QuestionSBA
QuestionChoice
This would not be appropriate as hoarseness could be a sign of underlying malignancy
32326
d
Reassure and discharge
QuestionChoice
Delay in investigations can affect prognosis, and it is therefore recommended that this patient be referred urgently under the 2-week wait pathway
32327
e
Arrange a follow-up GP appointment in two weeks to monitor symptoms
QuestionChoice
Hoarseness is a red flag for laryngeal cancer. Guidelines suggest that all patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness
32323
a
Urgent referral for investigation of laryngeal cancer
QuestionChoice
GORD can lead to voice changes due to the effect of acid on the vocal cords. However, this patients GORD symptoms appear to be well controlled on omeprazole. Regardless, persistent hoarseness is concerning, and he should be referred urgently to exclude laryngeal cancer
32324
b
Increase omeprazole dosing to 20mg twice a day
QuestionChoice
Apical lung cancer can compress the recurrent laryngeal nerve and lead to hoarseness. However, the lung cancer pathways require an abnormal chest X-ray or unexplained haemoptysis in patients over 40 before urgent referral
32325
c
Urgent referral for investigation of lung cancer
Concept
Chapter
# Summary

Hoarseness, an inability to produce sound with altered voice pitch or quality, is a common complaint often indicative of underlying conditions such as laryngeal cancer, chronic laryngitis, acute laryngitis, or Reinke's Oedema. Hoarseness lasting more than three weeks necessitates an investigation due to its potential association with laryngeal cancer. Key signs and symptoms, investigations, and management strategies for each condition are detailed in the following sections.

# Definition

Hoarseness is characterized by the inability to produce sound or a change in voice pitch or quality. It is often a symptom of an underlying condition and not a disease in itself.

# Epidemiology

Hoarseness is a common presenting complaint in primary care and ENT clinics. While the exact prevalence is not known, it is frequently associated with a range of conditions from benign vocal cord lesions to more serious laryngeal cancers.

# Aetiology

The primary causes of hoarseness include:

**Laryngeal cancer**

- Hoarseness lasting more than 3 weeks.
- Significant smoking history is a common feature in the patient's history.

**Chronic Laryngitis**

- Associated with gastroesophageal reflux disease.
- Often presents as worse in the morning.

**Acute Laryngitis**

- A common cause of hoarseness, typically viral and self-limiting.
- May be secondary to gastroesophageal reflux disease (GORD) or autoimmune disease.

**Reinke's Oedema**

- Enlargement of the vocal cords associated with hypothyroidism, leading to persistent hoarseness.

# Signs and symptoms

The primary symptom of these conditions is hoarseness. However, each condition has unique features:

**Laryngeal cancer**

- Hoarseness lasting more than 3 weeks.
- A history of significant smoking.

**Chronic Laryngitis**

- Hoarseness, particularly severe in the morning.
- Potential history of gastroesophageal reflux disease.

**Acute Laryngitis**

- Hoarseness, typically viral and self-limiting.
- Can be secondary to GORD or autoimmune disease.

**Reinke's Oedema**

- Prolonged and persistent hoarseness.
- Potential history of hypothyroidism.

# Differential diagnosis

The differential diagnosis for hoarseness includes:

- Laryngeal cancer: Characterized by hoarseness lasting more than 3 weeks and a history of significant smoking.
- Chronic laryngitis: Hoarseness that is worse in the morning and potentially associated with gastroesophageal reflux disease.
- Acute laryngitis: Hoarseness that is typically viral and self-limiting, and could be secondary to GORD or autoimmune disease.
- Reinke's Oedema: Persistent hoarseness due to enlargement of the vocal cords, associated with hypothyroidism.

# Investigations

Investigations for hoarseness primarily involve referral to an ENT specialist for further evaluation, which may include laryngoscopy, imaging studies, and potentially biopsy in cases where malignancy is suspected.

# Management

Management strategies for hoarseness depend on the underlying cause:

- Laryngeal cancer: Urgent referral to ENT specialists under a 2-week wait rule.
- Chronic laryngitis: Management of underlying gastroesophageal reflux disease.
- Acute laryngitis: Typically self-limiting and supportive care is often sufficient.
- Reinke's Oedema: Treatment of underlying hypothyroidism and voice therapy.

# References

[Click here for NICE CKS on head and neck cancers - recognition and referral](https://cks.nice.org.uk/topics/head-neck-cancers-recognition-referral/)
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Hoarseness
Topic
24
Ear, Nose & Throat
6465
All patients over 45 years old should be referred urgently to secondary care if they have unexplained and persistent hoarseness
A 65-year-old man presents to his general practitioner (GP) complaining that his voice has become more hoarse over the last three months. He denies any other symptoms.

His past medical history is significant for gastro-oesophageal reflux disease (GORD), for which he takes 20mg of omeprazole once a day.

There are no notable findings on examination.

Which of the following is the next best step in management?
a