Reasoning GP · Algorithm · 1-page summary
Hoarseness (dysphonia) in adults
For: adults with new or persistent hoarseness, face to face or remote. Not for: children — stridor, drooling or a hoarse febrile child goes to block 0; otherwise use paediatric pathways.
Core rule: persistent unexplained hoarseness (in practice beyond about 3 weeks) needs the larynx seen. Aged 45+ → consider a suspected cancer pathway referral (NG12). Never re-treat with PPI, antibiotics or voice rest instead.
0Stop — call 999 now — threatened airway or stroke
- Stridor with distress, hypoxia, drooling, tripod position, reduced consciousness or sudden inability to phonate → 999
- Suspected epiglottitis (drooling + stridor + hoarse voice + fever, any age); bilateral cord palsy with stridor or respiratory compromise → 999
- Sudden dysarthria or speech disturbance → 999 stroke pathway.
- While waiting: keep upright and calm; do NOT examine the throat or lie flat; oxygen if needed. Do not delay transfer for anything.
1Triage by duration and age
| Picture | Action |
|---|---|
| <3 weeks, after URTI | Likely laryngitis → voice care; reassess if not better at about 3 weeks. |
| Persistent, 45+ | Unexplained → consider Suspected cancer head and neck pathway (NG12). |
| Persistent, younger | No clear benign cause → Urgent ENT laryngoscopy on clinical judgement. |
| Stridor, no distress | Still an emergency → Same-day emergency ENT via on-call ENT now; very low threshold for 999 |
2Screen — one row is enough, any age
- Neck lump with hoarseness → Suspected cancer head and neck. Hard, irregular thyroid mass → thyroid pathway.
- Dysphagia, weight loss, odynophagia, unilateral otalgia or aspiration → Suspected cancer on the pathway of the dominant syndrome (head and neck or upper GI).
- Haemoptysis aged ≥40, or vocal-fold palsy with no cause found → Suspected cancer lung.
- Breathy weak voice, weak cough, suspected cord palsy, Pancoast features → prompt ENT + Urgent CXR
- Rapidly progressive neck swelling, severe dysphagia or aspiration; after thyroid/chest surgery with bilateral palsy → Same-day
- Progressive dysarthria with dysphagia → Urgent neurology; breathless at rest or lying flat with bulbar signs → immediate Same-day (NG127).
3Assess — only once blocks 0–2 are answered
☐ Smoking, vaping, alcohol, voice use, reflux, inhaled steroids ☐ Voice quality, cough strength, swallow ☐ Neck: thyroid, nodes, trachea ☐ Neurology: parkinsonism, tongue fasciculations, palate ☐ Stridor; SpO₂ and RR if indicated
Tests only if indicated: TSH if hypothyroid features; CXR for lung features, haemoptysis, older smoker or suspected palsy. No routine calcium. Laryngoscopy and CT are secondary care.
4Classify — only if the screen is negative
- Acute laryngitis — post-URTI, sore throat, viral prodrome → voice care; can take several weeks.
- Nodules / polyps — rough voice in heavy voice users → ENT voice clinic, SALT.
- Reflux — only with heartburn or regurgitation. Throat clearing, globus, cough or morning hoarseness alone are not LPR.
- Hypothyroidism — husky voice, weight gain, cold intolerance → TSH; levothyroxine per NG145.
- Neurological / functional — Parkinson's quiet monotone voice; strained muscle-tension voice → ENT first to exclude structural disease.
- Uncertain — say so; arrange laryngeal assessment, not another empirical course.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Laryngitis: relative voice rest (no shouting or whispering), fluids, no smoking or alcohol, simple analgesia. No antibiotics; no steam bowls.
- Typical GORD only: lifestyle ± full-dose PPI for 4–8 weeks, then step down or stop (CG184).
- Inhaled steroid: check technique, spacer with MDI, rinse–gargle–spit, look for candida, review dose.
- Smoking and alcohol: very brief advice + NHS Stop Smoking; alcohol no more than 14 units/week.
6Refer routinely
- Professional voice users, suspected nodules or polyps → ENT voice clinic (earlier if job depends on voice or progressive).
- Functional dysphonia, nodules, Parkinson's hypophonia (LSVT LOUD) → SALT voice therapy, alongside or after laryngeal assessment.
7Never reassure by
- Repeated PPI, antibiotic or voice-rest courses for persistent hoarseness.
- Calling it reflux from throat symptoms alone.
- A normal CXR — it does not exclude laryngeal, lung or mediastinal disease.
- Young age — persistent unexplained dysphonia still needs ENT.
- A torch look at the throat — the larynx cannot be seen.
- Stridor without distress, or voice therapy in place of laryngeal assessment.
8Safety-net — say it, then document it
999 “Call 999 for noisy or difficult breathing, drooling or being unable to swallow your saliva, suddenly losing your voice, or sudden slurred speech or weakness.” Same day: “Voice getting rapidly worse, a new neck swelling, new trouble swallowing or choking on drinks, coughing up blood, or worsening nerve symptoms — contact us today.”
Review: “If your voice is not back to normal in about 3 weeks, come back — don't wait.” If referred: “If you have no appointment within 2 weeks, contact us.”
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies; no stridor
Duration, voice quality, smoking and alcohol recorded
Neck and neurological examination done
Persistent → laryngeal assessment arranged; route and urgency recorded
Safety-net and review date given
Summary of the full Reasoning GP hoarseness algorithm, which holds the detail, examination and evidence. Sources: NICE NG12 (updated April 2026), NG127, CG184, NG145; BTS chronic cough statement 2023; ENT UK; RCSLT. Follow local referral pathways. Clinical reference — check doses: NICE/SPC, BNF.