Hoarseness

Differential Diagnosis

Common Diagnoses

Occasional Diagnoses

  • GORD in adults
  • Benign Tumours: Singer’s Nodes, Polyps
  • Crico-Arytenoid Rheumatoid Arthritis
  • Functional (Hysterical) Aphonia

Rare Diagnoses

  • Acute Epiglottitis
  • Laryngeal Carcinoma
  • Recurrent Laryngeal Nerve Palsy
  • Physical Trauma (e.g. after Intubation)
  • Chemical Inhalation Trauma
  • Rare Inflammatory Lesions (e.g. TB, Syphilis)

Ready Reckoner

Key distinguishing features of the most common diagnoses

Acute LaryngitisOveruseHypothyroidismSmokingSinusitis
Recent IllnessYesNoPossibleNoYes
Tired, Cold and Slowed UpNoNoYesNoNo
Fever and MalaisePossibleNoNoNoYes
Symptoms ChronicNoPossibleYesYesNo
Facial Pain and CatarrhNoNoNoNoYes

Possible Investigations

Likely:None.

Possible:TFT, CXR, direct or indirect laryngoscopy.

Small Print:Throat swab.

  • TFT: In chronic hoarseness to exclude hypothyroidism.
  • CXR: To check for thoracic lesions causing recurrent laryngeal nerve palsy.
  • Indirect laryngoscopy: Useful for a GP with the necessary skills; most will refer to an ENT specialist.
  • Direct laryngoscopy: Using a flexible fibre-optic endoscope. This is a specialist investigation allowing close-up views and biopsy of suspicious lesions.
  • Throat swab: Useful, very rarely, if hoarseness is associated with a persisting pharyngitis.

Top Tips

  • In acute laryngitis, don’t forget to tell the patient to rest the voice, and remember that occupational factors are important – use of voice (e.g. by telephonists) or working in smoky environment (e.g. a pub) will aggravate and prolong symptoms, causing diagnostic confusion.
  • If you suspect a malignancy, arrange an urgent CXR immediately prior to referral. The referral can then be made to the correct specialist (chest rather than ENT) if a lung lesion is present, thus expediting appropriate management.
  • Don’t forget transient hoarseness caused by intubation – GPs are seeing this increasingly often as patients spend less post-operative time in hospital.

Red Flags

  • Every adult patient with persistent, unexplained hoarseness has carcinoma of the larynx until proved otherwise.
  • GORD is a common cause in the elderly, but beware of making this diagnosis without specialist investigation first.
  • Epiglottitis is rare but if you suspect it in any patient, admit immediately – and don’t examine the throat.
  • Hypothyroidism is easily overlooked – prompt diagnosis can save unnecessary anxiety and investigation.

Published: 2nd August 2022 Updated: 10th April 2024

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Based on the best-selling book Symptom Sorter, Nursing in Practice Reference is designed to help nurses working in primary and community care make sense of patient presentations. Written by GPs and adapted by nurses, it covers the vast majority of symptoms seen in primary care to inform different nursing disciplines with a range of responsibilities. Each symptom is organised into common, occasional or rare differentials, with distinguishing features, possible investigations and key points. It also provides guides on managing more than 350 conditions. The perspective is very much grass roots primary care, informed by the latest evidence and guidance.

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Disclaimer

Nursing in Practice Reference is based on the best-selling book Symptom Sorter. The experts behind Nursing in Practice Reference are Marilyn Eveleigh who is Nursing in Practice’s editorial advisor and a primary care nurse in East Sussex, Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.