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

Initial Workup for Voice Hoarseness

For patients presenting with voice hoarseness (dysphonia), initial workup should include targeted history, physical examination, and laryngoscopy if symptoms persist beyond 2-3 weeks or if concerning features are present. 1, 2

Initial Assessment

History and Physical Examination

• Key elements to assess:
  • Duration of hoarseness
  • Associated symptoms (dysphagia, dyspnea, hemoptysis)
  • Risk factors (smoking, alcohol use, voice overuse)
  • Recent neck surgery or trauma
  • Medication review (potential medication-induced hoarseness)
  • Occupational voice demands (professional voice users)
  • Neurological symptoms

Red Flags Requiring Expedited Evaluation

• Tobacco or alcohol use history
• Concomitant neck mass
• Hemoptysis
• Progressive symptoms
• Professional voice users
• Recent neck surgery (especially thyroid or cervical spine)
• Trauma to the neck or larynx
• Dysphagia or odynophagia
• Stridor or airway compromise 2

Diagnostic Approach

Laryngoscopy

• Timing for laryngoscopy:
  • Perform within 2-3 weeks if symptoms persist without a clear benign cause 1, 3
  • Perform earlier (immediate referral) if risk factors for malignancy are present 4
  • Perform within 2 weeks to 2 months for post-surgical patients 2

Imaging

• Not routinely indicated in initial workup unless specific concerns
• Consider after laryngoscopy if needed based on findings
• CT with contrast is preferred when evaluating for laryngeal tumors or vocal cord paralysis 5
• For left vocal cord paralysis, CT neck should extend to aorticopulmonary window 5

Common Causes of Hoarseness

• Acute laryngitis (42.1%) 4
• Functional vocal disturbances (30%) 4
• Benign vocal fold lesions (10.7-31%) 4
• Chronic laryngitis (9.7%) 4
• Vocal cord paralysis (2.8-8%) 4
• Malignancy (2.2-3%) 4
• Physiologic aging of the voice (2%) 4
• Psychogenic factors (2-2.2%) 4

Initial Management

Conservative Measures

• Voice rest (especially avoiding whispering) 3
• Vocal hygiene education 6
• Adequate hydration
• Avoid irritants (smoking, alcohol)

Targeted Treatment

• Avoid empiric use of:
  • Antibiotics
  • Oral corticosteroids
  • Antireflux medications without confirmed diagnosis 1, 3

Referral Indications

• Symptoms persisting >2-3 weeks
• Presence of any red flags
• Failed conservative management
• Suspected malignancy
• Airway compromise
• Professional voice users with persistent symptoms 2, 6

Voice Therapy

• Indicated when conservative measures fail
• Particularly beneficial for:
  • Functional dysphonia
  • Benign vocal fold lesions
  • Professional voice users
  • Prophylaxis in high-risk individuals 3, 7

Common Pitfalls to Avoid

1. Delaying laryngoscopy in high-risk patients
2. Empiric prescription of antibiotics or corticosteroids without clear indication
3. Overlooking medication-induced causes of hoarseness
4. Failing to consider systemic or neurologic causes
5. Inadequate follow-up for persistent symptoms
6. Assuming reflux as the cause without proper evaluation 1, 3, 7