Hoarseness and voice changes: causes, red flags and when to seek help

The voice is produced when air from the lungs passes between two bands of tissue, the vocal cords, in the voice box. Anything that swells, stiffens, thickens or weakens the cords, or that stops them closing neatly together, changes the sound. The result is a rough, breathy, weak or lower voice, or sometimes complete loss of voice.

Because the cords sit at the top of the airway, a persistent change is something clinicians take seriously: it is often the earliest sign of a cord problem that can be treated well if found promptly.

The NHS describes laryngitis as irritated or swollen vocal cords that usually comes on suddenly, gets worse over the first 3 days and is often linked to colds and flu. Its main symptoms are a hoarse voice, sometimes losing your voice, an irritating cough that does not go away, always needing to clear your throat, and a sore throat. It lists allergies to dust and fumes, acid reflux, long periods of coughing and constant throat clearing as other causes.

The NHS laryngeal cancer page lists the most common symptoms as a hoarse voice or change in your voice that does not go away, a lump or swelling in the neck, pain or difficulty when swallowing, and shortness of breath or difficulty breathing. Less common ones include an earache that does not go away, bad breath and unintentional weight loss. It says to see a GP for a hoarse voice or change in your voice that does not go away, a lump or swelling in your throat, including one that has been checked before but is getting bigger, or pain or difficulty swallowing.

The NHS lung cancer page also lists a hoarse voice that does not go away among less common symptoms, and the oesophageal cancer page lists a hoarse voice among its other symptoms, so persistent hoarseness may prompt a chest as well as a throat assessment.

The NHS says to contact NHS 111 if you have difficulty breathing, being more short of breath than usual, and to call 999 or go to A&E immediately if you have severe difficulty breathing, gasping, choking or being unable to get words out. For laryngitis it advises contacting 111 if it is very painful or difficult to swallow, and 999 or A&E if you or your child have difficulty breathing. A high-pitched noisy breath, drooling or being unable to swallow saliva is an emergency.

For laryngitis the NHS says the GP will try to work out the cause, may look inside your throat with a small mirror, take a swab, arrange a blood test or refer you to an ear, nose and throat (ENT) specialist if you keep getting laryngitis, and may prescribe antibiotics if an infection is the cause. For the laryngeal cancer page, the GP may look inside your mouth, feel your neck, listen to your chest and tummy, ask about family history and may arrange a blood test or chest X-ray, with referral to ENT, urgently if cancer is suspected. This does not definitely mean you have cancer.

The key test is laryngoscopy. In clinic, ENT passes a thin flexible camera through the nose to watch the vocal cords moving while you speak, which takes a few minutes with local anaesthetic spray. Videostroboscopy gives a slow-motion view of cord vibration. A biopsy under general anaesthetic is arranged if an abnormal area is seen.

The NHS advice for laryngitis is to speak as little as possible, drink plenty of fluids, keep the air moist with bowls of water because central heating and air conditioning dry it, and gargle with warm salty water for adults, not children. It says not to talk loudly or whisper, as both strain the voice, not to smoke, to avoid smoky or dusty places, and not to drink too much caffeine or alcohol, which can cause dehydration.

A pharmacist can suggest paracetamol or ibuprofen, cough syrup for the cough and gargles or lozenges for pain. If reflux is contributing, the measures in the heartburn guide help, such as avoiding late meals.

Wait a week or two if you have a cold and otherwise feel well. See your GP if the hoarseness has not improved in 2 weeks, keeps returning, or you have any of the warning symptoms above. Singers, teachers and others who rely on their voice may be referred to a voice therapist or speech and language therapist, who teaches voice use and vocal hygiene.