What is the initial workup for a patient presenting with chronic hoarseness?

Initial Workup for Chronic Hoarseness

Laryngoscopy should be performed for any patient with hoarseness that persists beyond 3 months or at any time if a serious underlying cause is suspected. 1

Evaluation Timeline

• For most cases of new-onset hoarseness, initial observation for 2-3 weeks is reasonable as viral laryngitis (the most common cause) typically resolves within this timeframe 1
• Immediate laryngoscopy is warranted for patients with:
  • Risk factors for malignancy (tobacco/alcohol use, neck mass)
  • Concerning symptoms (hemoptysis, dysphagia, odynophagia, otalgia, airway compromise)
  • Neurological symptoms
  • Unexplained weight loss
  • Worsening hoarseness
  • Immunocompromised status
  • Possible foreign body aspiration
  • Neonatal hoarseness
  • Post-surgical hoarseness (intubation or neck surgery) 1
• Professional voice users (singers, teachers, performers) may benefit from immediate evaluation due to occupational impact 1

Diagnostic Approach

History

• Duration of symptoms
• Pattern (intermittent vs. persistent)
• Associated symptoms (cough, throat clearing, globus sensation)
• Voice use patterns (occupational demands)
• Exacerbating/alleviating factors
• Smoking/alcohol history
• Medical history (neurological conditions, reflux disease)
• Medication review (inhaled corticosteroids can cause hoarseness) 1

Physical Examination

• Complete head and neck examination
• Assessment for neck masses
• Cranial nerve examination
• Oral cavity and oropharyngeal examination

Key Diagnostic Test

1. Laryngoscopy: The cornerstone of evaluation
   • Should be performed when hoarseness persists >3 months
   • Should be performed earlier if concerning features present
   • Allows direct visualization of vocal folds and laryngeal structures 1

Important Caution

Do not obtain CT or MRI for patients with hoarseness before laryngoscopy. 1

• Imaging before laryngoscopy leads to:
  • Unnecessary radiation exposure
  • Increased costs
  • Potential overdiagnosis
  • Delayed appropriate diagnosis 1, 2

Common Causes of Chronic Hoarseness

• Chronic laryngitis (9.7-10%)
• Functional vocal disturbances (30%)
• Benign vocal cord lesions (10.7-31%)
• Malignant tumors (2.2-3%)
• Neurogenic disturbances/vocal cord paresis (2.8-8%)
• Age-related voice changes (2%)
• Psychogenic factors (2-2.2%) 3

Referral Considerations

• Delayed referral to otolaryngology (>3 months) more than doubles healthcare costs 1
• Referral to otolaryngology results in changed diagnosis in 56% of cases initially diagnosed as "acute laryngitis" or "nonspecific dysphonia" 1
• Multidisciplinary voice clinics (laryngologists and speech-language pathologists) change the underlying diagnosis in 45-70% of cases 1

Pitfalls to Avoid

1. Empirical treatment without visualization: Treating without establishing a diagnosis delays appropriate care and can mask serious conditions
2. Delayed referral: Waiting too long before referring to otolaryngology can worsen outcomes, especially for malignancy
3. Premature imaging: Obtaining CT/MRI before laryngoscopy is not recommended and increases costs without benefit
4. Overlooking red flags: Failing to recognize warning signs that require immediate evaluation
5. Misattributing symptoms: Assuming hoarseness is due to common causes without proper evaluation

Remember that while most cases of hoarseness are benign, persistent hoarseness requires thorough evaluation to rule out serious conditions and establish appropriate treatment.