What is the best course of action for a patient with posterior neck pain, left shoulder and back pain, and a gurgling or coarse voice, who had anterior neck surgery (anterior cervical spine surgery) with bone spur removal and has stable vital signs (VSS), with the voice symptom present prior to surgery, resolving post-operatively, and now returning?

Management of Post-Anterior Cervical Surgery Voice Changes and Pain

This patient requires urgent laryngoscopy within 24-48 hours to evaluate for recurrent laryngeal nerve (RLN) injury, as the return of voice changes after anterior cervical spine surgery is a red flag for serious underlying pathology. 1, 2

Immediate Priority: Laryngoscopy Evaluation

The American Academy of Otolaryngology-Head and Neck Surgery explicitly identifies "unresolving hoarseness after surgery (intubation or neck surgery)" as a condition requiring suspicion of serious underlying cause. 1 The patient's gurgling/coarse voice that initially resolved but has now returned is particularly concerning and mandates expedited laryngeal visualization. 1

Why Urgent Laryngoscopy is Critical

• Anterior cervical spine surgery causes hoarseness in up to 50% of patients immediately post-operatively, with RLN injury occurring in a subset of these cases. 2
• The fact that the voice symptom resolved and then recurred suggests either delayed nerve injury manifestation or a new complication rather than simple post-operative inflammation. 2
• Early diagnosis of vocal fold paralysis can effectively alleviate significant negative health and quality of life consequences and prevent aspiration complications. 1, 2
• Laryngoscopy should occur between 2 weeks and 2 months following surgery for new-onset postoperative dysphonia, but given the recurrence pattern here, evaluation should be expedited. 1

Assessment for Airway Emergency

Before arranging laryngoscopy, immediately assess for signs requiring emergency department referral:

• Respiratory distress or stridor (suggests bilateral RLN palsy, which is a medical emergency). 2
• Difficulty swallowing saliva or aspiration symptoms (impaired airway protection). 2
• Fever >101.5°F (suggests infection). 1
• Rapidly enlarging neck swelling or visible neck mass. 3

If any of these are present, send to the emergency department immediately rather than scheduling outpatient laryngoscopy. 3

Differential Diagnosis to Consider

The combination of posterior neck pain, left shoulder/back pain, and recurrent voice changes suggests:

Most Likely: Recurrent Laryngeal Nerve Injury

• RLN injury from anterior cervical surgery presents with hoarseness as the most common symptom. 2
• Recovery from RLN injury usually occurs within 1-3 months, but the recurrence of symptoms after initial improvement is atypical and concerning. 2
• Unilateral RLN palsy can cause aspiration of food and liquids due to impaired airway protection. 2

Also Consider: C5 Nerve Root Irritation

• The posterior neck and left shoulder/back pain pattern could represent C5 radiculopathy or nerve root irritation from the surgical site. 4
• However, this would not explain the voice changes, making RLN injury the primary concern. 4

Referral and Diagnostic Plan

Refer to otolaryngology urgently (within 24-48 hours) with the following information: 3

• Date of anterior cervical surgery and specific procedure performed
• Timeline: voice symptom present pre-operatively → resolved post-operatively → now returned
• Duration of intubation if known
• Current voice characteristics (gurgling/coarse quality)
• Associated posterior neck and left shoulder/back pain

Symptomatic Management While Awaiting Laryngoscopy

• Advise voice rest and avoidance of throat clearing or excessive coughing. 3
• Maintain adequate hydration to keep vocal cords moist. 3
• Address posterior neck pain with conservative measures (NSAIDs if not contraindicated, gentle range of motion). 5, 6
• Do not prescribe antibiotics, as they are not indicated for hoarseness. 1

Critical Safety Net Instructions

Instruct the patient to go to the emergency department immediately if they develop: 3, 2

• Difficulty breathing or shortness of breath at rest
• Inability to swallow saliva
• Choking episodes with eating or drinking
• High fever
• Rapidly worsening voice or complete voice loss

Common Pitfall to Avoid

Do not attribute the recurrent voice changes to "normal post-surgical inflammation" or adopt a watch-and-wait approach. 3 The pattern of symptom resolution followed by recurrence after anterior cervical surgery is not typical post-operative course and mandates visualization of the larynx to rule out RLN injury or other serious complications. 1, 2 The posterior neck pain may distract from the more serious concern of the voice changes, but the voice symptom takes priority for urgent evaluation. 1, 2