In a resource-limited critical-access emergency department, what is the appropriate workup for a patient presenting with new onset voice changes (hoarseness)?

Workup for New-Onset Hoarseness in a Critical Access ED

In a resource-limited critical access emergency department, perform a focused history and physical examination to identify red flags requiring expedited referral, avoid imaging and empiric medications, and arrange outpatient laryngoscopy within 4 weeks if symptoms persist or immediately if concerning features are present. 1

Immediate Assessment in the ED

History - Key Red Flags Requiring Expedited Evaluation

Screen specifically for these high-risk features that mandate urgent otolaryngology referral: 1

• Recent surgery involving head, neck, or chest (especially thyroidectomy or anterior cervical spine surgery) 1
• Recent endotracheal intubation 1
• Concomitant neck mass 1
• Respiratory distress or stridor (requires immediate airway assessment) 1
• Tobacco abuse history (15-24% prevalence of laryngeal pathology in smokers) 1
• Professional voice user (singers, teachers, call center workers, attorneys, nurses, physicians) 1
• Dysphagia or aspiration symptoms 1

Physical Examination - Essential Components

Perform these specific assessments without requiring specialized equipment: 1

• Listen carefully to voice quality during conversation (perceptual evaluation) 1
• Inspect and palpate the neck for masses or lesions 1
• Observe swallowing for discomfort or difficulty 1
• Assess breathing for stridor or respiratory distress 1
• Indirect mirror laryngoscopy if feasible and clinician is trained 1

What NOT to Do in the ED

Avoid Imaging Prior to Laryngoscopy

Do not order CT or MRI for voice complaints before laryngeal visualization. 1 This recommendation is based on evidence showing imaging adds cost without benefit and delays appropriate diagnosis. 1

Avoid Empiric Medications

Do not prescribe these medications without laryngoscopy: 1

• No antireflux medications (PPIs or H2 blockers) for isolated dysphonia based on symptoms alone 1
• No corticosteroids routinely prior to laryngeal visualization 1
• No antibiotics routinely for dysphonia 1

The AAO-HNS guidelines provide strong recommendations against empiric treatment because it delays diagnosis, increases costs, and changes in diagnosis occur in 56% of cases after proper laryngeal visualization. 1

Disposition Algorithm

Immediate Referral (Same Day/Next Available)

Arrange emergent otolaryngology consultation for: 1

• Respiratory distress or stridor
• Recent neck/chest surgery (within 2 weeks to 2 months) 1
• Concomitant neck mass
• Recent intubation with persistent dysphonia

Expedited Outpatient Referral (Within 2 Weeks)

Fast-track referral for: 1

• Tobacco users (any history)
• Professional voice users with occupational impact
• Dysphagia or aspiration symptoms
• Neurologic symptoms suggesting cranial nerve involvement

Standard Outpatient Referral (Within 4 Weeks)

For dysphonia without red flags: 1

• If symptoms persist beyond 4 weeks, arrange laryngoscopy with otolaryngology or a clinician capable of performing it 1
• Most viral laryngitis resolves in 1-3 weeks spontaneously 1
• Observation is reasonable for recent-onset dysphonia with upper respiratory symptoms (rhinitis, fever >101.5°F, fatigue) 1

Discharge with Reassurance

Safe to discharge without immediate follow-up if: 1

• Recent onset (<1-3 weeks)
• Associated upper respiratory infection symptoms
• No red flag features
• Provide return precautions for worsening symptoms or persistence beyond 4 weeks

Critical Pitfalls to Avoid

Delaying referral beyond 3 months more than doubles healthcare costs ($271 to $711) and risks missing serious diagnoses. 1 In one large study, 56% of patients initially diagnosed with "acute laryngitis" or "nonspecific dysphonia" received different diagnoses after laryngoscopy, including vocal fold paralysis (n=369) and laryngeal cancer (n=293). 1

Post-surgical dysphonia requires expedited evaluation between 2 weeks and 2 months because early diagnosis and treatment of vocal fold paralysis significantly improves quality of life and reduces work absenteeism. 1

Documentation for Referral

Include in your ED documentation: 1

• Duration of symptoms
• Presence or absence of red flag features
• Occupational voice demands
• Smoking history (pack-years)
• Recent surgical or intubation history
• Rationale for urgency level of referral