What is the appropriate evaluation and management for a patient with sudden onset hoarseness of unknown cause?

Sudden Hoarse Voice: Evaluation and Management

Immediate Diagnostic Decision

Perform laryngoscopy or refer to a specialist who can perform laryngoscopy within 4 weeks if hoarseness persists, or immediately if any red flags are present, regardless of symptom duration. 1, 2

Initial Assessment: What to Look For

Critical Red Flags Requiring Immediate Laryngoscopy (Same Day to Within Days)

• Tobacco or alcohol use history – significantly increases risk of laryngeal malignancy 2, 3
• Hemoptysis, dysphagia, odynophagia, or otalgia – suggests possible malignancy or advanced disease 2, 3
• Concomitant neck mass – requires urgent evaluation for malignancy 2, 3
• Unexplained weight loss or night sweats – concerning for systemic disease or malignancy 1
• Recent neck, chest, or thyroid surgery – may indicate recurrent laryngeal nerve injury 2, 3
• Recent endotracheal intubation – can cause vocal fold injury or paralysis 2
• Respiratory distress or stridor – suggests airway compromise requiring immediate intervention 2
• Professional voice user (teacher, singer, public speaker) – occupational impact warrants expedited evaluation 2, 3
• Progressive worsening of symptoms – suggests evolving pathology 3
• Immunocompromised status – increases risk of opportunistic infections 3

Pertinent History Elements

• Onset pattern: sudden versus gradual onset 1
• Voice characteristics: pitch changes, vocal effort required, voice fatigue with use, difficulty projecting 1
• Associated symptoms: chronic throat clearing, cough, globus sensation, acid reflux, heartburn, post-nasal drainage 1
• Medication review: inhaled corticosteroids (can cause fungal laryngitis or direct irritation) 3
• Occupational voice demands: extent of voice use at work 1, 2
• Prior episodes of hoarseness and their resolution 1

Timeline for Laryngoscopy

Most viral laryngitis resolves within 1-3 weeks. 1, 3 The guideline-based algorithm is:

• Hoarseness ≤3 weeks without red flags: Observation is reasonable, as viral laryngitis typically resolves spontaneously 1, 3
• Hoarseness >3-4 weeks: Laryngoscopy is mandatory, as symptoms exceeding this duration raise concern for non-self-limiting pathology 1, 2
• Any red flags present: Immediate laryngoscopy regardless of duration 1, 2
• Maximum wait time: No patient should wait longer than 3 months for laryngeal examination 2, 4

What NOT to Do Before Laryngoscopy

Do not empirically prescribe antibiotics, corticosteroids, or proton pump inhibitors without visualizing the larynx first. 1, 2, 4 This approach:

• Delays accurate diagnosis in 56% of cases (primary care diagnoses change after specialist laryngoscopy) 2
• Misses critical diagnoses including laryngeal cancer (293 cases), vocal fold paralysis (369 cases), and benign vocal fold pathology (1,384 cases) in one large study 1
• More than doubles healthcare costs when referral is delayed beyond 3 months ($271 to $711) 2

Do not order imaging (CT, MRI, or ultrasound) before laryngoscopy. 2, 4 Imaging should only follow direct visualization to evaluate specific identified pathology 2, 4

Appropriate Conservative Management During Observation Period (If No Red Flags)

• Voice rest: avoid excessive talking and specifically avoid whispering (which strains vocal folds more than normal speech) 5
• Vocal hygiene: adequate hydration, humidification, avoid irritants 5, 6
• Symptomatic relief: ibuprofen or acetaminophen for associated throat discomfort 3

Laryngoscopy Findings and Next Steps

If Vocal Fold Paralysis is Found

Order CT with contrast from skull base to aorticopulmonary window (especially for left-sided paralysis) to evaluate the entire recurrent laryngeal nerve pathway 2, 7

If Laryngeal Mass or Lesion is Found

CT with contrast is the imaging of choice to evaluate extent and guide treatment planning 7

If Benign Pathology is Found (Nodules, Polyps, Granulomas)

Refer to speech-language pathologist for voice therapy, which has level 1a evidence for effectiveness in functional and organic vocal disturbances 8, 5

If Laryngoscopy is Normal but Symptoms Persist

Consider videostroboscopy at a multidisciplinary voice clinic, which changes diagnosis in 45-70% of cases and alters management 1

Common Pitfalls to Avoid

• Treating as "laryngitis" or "reflux" for weeks without confirmation – 56% of primary care diagnoses change after laryngoscopy 2
• Waiting for "one more trial" of medication – delays diagnosis of malignancy and worsens outcomes 1, 2
• Ordering imaging before laryngoscopy – wastes resources and delays definitive diagnosis 2, 4
• Failing to recognize occupational voice demands – professional voice users require expedited evaluation even without other red flags 2
• Delaying referral in smokers or alcohol users – these patients require immediate laryngoscopy regardless of symptom duration 2, 3

Referral Communication

When referring for laryngoscopy, explicitly state all red flags present, symptom duration, and request expedited evaluation within days if multiple concerning features exist. 2 Include specific concerns such as "possible malignancy" or "concern for vocal fold paralysis" to ensure appropriate prioritization 2