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Referral and warning signs
When to refer
Refer to ENT specialist if: Hoarseness persists > 3 weeks. Associated symptoms like difficulty breathing, stridor, haemoptysis, significant throat pain, difficulty swallowing, neck mass. Professional voice user with persistent hoarseness. Suspicion of malignancy (e.g., older patient, smoker).
Red flags
- Hoarseness persisting > 3 weeks
- Associated dyspnoea or stridor
- Haemoptysis
- Severe throat pain or dysphagia
- Neck mass
- History of smoking/heavy alcohol use with persistent hoarseness
Signs and symptoms
- Hoarseness (dysphonia) or aphonia (loss of voice) - primary symptom.
- Throat discomfort or scratchiness.
- Dry cough.
- Feeling of lump in the throat.
- May follow symptoms of an upper respiratory tract infection.
- Fever usually absent or mild (if acute viral cause).
Risk factors
- Viral upper respiratory tract infection (most common acute cause)
- Voice overuse or strain (shouting, prolonged talking/singing)
- Exposure to irritants (smoke, dust, chemicals, allergens)
- Gastroesophageal reflux disease (GERD)
- Smoking
- Excessive alcohol use
- Chronic sinusitis/post-nasal drip
Diagnosis
Clinical assessment
Diagnosis usually based on characteristic symptom of hoarseness, often in context of URTI or voice strain. Examination may show mild pharyngeal redness. Important to consider red flags suggesting other pathology. Differential diagnosis: Vocal cord nodules/polyps/cysts, Laryngeal cancer (esp. if >2-3 weeks hoarseness in smoker/older adult), Neurological causes (vocal cord paralysis), Hypothyroidism, Epiglottitis/Croup (if stridor/distress present), GERD.
Investigations
- Usually none required for acute laryngitis.
- Laryngoscopy (indirect or flexible fiberoptic): Indicated if hoarseness persists > 3 weeks, or if red flags present, to visualize vocal cords and rule out other pathology (specialist - ENT).
Diagnostic criteria
Clinical diagnosis based on hoarseness, typically self-limiting if acute viral.
Management
Non-pharmacological management
- Voice Rest: Crucial. Avoid talking, whispering, shouting.
- Humidification: Steam inhalation, humidifiers.
- Increased fluid intake.
- Avoid irritants (smoking, alcohol, dust).
- Treat underlying cause if chronic (e.g., GERD treatment, smoking cessation).
Pharmacological treatment
- Antibiotics: NOT indicated for typical acute (viral) laryngitis.
- Analgesia: Paracetamol or NSAIDs for throat discomfort.
- Cough suppressants: Generally not needed.
- Proton Pump Inhibitors (PPIs): If GERD is suspected cause of chronic laryngitis.
Monitoring
- Monitor for resolution of hoarseness (usually within 1-2 weeks for acute viral).
- Monitor for development of red flags.
Complications
- Rare for acute viral laryngitis.
- Chronic hoarseness.
- Development of vocal cord nodules/polyps (if chronic voice abuse).
Prevention
- Avoid voice strain.
- Smoking cessation.
- Manage GERD.
- Good hydration.
- Treat URTIs promptly (though usually viral).
Patient education
- Explain likely viral cause and self-limiting nature.
- Emphasize voice rest.
- Advise on hydration and humidification.
- Explain antibiotics are not needed.
- Advise on when to seek further evaluation (persistent hoarseness, red flags).
Uganda-specific notes
Usually managed symptomatically. Importance of ruling out more serious causes (like TB larynx or malignancy) if hoarseness persists.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 5, Section 5.2.6