How to evaluate a 56-year-old male with hoarseness of voice for 1 month, considering potential underlying conditions such as laryngeal cancer, vocal cord lesions, or gastroesophageal reflux disease (GERD)?

Evaluation of a 56-Year-Old Male with Hoarseness for 1 Month

This patient requires laryngoscopy now—hoarseness persisting beyond 4 weeks mandates direct visualization of the larynx, and at age 56, the risk of serious pathology including laryngeal cancer is significant enough that waiting is not appropriate. 1, 2

Immediate Action Required

Perform or refer for laryngoscopy within days, not weeks. The American Academy of Otolaryngology-Head and Neck Surgery explicitly states that laryngoscopy is required when hoarseness fails to resolve within 4 weeks, and no patient should wait longer than 3 months for laryngeal examination. 3, 1 Delays beyond 3 months more than double healthcare costs ($271 to $711) and significantly worsen outcomes for malignancy, leading to higher disease stage and poorer survival. 1, 4

Critical Red Flags to Assess Immediately

Before or during referral, actively screen for these warning signs that would escalate urgency even further: 3, 1, 4

• Tobacco or alcohol use history (this patient's age group has high prevalence)
• Hemoptysis (even minimal blood-tinged sputum)
• Dysphagia or odynophagia (swallowing difficulty or pain)
• Otalgia (referred ear pain, especially unilateral)
• Neck mass on palpation
• Unexplained weight loss
• Progressive worsening of voice quality
• Stridor or respiratory distress
• Recent neck, chest, or thyroid surgery
• Recent endotracheal intubation
• Professional voice user (teacher, singer, salesperson)

The presence of any of these factors requires immediate same-day or next-day laryngoscopy, not routine referral. 1, 4

What NOT to Do Before Laryngoscopy

Do not empirically treat this patient without visualization of the larynx. 1, 4, 2 The American Academy of Otolaryngology-Head and Neck Surgery makes strong recommendations against:

• No antibiotics (unless concurrent signs of bacterial infection beyond the larynx)
• No corticosteroids (systemic or inhaled)
• No proton pump inhibitors or antireflux medications (unless concurrent GERD symptoms are clearly present)

This prohibition exists because 56% of primary care diagnoses change after specialist laryngoscopy, meaning empiric treatment delays accurate diagnosis and risks missing laryngeal cancer or vocal fold paralysis. 1

Pertinent History to Obtain

Conduct a targeted voice-specific history: 3

Voice characteristics:

• Onset pattern (sudden vs. gradual)
• Whether voice is ever normal during the day
• Pain with talking
• Voice fatigue or increased effort to speak
• Changes in pitch, range, or ability to project
• Running out of air when talking
• Voice cracking or breaking

Associated symptoms requiring immediate attention: 3, 1

• Globus sensation (lump in throat)
• Dysphagia or odynophagia
• Chronic throat clearing or cough
• Hemoptysis
• Otalgia
• Dyspnea
• Weight loss or night sweats

Medication review: 4

• Inhaled corticosteroids (cause vocal fold edema)
• ACE inhibitors (chronic cough affecting voice)
• Antihistamines (drying effect)
• Anticoagulants (risk of vocal fold hemorrhage)

Occupational and social history: 3

• Voice demands at work
• Absenteeism due to hoarseness
• Tobacco use (60% of hoarseness patients in one study)
• Alcohol use

Medical history: 3

• Neurologic conditions (stroke, Parkinson's disease, myasthenia gravis)
• Prior neck/chest surgery or radiation
• Diabetes, hypothyroidism
• GERD symptoms
• Asthma or COPD (inhaled steroid use)

Physical Examination

Perform a focused head and neck examination: 3

• Listen to the voice quality (perceptual evaluation of pitch, breathiness, strain)
• Palpate the neck for masses, thyroid enlargement, or lymphadenopathy
• Observe swallowing for discomfort or difficulty
• Assess breathing for stridor or respiratory distress
• Attempt indirect mirror laryngoscopy if trained and equipped (but this does not replace formal laryngoscopy)

Laryngoscopy: The Definitive Diagnostic Step

Laryngoscopy is not optional—it is mandatory at this point. 3, 2 Multiple techniques are acceptable: 3

• Transnasal flexible fiberoptic laryngoscopy (most common in office)
• Transoral rigid endoscopy
• Stroboscopy (adds assessment of vocal fold pliability and vibration, particularly useful when symptoms seem out of proportion to findings)

During laryngoscopy, assess: 1

• Vocal fold mobility (paralysis?)
• Mucosal lesions (nodules, polyps, leukoplakia, masses)
• Structural abnormalities
• Signs of inflammation or edema

When to Order Imaging (Only AFTER Laryngoscopy)

Never order CT or MRI before visualizing the larynx. 1, 2 Imaging should only follow laryngoscopy and is indicated when: 2, 5

• Vocal fold paralysis is identified (CT with contrast from skull base to aorticopulmonary window to evaluate the entire recurrent laryngeal nerve path)
• Laryngeal tumor is visualized (CT with contrast to assess extent and staging)
• Unexplained findings require further anatomic evaluation

CT with contrast is the imaging of choice when needed. 2, 5

Critical Context: Why This Matters

52% of laryngeal cancer patients thought their hoarseness was harmless and delayed seeking care, and 40% waited 3 months before seeking attention. 3, 4 In this age group with one month of symptoms, the window for optimal outcomes is narrowing. Population-based studies demonstrate that delays beyond 3 months lead to higher disease stage at diagnosis and worse prognosis. 3

Referral Communication

When referring to otolaryngology, explicitly state: 1

• Duration of hoarseness (1 month)
• Patient age (56, higher risk demographic)
• Presence of any red flags identified
• Request for expedited laryngoscopy within days
• Concern for possible malignancy or vocal fold paralysis

Common Pitfalls to Avoid

• Assuming hoarseness is benign based on duration alone—one month is already beyond the typical 1-3 week viral laryngitis window 3
• Treating empirically as "laryngitis" or "reflux" without confirming diagnosis 1
• Ordering imaging before laryngoscopy—this delays diagnosis and increases costs 1, 2
• Waiting for symptoms to worsen before acting—early identification improves outcomes 3
• Overlooking patient minimization—patients often don't recognize severity; consider input from family members 4