What is the recommended initial evaluation and imaging for a patient who now reports new voice changes?

Initial Evaluation of New Voice Changes

For a patient presenting with new voice changes, perform laryngoscopy (or refer for laryngoscopy) as the primary diagnostic step—do NOT order CT or MRI imaging before visualizing the larynx. 1, 2

Immediate Assessment Required

The initial evaluation must identify factors requiring expedited laryngeal examination. Perform urgent laryngoscopy if any of these high-risk features are present: 1

• Recent surgical procedures involving the head, neck, or chest 1
• Recent endotracheal intubation 1
• Presence of concomitant neck mass 1
• Respiratory distress or stridor 1
• History of tobacco abuse 1
• Professional voice user status 1
• History of cancer 2

History and Physical Examination

Conduct a focused head and neck examination including: 1

• Perceptual voice evaluation (listen to voice quality, pitch, loudness, vocal effort) 1
• Neck inspection and palpation for masses or lesions 1
• Assessment of swallowing and breathing for discomfort or difficulty 1
• Medication review for drugs causing dysphonia (inhaled steroids, ACE inhibitors, antihistamines, diuretics, anticholinergics, anticoagulants) 1

Key historical red flags requiring immediate laryngoscopy: 1

• Duration >4 weeks (if no red flags, laryngoscopy can wait up to 4 weeks for self-limited causes) 1
• Smoking history (15-24% prevalence of laryngeal pathology in smokers with dysphonia) 1
• Occupational voice demands 1

Laryngoscopy: The Cornerstone of Diagnosis

Laryngoscopy must be performed before any advanced imaging. 1, 2 This approach: 1, 2

• Provides direct visualization of vocal fold mobility and lesions 2
• Changes diagnosis in 56% of cases initially labeled as "acute laryngitis" or "nonspecific dysphonia" 1
• Identifies benign vocal fold pathology, vocal fold paralysis, and laryngeal cancer that would otherwise be missed 1
• Avoids unnecessary radiation exposure and cost from premature CT/MRI 1

Delaying otolaryngology referral beyond 3 months more than doubles healthcare costs ($271 to $711). 1

Imaging: When and Why NOT to Order

Do NOT obtain CT or MRI prior to laryngoscopy. 1, 2 The rationale: 1

• No evidence supports benefit of imaging before laryngeal visualization 1
• CT scans carry real radiation-induced malignancy risk (average organ dose of 20 mSv per scan) 1
• Imaging should only be considered AFTER laryngoscopy reveals specific findings requiring further anatomic delineation 2

Special Populations

For patients with cancer history: 2

• Expedited laryngeal evaluation is mandatory due to increased risk of recurrence or new primary malignancies 2
• Laryngoscopy remains the first-line diagnostic approach, not MRI 2

For patients post-thyroid surgery: 1

• Examine vocal fold mobility if voice changes occur 1
• Assessment should occur between 2 weeks and 2 months post-surgery (avoiding false positives from post-anesthetic changes lasting up to 14 days) 1
• Preoperative vocal fold paralysis strongly suggests invasive thyroid malignancy (>70% in invasive disease vs 0.3% in noninvasive disease) 1

Common Pitfalls to Avoid

• Do not assume voice symptoms always indicate vocal fold pathology: 32% of patients with vocal fold motion impairment are completely asymptomatic 3
• Do not assume impairment is ipsilateral to a thyroid lesion: 22.5% of patients with thyroid disease have contralateral vocal fold impairment 3
• Do not prescribe empiric antireflux medications, corticosteroids, or antibiotics without laryngoscopy 1
• Do not delay evaluation in professional voice users: early diagnosis prevents psychological and economic ramifications 1