiotics, PPIs, or voice rest can delay diagnosis of laryngeal cancer. Vocal cord medialization for permanent unilateral palsy not only improves voice quality but also prevents aspiration — the paralysed cord sits in an abducted position and cannot protect the airway during swallowing. Injection augmentation (Restylane, fat, hydroxyapatite) produces immediate improvement and is an important quality-of-life intervention.