Hoarse Voice That Won't Go Away: Causes & When to See a Doctor

What causes a hoarse voice to persist for weeks?

Hoarseness (dysphonia) occurs when the vocal cords do not vibrate smoothly. Acute hoarseness from a cold or vocal strain usually resolves within one to two weeks. When it lingers, the causes include:

Common benign causes - Laryngopharyngeal reflux (LPR) / GERD — stomach acid reaching the larynx irritates the vocal cords and is a common, underrecognised cause of chronic hoarseness 2Ref 2Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ (2022).ACG Clinical Guideline: Diagnosis and Management of Gastroesophageal Reflux Disease.Laryngopharyngeal reflux as a cause of chronic hoarseness without classic heartburn; lifestyle measures including head-of-bed elevation and dietary modification - Vocal nodules, polyps, or cysts — benign growths from overuse or misuse of the voice - Muscle tension dysphonia — abnormal tension in the laryngeal muscles, often triggered by stress or prolonged vocal overuse - Post-viral irritation — inflammation that outlasts the original respiratory infection - Hypothyroidism — swelling of laryngeal tissues can change voice quality; a blood test can check thyroid function - Inhaled corticosteroids — can cause fungal laryngitis if not rinsed from the mouth after each dose 1Ref 1Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. (2018).Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).Two-to-three week threshold for ENT evaluation of persistent hoarseness; laryngoscopy as the diagnostic standard; causes of dysphonia including reflux, vocal nodules, paralysis, and laryngeal malignancy; recommendations against empirical proton pump inhibitor therapy without laryngoscopy

Causes that require prompt investigation - Vocal cord paralysis — the cord is not moving properly, often because of nerve compression or injury from thyroid surgery, an aortic aneurysm, or a mass along the recurrent laryngeal nerve - Laryngeal cancer or other laryngeal growths — persistent hoarseness is one of the earliest symptoms; smoking and alcohol are the main risk factors 1Ref 1Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. (2018).Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).Two-to-three week threshold for ENT evaluation of persistent hoarseness; laryngoscopy as the diagnostic standard; causes of dysphonia including reflux, vocal nodules, paralysis, and laryngeal malignancy; recommendations against empirical proton pump inhibitor therapy without laryngoscopy

Why does the two-to-three-week rule exist?

Most infectious or inflammatory causes of hoarseness resolve within two weeks. The AAO-HNS clinical practice guideline recommends that a clinician should visualise the larynx when hoarseness persists beyond two to three weeks without an obvious, resolving explanation — not because most causes are serious, but because early detection of laryngeal conditions, when they are present, significantly improves outcomes 1Ref 1Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. (2018).Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).Two-to-three week threshold for ENT evaluation of persistent hoarseness; laryngoscopy as the diagnostic standard; causes of dysphonia including reflux, vocal nodules, paralysis, and laryngeal malignancy; recommendations against empirical proton pump inhibitor therapy without laryngoscopy.

Higher-risk groups — smokers, former smokers, people who use alcohol heavily, and professional voice users (teachers, singers, call-centre workers) — should have a lower threshold and seek evaluation sooner.

What happens at an ENT appointment for hoarseness?

An ENT specialist will typically perform laryngoscopy — a visualisation of the larynx and vocal cords. This can be done in the clinic with a flexible thin camera passed through the nose (flexible nasolaryngoscopy) or with a rigid scope via the mouth. The procedure takes a few minutes and is well tolerated.

Laryngoscopy allows the specialist to see: - Whether the vocal cords are moving symmetrically - Nodules, polyps, cysts, or other benign lesions - Signs of reflux irritation (redness, swelling of the arytenoids) - Any suspicious mucosal change that might need biopsy

The AAO-HNS guideline specifically recommends against prescribing empirical anti-reflux treatment as a substitute for laryngoscopy in patients with persistent hoarseness 1Ref 1Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. (2018).Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).Two-to-three week threshold for ENT evaluation of persistent hoarseness; laryngoscopy as the diagnostic standard; causes of dysphonia including reflux, vocal nodules, paralysis, and laryngeal malignancy; recommendations against empirical proton pump inhibitor therapy without laryngoscopy. The larynx needs to be examined directly. Depending on findings, further tests may include voice assessment with a speech-language pathologist, neck and chest imaging, or thyroid function tests.

What can be done at home while waiting for an appointment?

The following measures may ease discomfort and support healing, but they do not replace clinical evaluation:

• Hydration — keeping vocal cords moist helps healing; sip water throughout the day
• Voice rest — avoid whispering (which strains the cords as much as loud speech) and unnecessary vocal use
• Avoid irritants — tobacco smoke, alcohol, and acidic foods can worsen laryngeal inflammation
• Elevate the head of the bed — if reflux may be contributing, lying with the head slightly elevated reduces nighttime acid exposure 2Ref 2Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ (2022).ACG Clinical Guideline: Diagnosis and Management of Gastroesophageal Reflux Disease.Laryngopharyngeal reflux as a cause of chronic hoarseness without classic heartburn; lifestyle measures including head-of-bed elevation and dietary modification
• Steam inhalation — can relieve dryness; does not treat the underlying cause 3Ref 3National Library of Medicine (MedlinePlus) (2024).Hoarseness.Common and serious causes of hoarseness; when to contact a doctor (persisting beyond 2–3 weeks in adults or 1 week in children); home management while awaiting evaluation

Do not delay seeking care while waiting to see if these measures help. If hoarseness has been present for more than two to three weeks, book an appointment rather than continuing to self-manage 1Ref 1Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. (2018).Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).Two-to-three week threshold for ENT evaluation of persistent hoarseness; laryngoscopy as the diagnostic standard; causes of dysphonia including reflux, vocal nodules, paralysis, and laryngeal malignancy; recommendations against empirical proton pump inhibitor therapy without laryngoscopy.

What does ENT evaluation involve beyond laryngoscopy?

Once the larynx has been examined, the next steps depend on what is found:

• Benign vocal lesions (nodules, polyps) — voice therapy with a speech-language pathologist is first-line; surgical removal is reserved for lesions that do not respond 1Ref 1Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. (2018).Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).Two-to-three week threshold for ENT evaluation of persistent hoarseness; laryngoscopy as the diagnostic standard; causes of dysphonia including reflux, vocal nodules, paralysis, and laryngeal malignancy; recommendations against empirical proton pump inhibitor therapy without laryngoscopy
• Reflux-related hoarseness — dietary and lifestyle changes alongside medication; a confirmed LPR diagnosis on endoscopy or pH monitoring guides treatment 2Ref 2Katz PO, Dunbar KB, Schnoll-Sussman FH, Greer KB, Yadlapati R, Spechler SJ (2022).ACG Clinical Guideline: Diagnosis and Management of Gastroesophageal Reflux Disease.Laryngopharyngeal reflux as a cause of chronic hoarseness without classic heartburn; lifestyle measures including head-of-bed elevation and dietary modification
• Vocal cord paralysis — investigation to identify the cause (imaging of the neck and chest); treatment depends on the aetiology
• Suspicious lesion — biopsy under anaesthesia; early laryngeal cancer detected before it spreads is highly treatable 1Ref 1Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, et al. (2018).Clinical Practice Guideline: Hoarseness (Dysphonia) (Update).Two-to-three week threshold for ENT evaluation of persistent hoarseness; laryngoscopy as the diagnostic standard; causes of dysphonia including reflux, vocal nodules, paralysis, and laryngeal malignancy; recommendations against empirical proton pump inhibitor therapy without laryngoscopy

Gale can help you book a primary care review to start the process, and coordinate ENT referral when laryngoscopy is indicated.