What is the recommended initial imaging study for a patient with voice hoarseness after anterior neck surgery, should it be a CT (Computed Tomography) of the C-spine (cervical spine) with or without contrast?

Imaging for Voice Hoarseness After Anterior Neck Surgery

For voice hoarseness after anterior neck surgery, direct laryngoscopy is the essential first diagnostic step, not CT imaging—and if imaging is needed to evaluate the recurrent laryngeal nerve pathway, CT neck with contrast extending to the aorticopulmonary window is the appropriate study. 1, 2

Initial Diagnostic Approach

Laryngoscopy must be performed before ordering any imaging studies. 2 This is critical because:

• The incidence of recurrent laryngeal nerve (RLN) palsy after anterior cervical spine surgery ranges from 1.27% to 50% depending on whether laryngoscopy is performed, with clinical hoarseness occurring in only 8.3% while asymptomatic vocal cord dysfunction occurs in 15.9% of cases 1, 3
• Direct visualization by laryngoscopy identifies vocal cord paralysis, medialization of the arytenoid cartilage, true vocal cord atrophy, and other structural abnormalities that confirm the diagnosis 2, 4
• Approximately 80% of vocal fold paralysis after anterior cervical spine surgery resolves within 12 months, making early laryngoscopic documentation essential for prognosis 5

When CT Imaging Is Indicated

If laryngoscopy confirms vocal cord paralysis and imaging is needed to identify the etiology along the RLN pathway, CT neck with IV contrast is the imaging of choice. 2 The study should:

• Extend from the skull base through the aorticopulmonary window (especially for left-sided paralysis, as the left recurrent laryngeal nerve loops under the aortic arch) 2
• Include contrast to evaluate for masses, hematomas, or other lesions compressing the nerve pathway 2
• Cover the entire course of the vagus nerve and recurrent laryngeal nerve from the medulla through the jugular foramen, carotid space, and upper mediastinum 2

CT Without Contrast Has No Role

CT cervical spine without contrast is not appropriate for evaluating hoarseness after anterior neck surgery because:

• The ACR Appropriateness Criteria do not support CT without contrast for soft tissue evaluation of the neck or laryngeal pathology 1
• CT without contrast cannot adequately assess for masses, inflammatory processes, or vascular lesions that may be compressing the recurrent laryngeal nerve 2
• The diagnostic question is about nerve injury and soft tissue pathology, not bony cervical spine trauma 1

Additional Diagnostic Considerations

Videofluoroscopic swallowing study and electromyography can complement laryngoscopy when evaluating for combined cranial nerve injuries (such as Tapia syndrome involving both the recurrent laryngeal and hypoglossal nerves), which can occur after anterior cervical spine surgery 4

Critical Pitfalls to Avoid

• Never order imaging before laryngoscopy—this violates the established diagnostic algorithm and may lead to unnecessary radiation exposure and cost 2
• Do not assume hoarseness alone indicates the severity of RLN injury—laryngoscopy reveals that two-thirds of RLN palsies are clinically silent without direct visualization 3
• For left-sided vocal cord paralysis, ensure CT imaging extends to the aorticopulmonary window to evaluate the full course of the left recurrent laryngeal nerve 2
• Recognize that most cases resolve spontaneously—83.3% of vocal fold paralysis after anterior cervical spine surgery recovers within 12 months with conservative management including speech therapy 5