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

Workup for Voice Hoarseness

Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when hoarseness fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. 1

Initial Assessment

History

• Duration of hoarseness
• Smoking and alcohol use history (critical risk factors for malignancy)
• Occupation, especially voice professionals
• Recent intubation or neck surgery
• Medication review (especially inhaled corticosteroids)
• Associated symptoms:
  • Weight loss
  • Hemoptysis
  • Dysphagia
  • Odynophagia
  • Otalgia
  • Neck mass
  • Neurologic symptoms
  • Airway compromise 2

Physical Examination

• Assess voice characteristics (roughness, breathiness, strain)
• Examine oral cavity and oropharynx
• Palpate neck for masses or lymphadenopathy
• Evaluate for signs of systemic diseases that may affect the voice 1, 2

Diagnostic Approach

Laryngoscopy Timing

• Perform laryngoscopy or refer for laryngoscopy when:
  • Hoarseness persists >4 weeks (updated from previous 3-month recommendation) 1
  • Any duration if serious underlying cause is suspected 1
  • Immediate evaluation for patients with:
    • History of tobacco/alcohol use
    • Neck mass
    • Hemoptysis
    • Post-trauma hoarseness
    • Dysphagia/odynophagia
    • Unexplained weight loss
    • Worsening hoarseness
    • Immunocompromised status
    • Possible foreign body aspiration
    • Neonatal hoarseness
    • Post-surgical hoarseness (intubation/neck surgery) 1, 2

Laryngoscopy Methods

• Transoral rigid endoscopy
• Transnasal flexible fiberoptic laryngoscopy
• Distal-chip laryngoscopy
• Consider stroboscopy (can alter diagnosis in up to 47% of cases by revealing functional abnormalities) 2

Imaging

• Do not obtain CT or MRI prior to visualization of the larynx 1, 2
• Consider imaging after laryngoscopy based on findings:
  • If vocal fold paralysis is identified, image from skull base to thoracic inlet/arch of aorta
  • If mass lesion is identified, proceed with biopsy and appropriate staging workup 2, 3

Management Considerations

Avoid Inappropriate Empiric Treatment

• Do not routinely prescribe antibiotics for hoarseness
• Do not prescribe antireflux medications for isolated hoarseness without laryngoscopy
• Do not routinely prescribe corticosteroids prior to visualization of the larynx 1, 2

Appropriate Interventions

• Voice rest (especially avoiding whispering)
• Voice therapy for functional and organic vocal disturbances
• Consider surgery for:
  • Suspected malignancy
  • Symptomatic benign vocal fold lesions not responding to conservative management
  • Glottic insufficiency 1

Common Pitfalls to Avoid

• Delaying evaluation in high-risk patients (especially smokers)
• Empiric medication use without proper diagnosis
• Incomplete examination of the vocal tract during laryngoscopy
• Waiting too long for referral (>3 months can double healthcare costs and delay diagnosis) 1, 2

Special Considerations

• Professional voice users may require more urgent evaluation
• Smokers with persistent hoarseness require prompt laryngoscopy regardless of duration
• Complete head and neck examination for suspected laryngeal cancer 2

The updated guidelines emphasize earlier evaluation (4 weeks versus previous 3 months) to prevent delayed diagnosis of serious conditions and improve outcomes 1.