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

Initial Workup for Hoarseness

Patients with hoarseness should undergo laryngoscopy if symptoms persist beyond 4 weeks or immediately if a serious underlying cause is suspected, regardless of duration. 1

Initial Assessment

History

• Determine onset (abrupt vs. gradual), duration, and progression of hoarseness 2
• Assess voice characteristics using standardized evaluation (roughness, breathiness, asthenia, strain) 2
• Identify modifying factors:
  • Recent surgical procedures involving the neck or affecting recurrent laryngeal nerve 1
  • Recent endotracheal intubation 1
  • Radiation treatment to the neck 1
  • Tobacco and alcohol use history 1
  • Occupation requiring voice use (singers, teachers, clergy) 1
  • Exposure to irritants 2
  • Use of inhaled corticosteroids 1

Physical Examination

• Examination of oral cavity and oropharynx
• Neck examination for masses or lymphadenopathy
• Neurological assessment if neurological symptoms are present

Indications for Immediate Laryngoscopy

Laryngoscopy should be performed without delay if any of these "red flag" conditions are present 1:

• History of tobacco or alcohol use
• Neck mass
• History of trauma
• Associated symptoms:
  • Hemoptysis
  • Dysphagia/odynophagia
  • Otalgia
  • Airway compromise
• Neurological symptoms
• Unexplained weight loss
• Worsening hoarseness
• Immunocompromised status
• Possible foreign body aspiration
• Hoarseness in a neonate
• Persistent hoarseness after surgery or intubation

Timing of Laryngoscopy

• Immediate laryngoscopy: For any red flag symptoms or high-risk patients 1
• Within 4 weeks: If hoarseness persists without improvement 1
  • Note: The 2018 guideline update shortened this timeframe from 3 months (in the 2009 guideline) to 4 weeks 1
• Professional voice users: Consider earlier evaluation due to occupational impact 1

Imaging Considerations

• Do not obtain CT or MRI prior to visualization of the larynx 1
• Imaging should only be considered after laryngoscopy and based on findings 3

Common Pitfalls to Avoid

1. Delayed diagnosis: Waiting too long for laryngoscopy can lead to delayed diagnosis of serious conditions like laryngeal cancer, resulting in poorer outcomes 1

2. Inappropriate antibiotic use: Do not routinely prescribe antibiotics to treat hoarseness 1

3. Empiric antireflux medication: Do not prescribe antireflux medications for isolated hoarseness without laryngoscopy 1

4. Empiric corticosteroids: Do not routinely prescribe corticosteroids for hoarseness 1, 4

5. Relying solely on imaging: Laryngoscopy, not imaging, is the fundamental diagnostic tool for evaluating persistent hoarseness 2, 3

By following this evidence-based approach to the initial workup of hoarseness, clinicians can ensure timely diagnosis and appropriate management, potentially improving outcomes for patients with serious underlying conditions.