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Referral
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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.
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 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
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 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 ICB -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 ICB - 15N
Referral Forms
Patient Information
Hoarseness -patient information leaflet (ENT net website)
Pathway Group
This guideline has been signed off on behalf of NHS Devon.
Publication date: October 2017
Updated: January 2021
