1. Laryngitis with a URI is almost always viral.
   
   
2. Voice changes in someone at risk for laryngeal cancer requires laryngoscopy. If the PCP is not skilled at laryngoscopy, referral is required. Tumor must be excluded.
   
   
3. A breathy voice caused by vocal cord paralysis. Laryngeal cancer, thyroid cancer, mediastinal cancer, 10th nerve Schwannoma or other neck tumor, CVA or idiopathic are the usual causes. ENT referral is recommended.
   
   
4. GERD (gastroesophageal reflux disease) is a common cause of voice change and cough. GERD Rx is discussed in the Globus algorithm.
   
   
5. a. Post Nasal Drip is a second common cause of voice change and cough. If specific diagnoses like sinusitis or allergic rhinitis cannot be made, treatment with antibiotics, nasal steroids and nasal saline irrigation (see #3 under Allergic Rhinitis) are prescribed.

   b. Post Nasal Drip with cough and voice changes is common, particularly in elderly males. Treatment is nasal irrigation, generally without antibiotics or nasal steroids. If the treatment is successful, the diagnosis is voice change of aging (presbylarynx) and post nasal drip. Treatment is hypotonic, pulsatile saline nasal irrigation bid and prn. One can expect resolution of symptoms with reasonable voice use and realistic voice expectations.

6. Not all ENT referrals are equal. Some otolaryngologists are better skilled and some are subspecialized with abilities for videostroboscopy and acoustic analysis. The subspecialty is called laryngology and laryngology clinics are often called voice clinics or voice disorder clinics. If your regular ENT referral does not make a good diagnosis and treatment, send your patient to a voice disorders clinic.

   Voice rest is the only treatment required. Absolute voice rest is no talking. Regular voice rest is keeping normal soft conversation to a minimum without shouting or yelling. Those whose employment requires speaking, (teachers or telephone operators) may require a 1-2 week work absence.

Overview of Hoarseness

There are two distinct abnormal voice qualities. The first is a breathy voice caused by paralysis or weakness of one or both vocal cords. This requires an ENT consultation. The second is a rough or coarse voice caused by a growth or swelling on the vocal cord and this results in a hoarse voice and is the subject of this algorithm.

Viral infections affecting the larynx cause inflammation of the vocal cords. The resulting edema causes a hoarse voice. As with all upper respiratory tract viral infections antibiotics and other treatments are not beneficial. The patient should be encouraged to not force their voice and to use their voice gently, for if they force it, they may injure the vocal cord and develop nodules or other abnormalities. There are no acute bacterial infections that present like a viral laryngitis.

Epiglottitis presents with pain and difficulty breathing. It does not present with hoarseness. If the patient is a smoker, cancer needs to be excluded. If the PCP can perform a good fiberoptic laryngoscopy, make a diagnosis and exclude cancer -- so be it. If that is not a skill in the PCP armamentarium, an ENT referral is recommended.

Assuming the patient is not at high risk for cancer, voice quality is checked, the breathy voice is identified and referred, and the hoarse voice is then evaluated. If the history is one of voice abuse such as: a high school cheerleader, a screaming parent, or a professional who is required to project their voice excessively, then voice rest is the preferred treatment. Absolute voice rest is difficult to achieve. This means writing every single thing you wish to communicate and most people do not tolerate this for more than a day or two. If the patient is willing, a 7-10 day course of absolute voice rest is optimal. Otherwise a 14-day trial of relative voice rest is advised.

If the voice returns to normal, no further treatment is required. If it continues abnormal, the patient will not improve until they learn how to correctly use their voice. Speech therapists are the ones who best teach patients proper voice techniques.

The two common medical causes for hoarseness are gastroesophageal reflux disease and post nasal drip. If these can be diagnosed in the history, treat them. If they cannot be elicited, and there is no other obvious cause, they can be empirically treated one at a time. If the hoarseness resolves, the patient can be safely observed, and if the hoarseness persists, an ENT referral is indicated.

This is a greatly simplified algorithm and the differential for hoarseness, is in fact, extensive. Nonetheless, this raises the single important red flag (tobacco induced cancer) that needs to be diagnosed early and will successfully manage the vast majority of people with voice disorders.