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

Initial Workup for Hoarseness (Dysphonia)

The initial workup for a patient with hoarseness should include a thorough history and physical examination, with laryngoscopy performed if symptoms persist beyond 4 weeks or immediately if serious underlying causes are suspected. 1, 2

Initial Assessment

• Identify dysphonia by recognizing altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life 1

• Assess the patient with specific voice-related questions to determine:

  • Onset (abrupt vs. slowly progressive) 1
  • Duration and pattern (constant vs. intermittent) 1
  • Association with upper respiratory tract infection 1
  • Presence of pain or effort when talking 1
  • Voice deterioration or fatigue with use 1
  • Changes in pitch, loudness, or projection ability 1

• Document associated symptoms that may indicate serious pathology:

  • Dysphagia, odynophagia, hemoptysis 1
  • Neck mass 1
  • Unexplained weight loss 1
  • Otalgia 1
  • Airway compromise 1
  • Neurologic symptoms 1

Risk Factor Assessment

• Obtain history of:
  • Tobacco and alcohol use (increases risk of malignancy) 1, 2
  • Recent intubation or surgery involving head, neck, or chest 1, 2
  • Occupational voice demands (professional voice users) 1, 2
  • Inhaled medication use (corticosteroids may cause dysphonia) 1
  • Radiation therapy to head and neck 1
  • Neurologic or arthritic conditions 1

Laryngoscopy Timing

• Perform laryngoscopy or refer to a clinician who can perform it when:

  • Hoarseness fails to resolve or improve within 4 weeks 1, 2
  • Serious underlying cause is suspected, regardless of duration 1, 2

• Conditions requiring immediate laryngoscopy include:

  • History of tobacco or alcohol use 1, 2, 3
  • Concomitant neck mass 1, 2
  • Hoarseness after trauma 1
  • Hoarseness with hemoptysis, dysphagia, odynophagia, otalgia, or airway compromise 1, 2
  • Accompanying neurologic symptoms 1
  • Unexplained weight loss 1, 2
  • Worsening hoarseness 1, 2
  • Immunocompromised host 1, 2
  • Possible foreign body aspiration 1, 2
  • Hoarseness in a neonate 1, 2
  • Unresolving hoarseness after surgery or intubation 1, 2
  • Professional voice users with significant vocal demands 1, 2

Imaging Considerations

• Do not obtain CT or MRI for patients with a primary voice complaint prior to visualization of the larynx 1, 2
• Imaging should only be considered after laryngoscopy has been performed 4

Common Pitfalls to Avoid

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

Clinical Implications

• Delayed diagnosis of laryngeal cancer can lead to higher disease stages and worse prognosis 1
• Delaying otolaryngology referral beyond 3 months more than doubles healthcare costs 1
• Advanced laryngeal visualization (e.g., stroboscopy) changes the initial diagnosis in up to 56% of cases 1
• Most hoarseness is caused by benign conditions, but early identification of serious disorders improves outcomes 1, 3