Table 22

Investigation and management of hoarseness

Investigations	Potential results	Clinical management plan
Actions from history, medication and dietary assessment
History findings	Hoarseness	Voice hygiene advice: Adequate hydration. Avoid vocal strain (shouting, throat clearing, excessive voice use). Smoking cessation advice if a smoker. Alcohol reduction (alcohol is an irritant and dehydrating). Refer to SLT.
	Dysphagia/aspiration	Discuss with supervising clinician within 24 hours.
	Presence of laryngeal obstruction Dyspnoea, stridor, wheeze, exertional dyspnoea, anxiety or signs of hypoxia Dysphagia or drooling Facial or oral oedema	This is an emergency. Refer to ENT team immediately.
	Presence of other ENT symptoms Throat or ear pain Nasal blockage	Refer to the ENT team requesting an appointment within 2 weeks.
First line
Laryngoscopy	Vocal cord palsy	CT scan and refer to cancer MDT within 2 weeks. Referral to SLT.
CT chest, abdomen, pelvis	Malignancy/tumour recurrence	Discuss and refer urgently to the appropriate cancer MDT requesting an appointment within 2 weeks.
	Superior vena cava obstruction	This is an emergency. Contact acute oncology service immediately.
Second line
OGD	GORD	Start PPI or H2 antagonist. If following oesophagectomy, consider promotility agents (see p. 78).
	Cervical inlet patch	Treat with PPI or ablation.
Third line
If normal investigations/no response to intervention		Reassure.

CT, computerised tomography; ENT, ear, nose and throat; GORD, gastro-oesophageal reflux disease; H2, histamine receptor 2; MDT, multidisciplinary team; OGD, upper GI endoscopy (oesophago-gastroduodenoscopy); PPI, proton pump inhibitor; SLT, speech and language therapy.