Dysphonia/Altered voice in Adults and Children

Scope

Adults and children with altered voice. Dysphonia is defined as when an individual’s voice quality, pitch, loudness or vocal effort impairs communication and affects quality of life.

For patients with an episodic or variable dysphonia in the absence of red flag symptoms refer to the SLT-led parallel clinic. This is a clinic led by Specialist Speech and Language Therapists who provide the initial assessment of the larynx using nasendoscopy in lieu of an ENT consultant. This clinic is run in parallel with a general ENT clinic in order that second opinion can be sought if necessary. All images are recorded and reviewed at the end of the clinic by the ENT consultant.

​Assessment

Signs and Symptoms

  • Dysphonia is defined as when an individual’s voice quality, pitch, loudness or vocal effort impairs communication and affects quality of life.

History and Examination

See Management Section

Differential Diagnosis

See Management Section

Red Flags

Red Flags in adults

Persistently altered voice for more than 3 weeks with a negative CXR: consider referral via Head and Neck Cancer 2ww

Please note that a sinister cause is more likely if:

  • History of smoking/alcohol
  • Referred otalgia
  • Dysphagia
  • Stridor
  • Cervical lymph nodes
Urgent
  • Episodic or Variable dysphonia for 3 weeks and:
    • Professional voice user, e.g., singer or teacher
    • High psychosocial distress

Urgent referral to Speech and Language Therapist-led parallel voice clinic

Management

Primary Care Management
  • Consider checking thyroid status
  • Consider chest x-ray
  • Consider alginate-based reflux treatment
  • Steroid inhaler technique review; consider use of a spacer
  • Smoking cessation if relevant
  • Voice rest for up to two weeks ONLY in the case of ACUTE laryngitis
  • Clinicians should not routinely prescribe antibiotics to treat dysphonia.
  • Recommend increasing hydration and steam inhalations
  • Counsel against continued misuse of the voice such as shouting or whispering

Follow up in 4 weeks or sooner if worsening. If:

  • Episodic or Variable dysphonia and:
    • No red flags
    • No professional voice use
    • No high psychosocial distress

AND

  • No improvement following Primary Care Management

Routine referral - Speech and Language Therapist (SLT)-led parallel voice clinic

Referral

Referral Criteria

Referral Criteria - Adults
1. 2WW
  • Persistently altered voice for more than 3 weeks with a negative CXR: consider referral via Head and Neck Cancer 2ww
  • Please note that a sinister cause is more likely if:
    • History of smoking/alcohol
    • Referred otalgia
    • Dysphagia
    • Stridor
    • Cervical lymph nodes
2. Urgent
  • Episodic or Variable dysphonia for 3 weeks and:
    • Professional voice user, e.g., singer or teacher
    • High psychosocial distress

Urgent referral to Speech and Language Therapist-led parallel voice clinic

3. Routine
  • Episodic or Variable dysphonia and:
    • No red flags
    • No professional voice use
    • No high psychosocial distress

AND

  • No improvement following Primary Care Management

Routine referral - Speech and Language Therapist (SLT)-led parallel voice clinic

Referral Instructions

2WW referrals
  • e-Referral Service selection
    • Specialty: 2ww
    • Clinic type: Head and Neck
    • Service: 2WW-Head and Neck-TSDFT-Torbay-RA9
For adults
  • e-Referral service selection
    • Specialty - ENT
    • Clinic type - Throat
    • Service - DRSS-South Devon & Torbay-Ear Nose and Throat- Devon CCG -15N
For children

e-Referral selection

  • Speciality: Children's & Adolescent Services
  • Clinic type: ENT/Joint Voice Clinic
  • Service: DRSS-South Devon & Torbay-Children's & Adolescent Services- Devon CCG - 15N

Referral Forms

Head and Neck Cancer 2ww

DRSS Referral Form

Torbay and South Devon seeking advice form

Supporting Information

Patient Information

Hoarseness -patient information leaflet (ENT net website)

Common problems with the voice - patient leaflet (ENT net website)

Pathway Group

This guideline has been signed off by South Devon and Torbay CCG

Publication date: October 2017

Updated: January 2021

Last updated: 29-01-2021

 

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