Should I order an MRI (Magnetic Resonance Imaging) for a patient with dysphonia and a history of cancer?

Management of Dysphonia in a Patient with Cancer History

For a patient with dysphonia and history of cancer, you should NOT order an MRI prior to visualization of the larynx. Instead, perform laryngoscopy or refer to a clinician who can perform laryngoscopy to directly visualize the larynx first 1.

Initial Approach to Dysphonia with Cancer History

• Dysphonia in a patient with cancer history requires prompt evaluation due to increased risk of serious underlying pathology 1
• The American Academy of Otolaryngology-Head and Neck Surgery strongly recommends expedited laryngeal evaluation in patients with history of cancer 1, 2
• Delayed diagnosis of laryngeal cancer can lead to higher stages of disease and worse prognosis 3

Diagnostic Algorithm

1. First Step: Laryngoscopy

   • Perform laryngoscopy or refer to a clinician who can perform laryngoscopy as the initial diagnostic step 1
   • Laryngoscopy is the cornerstone of diagnosis and should be performed before any advanced imaging 1, 2
   • Direct visualization allows for identification of vocal fold lesions, paralysis, or other laryngeal pathology 1

2. When to Consider Advanced Imaging

   • Only after laryngoscopy has been performed should advanced imaging be considered 1
   • CT or MRI should not be obtained for patients with primary voice complaints prior to visualization of the larynx 1
   • Advanced imaging may be appropriate after laryngoscopy if findings suggest the need for further evaluation 1

Rationale Against Initial MRI

• Ordering MRI before laryngoscopy is explicitly recommended against in clinical practice guidelines 1
• Unnecessary imaging increases healthcare costs and may expose patients to contrast-related risks 1
• Laryngoscopy provides direct visualization and is more cost-effective as the initial diagnostic approach 1
• Delayed otolaryngology referral (>3 months) more than doubles healthcare costs and may delay appropriate diagnosis 1

Special Considerations in Cancer Patients

• Patients with history of cancer require expedited evaluation due to higher risk of recurrence or new primary malignancies 1
• Seeking medical assistance for dysphonia is associated with improved survival rates in laryngeal cancer 3
• Dysphonia in cancer patients may result from treatment effects including radiation-induced fibrosis or neuropathy 4
• Patients who have undergone head and neck surgery, radiation, or chemotherapy are at higher risk for vocal fold paralysis and other laryngeal pathologies 4, 5

Follow-up After Laryngoscopy

• If laryngoscopy reveals concerning findings, then appropriate imaging can be ordered based on those specific findings 1
• For benign findings amenable to voice therapy, refer for specialized voice rehabilitation 6, 4
• Document resolution, improvement, or worsening of symptoms after evaluation and treatment 1, 2

Common Pitfalls to Avoid

• Delaying laryngoscopy while pursuing advanced imaging can lead to delayed diagnosis and worse outcomes 3
• Assuming dysphonia is simply due to prior cancer treatment without proper evaluation 4, 7
• Failing to recognize that dysphonia may be the first sign of recurrent disease or a new primary cancer 3, 7