Initial Workup for Chronic Hoarseness
Patients with chronic hoarseness should undergo laryngoscopy if symptoms persist beyond 3 months or earlier if concerning features are present. 1
Definition and Initial Assessment
Hoarseness (dysphonia) is defined as altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life. The initial workup should focus on:
Key History Elements
- Duration of symptoms (acute vs chronic)
- Onset (sudden vs gradual)
- Pattern (constant vs intermittent)
- Risk factors for serious pathology:
- Tobacco and alcohol use
- Recent neck surgery or intubation
- Radiation treatment to the neck
- Professional voice use (singers, teachers)
- Accompanying symptoms (dysphagia, hemoptysis, weight loss)
Specific Questions to Ask
- Voice-specific questions:
- Changes in pitch or range
- Voice fatigue with use
- Pain when talking
- Increased effort when speaking
- Voice breaks or cracks
Associated Symptoms to Document
- Globus sensation (lump in throat)
- Dysphagia or odynophagia
- Chronic throat clearing
- Cough
- Reflux symptoms
- Weight loss
- Hemoptysis
- Neck mass
- Breathing difficulties
Laryngoscopy Timing Algorithm
Immediate laryngoscopy indicated for:
- Hoarseness with history of tobacco/alcohol use
- Presence of neck mass
- Post-trauma hoarseness
- Hoarseness with hemoptysis, dysphagia, odynophagia, otalgia, or airway compromise
- Neurologic symptoms
- Unexplained weight loss
- Worsening hoarseness
- Immunocompromised patients
- Suspected foreign body aspiration
- Neonatal hoarseness
- Persistent hoarseness after surgery or intubation
Laryngoscopy within 3 months for:
- Any hoarseness persisting beyond 3 months without obvious benign cause
Important Cautions
- Do not obtain CT or MRI before laryngoscopy - imaging should only follow visualization of the larynx 1
- Do not empirically treat with antibiotics or corticosteroids without establishing diagnosis 2
- Do not delay referral beyond 3 months as this more than doubles healthcare costs and may delay diagnosis of serious conditions 1
Common Etiologies to Consider
- Acute and chronic laryngitis (42.1% and 9.7% respectively)
- 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%)
Special Populations
- Children: Often have vocal fold nodules (77% of cases)
- Elderly: Consider vocal fold atrophy, neurologic disorders (Parkinson's, stroke)
- Professional voice users: Lower threshold for specialist referral
- Smokers: Require expedient assessment for malignancy
- Post-surgical/intubation: Consider vocal fold immobility or trauma
Pitfalls to Avoid
- Delaying laryngoscopy beyond 3 months in persistent cases
- Ordering imaging before laryngoscopy
- Missing red flags that warrant immediate evaluation
- Attributing hoarseness to reflux without proper laryngeal examination
- Failing to recognize the impact on quality of life, especially in professional voice users
Early visualization of the larynx in appropriate cases leads to shorter time to diagnosis, more cost-effective care, and prevention of delayed diagnosis of potentially serious conditions 1.