What is the recommended approach for evaluating hoarseness?

Recommended Approach for Evaluating Hoarseness (Dysphonia)

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

• Identify dysphonia in patients presenting with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life 1
• Conduct a targeted history and physical examination to identify underlying causes and factors that modify management 1
• Document specific voice characteristics, duration of symptoms, and associated symptoms 2

Expedited Evaluation Factors

Expedited laryngeal evaluation is indicated in patients with any of these risk factors:

• Recent surgical procedures involving the head, neck, or chest 1
• Recent endotracheal intubation 1
• Presence of concomitant neck mass 1
• Respiratory distress or stridor 1
• History of tobacco or alcohol abuse 1, 2
• Professional voice users (singers, teachers, public speakers) 1
• Hoarseness with hemoptysis, dysphagia, odynophagia, otalgia, or airway compromise 1
• Unexplained weight loss 1
• Progressive worsening of hoarseness 1
• Immunocompromised host 1
• Possible aspiration of a foreign body 1
• Hoarseness in a neonate 1
• Unresolving hoarseness after surgery 1

Diagnostic Approach

Timing of Laryngoscopy

• Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia (option) 1
• Laryngoscopy is required when hoarseness fails to resolve within 4 weeks (updated from previous 3-month recommendation in 2009 guideline) 1
• Immediate laryngoscopy is indicated regardless of duration if a serious underlying cause is suspected 1

Imaging Considerations

• Do not obtain CT or MRI for patients with a primary voice complaint prior to visualization of the larynx 1
• When imaging is needed after laryngoscopy, CT with contrast is the imaging of choice to evaluate laryngeal tumors and find the etiology of vocal cord paralysis 3
• For left vocal cord paralysis evaluation, CT neck must cover the aorticopulmonary window 3

Treatment Approach

Medications to Avoid for Empiric Treatment

• Do not routinely prescribe antibiotics to treat dysphonia 1
• Do not prescribe antireflux medications to treat isolated dysphonia based on symptoms alone without laryngoscopy 1
• Do not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx 1

Appropriate Interventions

• Perform diagnostic laryngoscopy before prescribing voice therapy and communicate results to the speech-language pathologist 1
• Voice therapy is effective for improving voice quality in patients with nonorganic dysphonia and for treating many benign pathologic vocal cord lesions 4, 5
• Consider surgery for conditions amenable to surgical intervention (suspected malignancy, symptomatic benign vocal fold lesions that don't respond to conservative management, glottic insufficiency) 1, 2
• Offer botulinum toxin injections for dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia 1

Preventive Measures and Follow-up

• Educate patients about vocal hygiene and control/preventive measures 1, 6
• Document resolution, improvement, or worsening of symptoms after treatment or observation 1
• Voice therapy may be helpful for prophylaxis in high-risk individuals (vocalists, public speakers) 2, 4

Common Pitfalls to Avoid

• Delaying laryngoscopy beyond 4 weeks in persistent hoarseness 1
• Empiric treatment with antibiotics, corticosteroids, or proton pump inhibitors without visualization of the larynx 1, 2
• Ordering imaging studies before laryngoscopy 1
• Failing to recognize risk factors requiring expedited evaluation 1
• Overlooking occupational voice demands when developing treatment plans 1, 2