Adults and children with altered voice.

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
Episodic or Variable dysphonia for 3 weeks and:
  • Professional voice user, e.g., singer or teacher
  • High psychosocial distress


Trial of lifestyle advice

  • Advise against over use and abuse of voice
  • Check thyroid status
  • Hydration
  • Reflux treatment
  • Steroid inhaler technique review, consider use of a spacer
  • Consider chest x-ray
  • Smoking cessation if relevant

Follow up in 4 weeks or sooner if worsening

  • Check for new red flags


If symptoms resolve, plan to review the patient in primary care if indicated.

Patients with ongoing symptoms should be referred for a consultant opinion in ENT.

Chapter 12- ENT


Referral Criteria

  • Persistant altered voice
  • No red flags present and no improvement following the above treatment

Referral Instructions

2WW referrals

e-Referral Service selection

  • Specialty: 2ww
  • Clinic type: Head and Neck
  • Service: 2ww - Head and Neck – RD&E
For adults

e-Referral service selection

  • Specialty - ENT
  • Clinic type - Throat
  • Service - DRSS-Eastern-Ear Nose and Throat-Devon CCG- 15N
For children

e-Referral selection

  • Speciality: Children's & Adolescent Services
  • Clinic type: ENT
  • Service: DRSS-Eastern-Child & Adolescent Services-Devon CCG - 15N

Referral Forms

DRSS Referral Form

Supporting Information

Patient Information

Hoarseness -patient information leaflet (ENT Health website)

Throat (ENT Health website)


This guideline has been developed by Royal Devon and Exeter Healthcare Foundation Trust based on local guidelines.

Pathway Group

This guideline has been signed off by the Eastern Locality on behalf of NEW Devon CCG.

Publication date: 02 December 2016

Updated: April 2021

Last updated: 27-04-2021


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