What is the best course of treatment for a 41-year-old male with a 1-week history of cough and hoarseness?

Management of Acute Cough and Hoarseness in a 41-Year-Old Male

For a 41-year-old male with 1 week of cough and hoarseness, provide symptomatic treatment and reassurance, as this represents acute viral laryngitis that typically resolves within 1-3 weeks without intervention. 1

Do NOT Prescribe Antibiotics, Corticosteroids, or Proton Pump Inhibitors

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routinely prescribing antibiotics, antireflux medications, or corticosteroids to treat hoarseness prior to visualization of the larynx. 1
• At 1 week duration, this presentation is consistent with acute viral laryngitis, for which antibiotics provide no benefit and contribute to antimicrobial resistance. 2, 3
• The ACCP guidelines specifically state that during the first week of upper respiratory tract infection symptoms, bacterial sinusitis should not be diagnosed, and clinical judgment is required before instituting antibiotic therapy. 2

Symptomatic Management Approach

• Recommend voice rest, adequate hydration, and humidified air to support natural recovery from viral laryngitis. 1
• If cough suppression is needed for quality of life, prescribe dextromethorphan liquid 30-60 mg (optimal dose 60 mg for maximum suppression), as it has superior safety compared to codeine-based products. 4
• Dextromethorphan provides relief within 30-60 minutes, with dosing of 10-15 mg three to four times daily (maximum 120 mg daily). 4

Critical Decision Point: When to Perform Laryngoscopy

• Laryngoscopy is NOT indicated at 1 week unless red flags are present. 1
• The American Academy of Otolaryngology-Head and Neck Surgery recommends laryngoscopy only when hoarseness fails to resolve or improve within 4 weeks, or immediately if a serious underlying cause is suspected. 1

Red Flags Requiring Immediate Laryngoscopy (Regardless of Duration):

• Hemoptysis, dysphagia, odynophagia, or otalgia 1
• Concomitant neck mass or respiratory distress/stridor 1
• History of tobacco or alcohol abuse 1
• Recent head, neck, or chest surgery or endotracheal intubation 1
• Unexplained weight loss or immunocompromised status 1
• Professional voice user with occupational concerns 1

Follow-Up Plan and Timeline

• Schedule follow-up at 3-4 weeks if symptoms persist, as most viral laryngitis resolves within 1-3 weeks. 1
• If hoarseness persists beyond 4 weeks, refer to otolaryngology for laryngoscopy, as 56% of primary care diagnoses change after specialist evaluation. 1
• Delaying referral beyond 3 months more than doubles healthcare costs ($271 to $711) and risks missing critical diagnoses including laryngeal cancer and vocal fold paralysis. 1

What NOT to Do: Common Pitfalls

• Do not treat empirically as "laryngitis" or "reflux" with PPIs without confirming diagnosis, as this delays appropriate evaluation and misses serious pathology. 1
• Do not order CT or MRI before laryngoscopy—imaging should only follow direct visualization if specific pathology is identified. 1, 5
• Do not assume this is GERD-related hoarseness at 1 week duration; atypical reflux symptoms require reliable diagnostic confirmation, and PPI therapy often fails in these cases. 6

If Symptoms Progress to Chronic Cough (>8 Weeks)

• Systematically evaluate for the three most common causes: upper airway cough syndrome (postnasal drip), asthma/nonasthmatic eosinophilic bronchitis, and gastroesophageal reflux disease, which account for 85-100% of chronic cough in adults. 2, 7, 8
• Consider chest radiography if not already obtained, especially given any risk factors, to exclude pneumonia, malignancy, heart failure, or structural abnormalities. 3, 7
• Refer to pulmonology if cough persists beyond 8 weeks despite systematic empiric treatment. 3