What investigations should be done for a patient with a hoarse voice and significant smoking history?

Investigations for a Patient with Hoarse Voice and Significant Smoking History

For a patient with hoarse voice and significant smoking history, laryngoscopy should be performed immediately to visualize the larynx, followed by chest CT imaging to evaluate for pulmonary pathology including lung cancer. 1

Initial Evaluation

• Patients with hoarse voice and significant smoking history require expedited laryngeal evaluation due to increased risk of laryngeal cancer and other serious underlying conditions 1
• A complete head and neck examination should be performed with particular attention to:
  • Perceptual evaluation of the voice quality 1
  • Inspection and palpation of the neck for masses or lesions 1
  • Assessment of swallowing and breathing for any discomfort or difficulty 1

Laryngoscopy

• Laryngoscopy is the primary diagnostic modality and should be performed immediately in patients with hoarse voice and tobacco abuse history 1
• Visualization of the larynx is essential to rule out serious underlying conditions such as laryngeal cancer, vocal fold paralysis, or other pathologies 1
• Stroboscopy may be considered when hoarseness symptoms are out of proportion to the initial laryngoscopic examination, allowing for assessment of vocal fold pliability 1

Chest Imaging

• CT chest imaging should be performed in patients with significant smoking history and hoarse voice 1
• CT chest is superior to chest radiography for detecting pulmonary nodules, with chest radiography having sensitivity as low as 28% compared to CT 1
• Options for chest imaging include:
  • CT chest with IV contrast: Provides superior detection of mediastinal and hilar adenopathy, and delineation of soft tissue extension of skeletal metastatic disease 1
  • CT chest without IV contrast: Appropriate for detecting pulmonary nodules and can be used if contrast is contraindicated 1
  • Low-dose CT (LDCT): May be appropriate for lung cancer screening in eligible patients with ≥20 pack-year smoking history who are aged 50-80 years 2, 3

Additional Imaging Considerations

• Imaging should not be obtained prior to visualizing the larynx 1
• After laryngoscopy, if vocal fold paralysis is identified, imaging from the skull base to the thoracic inlet/arch of the aorta is warranted to evaluate the entire path of the recurrent laryngeal nerve 1
• In cases where laryngoscopy identifies a suspicious lesion, further imaging may be necessary to determine the extent of disease 1

Common Pitfalls to Avoid

• Delaying laryngoscopy beyond 4 weeks in persistent hoarseness 4
• Ordering imaging studies before laryngoscopy 1, 4
• Using chest radiography alone for evaluation, as it has poor sensitivity for detecting pulmonary metastases or primary lung cancer 1
• Empiric treatment with antibiotics, corticosteroids, or proton pump inhibitors without visualization of the larynx 4
• Failing to recognize that smoking is a risk factor for both laryngeal cancer and primary lung cancer, requiring comprehensive evaluation 1

Specific Considerations for Smokers

• Smokers with hoarse voice have a higher risk of both laryngeal and lung cancer, necessitating thorough evaluation of both areas 1, 5
• Studies have shown that 7-14% of patients have a separate lung primary at the time of initial staging of head and neck squamous cell carcinoma 1
• Expanded analysis of CT scans in smokers can identify previously undiagnosed cardiovascular disease, emphysema, or osteoporosis that may require additional management 5

By following this systematic approach to investigating hoarse voice in patients with significant smoking history, clinicians can ensure timely diagnosis of potentially serious conditions and improve patient outcomes.