Hoarseness Lasting Over 3 Weeks: Causes and When You Need a Laryngoscopy

Several of these recommendations run counter to what many patients expect. First, the guideline explicitly advises against routine antibiotics for hoarseness: the most common causes of acute hoarseness are viral or mechanical, not bacterial. Second, it advises against reaching for antireflux drugs 'as a trial' in someone with hoarseness alone before anyone has looked at the larynx. Third, it advises against CT and MRI as the first test: the larynx has to be seen directly first.

Laryngoscopy usually means looking at the larynx with a thin flexible endoscope passed through the nose, or a rigid endoscope through the mouth, often with or without local anaesthetic, in the ENT clinic; it is brief. It allows the vocal folds (movement, shape, surface, any lesions) to be assessed and a decision to be made about further management. The guideline also allows laryngoscopy to be performed at any time in a person with dysphonia if the clinician so decides.

Hoarseness arises when the vocal folds do not close evenly or do not vibrate freely. This may be due to changes on their surface, weakness or paralysis of the laryngeal nerve and muscles, excessive tension of the neck and laryngeal muscles, or irritation of the mucosa. Below we go through the main groups of causes, starting with the most common.

In a population study from Stockholm (Lyberg-Åhlander et al., 2019), 16.9% of respondents reported voice problems, 1.4% to a great extent; women reported them significantly more often, and problems were more common after age 65, with the highest rates in teaching and service occupations. These are questionnaire data, not laryngeal examinations, so they do not say what changes lie behind the complaints, but they show that voice disorders are common and linked to occupation, age and sex.

The most common group of causes of persistent hoarseness in young and middle-aged non-smokers is functional or mechanical strain on the voice. Prolonged loud talking, without breaks, in noise or with poor technique leads to minor injuries of the vocal fold lining, which respond with swelling and may in time thicken into nodules; polyps also arise after a single or repeated injury. These lesions are benign but affect the vibration of the folds and the sound of the voice.

Muscle tension dysphonia is a disorder in which the structure of the folds is normal and hoarseness is caused by excessive tension of the laryngeal and neck muscles during speaking. It is diagnosed after the larynx has been examined, when no organic lesion is found and the symptom goes with effort, vocal fatigue, pain or tension in the neck. Such disorders respond to voice therapy, and the guideline advises it for causes amenable to it, after the larynx has been looked at.

Voice therapy, delivered by a speech-language pathologist or phoniatrician, includes learning correct breathing and voice use, exercises that reduce tension and rules of vocal hygiene. High-quality evidence for individual techniques is limited, as the trial above itself shows, but the guideline strongly recommends voice therapy for causes amenable to it. In practice, with nodules one usually starts with therapy, and surgery is considered when a symptomatic benign lesion does not respond to conservative treatment.

Laryngopharyngeal reflux (LPR), the backflow of stomach contents into the larynx and throat, is one of the most often named 'causes' of hoarseness, but also one of the most disputed diagnoses. The symptoms (hoarseness, throat clearing, a feeling of mucus, cough) are non-specific, and there is no accepted diagnostic standard. That is why the guideline advises against prescribing antireflux drugs for isolated dysphonia on the basis of symptoms alone, without looking at the larynx.

A 2019 meta-analysis (Lechien et al.) covering 10 randomised trials pointed to a mild superiority of PPIs over placebo (pooled relative risk 1.31) and to the importance of diet as an additional treatment, while stressing considerable heterogeneity between trials caused by the lack of a diagnostic gold standard and varying regimens, which limits clear conclusions. In other words: PPIs may reduce complaints in some people, but the effect is modest and the diagnosis uncertain.

Hoarseness can result from weakness or paralysis of one vocal fold, which then does not close properly. The voice is then quiet, 'breathy' and tiring, and speaking loudly or singing can become difficult. The best-known cause is injury to the recurrent laryngeal nerve, which runs close to the thyroid and through the chest, so it can be damaged by surgery on the thyroid, parathyroids, neck or chest, by intubation or by a tumour.

Voice disorders can also accompany general disease. Hypothyroidism can cause a hoarse, low voice, so with persistent hoarseness and no other explanation a doctor may order a TSH test, and we write about interpreting it in the entry on thyroid hormones. Neurological diseases such as Parkinson's disease may cause a quiet, monotone voice, and laryngeal dystonia (spasmodic dysphonia) shows as an interrupted, 'strained' voice; the guideline advises botulinum toxin injections for it. A new, unexplained vocal fold weakness always needs a search for the cause, including in the chest and neck.

Laryngeal cancer is a rare cause of hoarseness, but it is the reason persistent hoarseness must not be dismissed. The most important risk factor is tobacco smoking, aggravated by alcohol misuse. In a smoker with hoarseness lasting longer than a few weeks, the larynx should be examined without delay. The guideline lists tobacco use as one of the factors justifying expedited laryngeal evaluation, alongside recent head, neck or chest procedures, recent intubation, a neck mass, breathlessness and stridor, and professional voice use.

Cancer of the glottis can cause hoarseness at an early stage because it changes the vibration of the fold, which is one of the arguments for examining the larynx quickly. If hoarseness turns out to be due to a lesion suspected of malignancy, the guideline advises surgery as a therapeutic option. We do not describe the treatment of laryngeal cancer here, because it requires specialised oncological care.

The guideline advises informing patients about control and preventive measures for dysphonia. The actions below are general rules of vocal hygiene, not treatment of the cause. They make sense as a supplement but do not replace looking at the larynx if hoarseness lasts longer than a few weeks.

The first step is a visit to a family doctor or directly to an ENT specialist, who will take a history (duration, smoking, occupation, drugs, operations, intubations, accompanying illnesses), examine the neck and perform laryngoscopy. Only the result of laryngoscopy decides further management: observation, voice therapy with a speech-language pathologist or phoniatrician, treatment of the cause (for example reflux, thyroid), surgery for lesions not responding to conservative treatment or when cancer is suspected, and botulinum toxin for laryngeal dystonia. Imaging (CT, MRI) makes sense after the larynx has been looked at, when a specific lesion requires it.

Hoarseness is one of the few symptoms where a simple examination (looking at the larynx) quickly and reliably settles what is going on. The best approach is not to guess: do not take antibiotics and antireflux drugs as a trial, but book a laryngoscopy after a few weeks without improvement, or sooner with risk factors. It is also good to rest your voice, not smoke and drink water, but that is a supplement, not a substitute for diagnosis.