Is ultrasound indicated in a patient with persistent hoarseness?

Is Ultrasound Indicated in Persistent Hoarseness?

No, ultrasound is not indicated in the evaluation of persistent hoarseness—laryngoscopy is the essential diagnostic procedure, and imaging (if needed) should only follow direct visualization of the larynx. 1, 2, 3

Primary Diagnostic Approach

Laryngoscopy is mandatory when hoarseness persists beyond 4 weeks or immediately if red flags are present. 1, 2 The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends visualization of the larynx as the cornerstone of evaluation, not imaging studies. 1, 2

Critical Timing for Laryngoscopy

• Perform or refer for laryngoscopy within 4 weeks if hoarseness fails to improve, and no patient should wait longer than 3 months for laryngeal examination. 2, 4
• Immediate laryngoscopy is required regardless of duration if any red flags are present, including:
  • History of tobacco or alcohol use 1, 2
  • Concomitant neck mass 1, 2
  • Hemoptysis, dysphagia, odynophagia, or otalgia 1, 2
  • Unexplained weight loss or progressive worsening 1, 2
  • Recent neck/chest surgery or endotracheal intubation 1
  • Professional voice users 2, 4
  • Respiratory distress or airway compromise 2, 4

Why Ultrasound Is Not Appropriate

Ultrasound has no role in evaluating the vocal folds or laryngeal pathology causing hoarseness. 3 The larynx requires direct visualization to identify:

• Vocal fold paralysis 1, 3
• Laryngeal masses or malignancy 1, 3
• Benign vocal fold lesions (nodules, polyps, granulomas) 1, 5
• Functional or neurologic disorders 1

Ultrasound cannot assess vocal fold mobility, mucosal lesions, or the dynamic function of the larynx—all critical to diagnosing the cause of hoarseness. 3

When Imaging Is Appropriate (After Laryngoscopy)

CT with contrast is the imaging of choice, but only after laryngoscopy identifies specific pathology requiring further evaluation. 3

Specific Post-Laryngoscopy Imaging Indications

• Vocal fold paralysis found on laryngoscopy warrants CT imaging from skull base to thoracic inlet (including the aorticopulmonary window for left-sided paralysis) to evaluate the entire recurrent laryngeal nerve path. 2, 3
• Laryngeal tumors identified on laryngoscopy require CT with contrast to assess extent, staging, and treatment planning. 3
• Suspected mediastinal or intracranial pathology (in infants with hoarseness, consider Arnold-Chiari malformation or posterior fossa mass). 1

Critical Pitfalls to Avoid

• Never order imaging before laryngoscopy—this delays diagnosis, increases costs (from $271 to $711), and risks missing critical diagnoses like laryngeal cancer or vocal fold paralysis. 2, 4
• Do not empirically treat with antibiotics, corticosteroids, or anti-reflux medications without visualizing the larynx first. 2, 4
• Do not assume "laryngitis" or "reflux" without confirmation—56% of primary care diagnoses change after specialist laryngoscopy. 2
• Delaying laryngoscopy beyond 3 months significantly worsens outcomes for malignancy and increases healthcare costs. 2, 4

Clinical Algorithm

1. History and physical examination focusing on red flags (tobacco use, neck mass, dysphagia, weight loss, recent surgery/intubation, occupational voice demands). 1, 2
2. Laryngoscopy within 4 weeks (or immediately if red flags present) to visualize vocal folds and identify pathology. 1, 2, 4
3. If laryngoscopy reveals vocal fold paralysis: Order CT from skull base to aorticopulmonary window. 2, 3
4. If laryngoscopy reveals laryngeal mass: Order CT with contrast for staging and refer to oncology. 3
5. If laryngoscopy reveals benign lesions or functional dysphonia: Initiate voice therapy and vocal hygiene education. 4, 5

Ultrasound has no role at any step in this algorithm for evaluating hoarseness. 3