What is the appropriate management for a patient with a 30-year smoking history presenting with a hoarse voice and potential respiratory issues?

Management of Hoarseness in a 30-Year Smoker

This patient requires expedited laryngeal examination by an otolaryngologist to rule out head and neck cancer, as the combination of 30-year smoking history and hoarseness is a red flag that mandates urgent evaluation. 1

Immediate Action Required

Expedited laryngeal evaluation is strongly recommended because history of tobacco abuse is a specific indication for escalation of care in patients with hoarseness. 1 The American Academy of Otolaryngology-Head and Neck Surgery provides a strong recommendation that clinicians must assess patients with dysphonia and smoking history through expedited laryngeal examination, as delay in head and neck cancer diagnosis results in higher initial staging, more invasive oncologic treatments, and worse quality of life outcomes. 1

Why This Is Urgent

• Smoking increases the odds of head and neck cancer 2- to 3-fold, and dysphonia in smokers is of particular concern with prevalence rates of laryngeal pathology ranging from 15% to 24%. 1
• Delayed referral to otolaryngology is more evident among patients eventually diagnosed with laryngeal cancer, and several observational studies demonstrate that diagnostic delay leads to reduced survival rates. 1
• Early detection is critical because patients and clinicians often overlook the relationship between dysphonia and head and neck cancer, resulting in delayed referral despite clear historical risk factors. 1

Concurrent Evaluation for Lung Disease

While arranging urgent ENT referral, simultaneously evaluate for chronic obstructive pulmonary disease and lung cancer:

Lung Cancer Screening

• Low-dose CT chest is indicated for patients aged 55-80 years with 30 or more pack-years smoking history who currently smoke or quit within the last 15 years. 1
• Never assume COPD or chronic bronchitis explains symptoms in a smoker—lung cancer must be ruled out in all patients with persistent pulmonary symptoms and smoking history. 2
• Pulmonary nodules represent the most typical radiographic presentation of early lung cancer, and CT chest is superior to plain radiography for detection. 2

COPD Assessment

• Spirometry is essential to confirm COPD diagnosis, with post-bronchodilator FEV1/FVC ratio <0.70 being diagnostic. 3
• The European Respiratory Society suggests that patients over 50 years who are long-term smokers with chronic breathlessness should be treated as having suspected COPD. 3
• Physical examination should identify wheezing during tidal breathing, prolonged forced expiratory time (>5 seconds), and use of accessory respiratory muscles. 3

Clinical Examination Details

The head and neck examination must include:

• Full head and neck examination with perceptual voice evaluation, inspection and palpation of the neck for masses or lesions. 1
• Indirect mirror laryngoscopy if feasible at initial presentation. 1
• Assessment for concomitant neck mass or lymphadenopathy, which could represent more advanced disease. 1
• Observations of swallowing and breathing to assess for discomfort or difficulty. 1

Smoking Cessation Intervention

Provide immediate smoking cessation counseling, as this is the only proven way of modifying the natural course of COPD and reducing risk for myocardial infarction and lung cancer. 4

• Offer nicotine replacement therapy (gum or transdermal patches) combined with behavioral intervention, which increases success rates. 3
• Provide clear explanation of smoking's effects and benefits of stopping, with strong encouragement to quit abruptly rather than gradually. 3
• Multiple attempts are often needed—approximately one-third of patients quit with support. 3

Common Pitfalls to Avoid

• Do not adopt a "wait and see" approach for hoarseness in a smoker—this delays potentially life-saving cancer diagnosis. 1, 2
• Do not assume hoarseness is simply from smoking-related irritation without direct laryngeal visualization. 1
• Do not delay investigation even if the patient has known COPD, as this does not exclude concurrent malignancy. 2
• Do not rely solely on physical signs to assess severity of airflow limitation in COPD, as they are poor guides. 3

Documentation Requirements

Document the rationale for escalation of care in the patient's medical record, specifically noting the 30-year smoking history as indication for expedited laryngeal evaluation. 1