For further detail about the cancer risk assessment of hoarseness, please see the RefHelp page on Neck Lump and Throat Cancer Risk Assessment.
Acute hoarseness is almost always due to an acute viral illness (laryngitis) and this can persist for a while.
Cancers are associated with constant (rather than intermittent) hoarseness – with the voice never being normal. The head and head and neck section of the Scottish Cancer Referral Guidelines outlines the risk factors:
- Socio-economic deprivation
- Smoking and tobacco chewing habits (including betel, gutkha, snus and pan)
- Human Papilloma Virus (HPV) (increasing incidence of oropharyngeal cancer in a younger population)
- Excessive alcohol use
- Recreational drug use (especially opioids and cannabis)
- Poor diet
- Older age.
In a large Scottish study, the mean age of diagnosis was 64. However, there is a changing pattern of disease (in particular HPV-associated cancers). Younger age and absence of smoking or alcohol history should not be barriers to referral if there are concerning features as described below.
Hoarseness due to infection can take some time to settle. Where there is a clear explanation for symptoms (persistent or post infection), and particularly when the person is otherwise low risk (<35 years, non-smoking, < 3 weeks) then it is appropriate to make a clinical judgement about duration of symptoms before referring.
Please consider other red flags particularly persistent unilateral throat pain, neck lump, symptoms suggestive of lung cancer, or a suspicious oral lesion.
Constant (NOT INTERMITTENT) hoarseness in those aged 35 or over, lasting for three weeks or more should be referred urgently for suspected cancer.
A.H. & C.M. – 2/2/26
Who to refer:
CONSTANT hoarseness lasting for ≥ three weeks in those aged 35 or over should be referred urgently, suspicious of cancer.
Intermittent hoarseness only needs to be referred when it is impacting significantly on the patient’s life. These patients are likely to be seen in a voice clinic with a speech and language therapist.
Who not to refer:
Hoarseness for which there is an explanation (most commonly acute infection), and which fully resolves in 3 weeks.
Those with SYMPTOMS SUGGESTIVE OF LUNG CANCER should have an urgent suspicion of cancer CXR and be referred to the respiratory services under the lung suspicion of cancer pathway.
How to refer:
SCI Gateway → Lauriston / St John’s → ENT → Throat.
