How should I manage a female patient with right‑sided throat pain, intermittent ear pain, hoarseness, cough, and mildly enlarged tonsil without visible signs of infection?

Management of Right-Sided Throat Pain with Hoarseness, Cough, and Referred Ear Pain

This patient requires urgent laryngoscopy to visualize the larynx because hoarseness with associated otalgia (referred ear pain) is a red flag for serious underlying pathology that must be ruled out immediately. 1

Immediate Diagnostic Evaluation

Laryngoscopy is Mandatory

• Clinicians should visualize the patient's larynx immediately when hoarseness is associated with otalgia (referred ear pain), as this combination raises suspicion of a serious underlying cause. 1
• The American Academy of Otolaryngology explicitly lists "hoarseness associated with otalgia" as a condition requiring laryngoscopy irrespective of duration, because it may indicate laryngeal pathology, including malignancy. 1
• The palpable throat gland enlargement that triggers hoarseness and cough when touched suggests a mass effect on the larynx or recurrent laryngeal nerve, which demands direct visualization. 1

Key Red Flags Present in This Patient

• Otalgia (ear pain) in the absence of visible ear canal or middle ear disease strongly suggests referred pain from laryngeal, pharyngeal, or upper aerodigestive tract pathology. 1
• Hoarseness combined with referred otalgia is specifically listed as a warning sign for head and neck cancer, particularly in the larynx, hypopharynx, or tongue base. 1
• The unilateral nature (right-sided) of symptoms further increases concern for structural pathology rather than simple inflammation. 1

Differential Diagnosis to Consider

Serious Pathology (Must Rule Out First)

• Laryngeal or hypopharyngeal malignancy: Unilateral throat pain with hoarseness and referred otalgia is a classic presentation, especially if there is a palpable neck mass. 1
• Vocal fold paralysis: Can present with hoarseness and may be caused by thyroid pathology, mediastinal masses, or neurologic disease. 1
• Laryngeal tuberculosis or atypical mycobacterial infection: Should be considered in immunocompromised patients or those with risk factors. 1

Benign Causes (After Malignancy Excluded)

• Laryngopharyngeal reflux: Can cause unilateral laryngeal inflammation, hoarseness, and globus sensation, but would not typically cause a palpable mass. 1
• Vocal fold lesions (polyps, nodules, cysts): May cause hoarseness and cough but less likely to cause significant otalgia. 1
• Chronic laryngitis: Possible but should not cause a palpable mass or significant referred ear pain. 1

Referred Otalgia Mechanism

• The glossopharyngeal nerve (CN IX) and vagus nerve (CN X) provide sensory innervation to both the pharynx/larynx and the ear, explaining why laryngeal pathology commonly presents with ear pain. 1
• Temporomandibular joint syndrome can cause referred otalgia but would not explain hoarseness or a palpable throat mass. 1
• Dental pathology, tonsillitis, and peritonsillar abscess can cause referred ear pain but are typically associated with visible oropharyngeal findings. 1

Management Algorithm

Step 1: Urgent Laryngoscopy (Within Days)

• Perform flexible fiberoptic laryngoscopy or refer to otolaryngology immediately for direct visualization of the larynx, vocal folds, hypopharynx, and tongue base. 1
• Document vocal fold mobility, presence of masses, mucosal lesions, or asymmetry. 1
• If laryngoscopy reveals a mass or suspicious lesion, biopsy is required for definitive diagnosis. 1

Step 2: Imaging if Indicated

• If laryngoscopy reveals a mass or if the palpable neck mass suggests deep space involvement, obtain contrast-enhanced CT or MRI of the neck and chest to assess extent and nodal involvement. 1
• Chest imaging may be needed to evaluate for mediastinal pathology if vocal fold paralysis is identified. 1

Step 3: Avoid Empiric Treatment Without Diagnosis

• Do not prescribe antibiotics empirically for hoarseness, as dysphonia is typically caused by non-bacterial conditions and antibiotics are ineffective. 1
• Antibiotics are only appropriate if laryngoscopy identifies a specific bacterial infection (e.g., epiglottitis, bacterial laryngotracheitis) or if the patient is immunocompromised with suspected atypical infection. 1
• Do not use systemic corticosteroids empirically without a confirmed diagnosis, as they carry significant risks and have limited evidence of benefit in most causes of hoarseness. 1

Step 4: Symptomatic Management While Awaiting Evaluation

• NSAIDs or acetaminophen for pain control. 2, 3
• Voice rest and hydration may provide symptomatic relief but do not substitute for diagnostic evaluation. 1
• Avoid throat clearing and whispering, which can worsen laryngeal irritation. 1

Critical Pitfalls to Avoid

• Never delay laryngoscopy in a patient with hoarseness and otalgia by treating empirically with antibiotics or steroids. This combination of symptoms mandates visualization to exclude malignancy. 1
• Do not assume the palpable "throat gland" is simply a reactive lymph node without direct visualization of the larynx. It could represent thyroid pathology, a laryngeal mass, or metastatic adenopathy. 1
• Do not attribute ear pain to otitis media or externa without examining the ear canal and tympanic membrane. Referred otalgia from laryngeal pathology is common and can be the presenting symptom of serious disease. 1
• Do not wait three months to perform laryngoscopy. While the guideline states laryngoscopy is indicated if hoarseness persists beyond three months, the presence of otalgia is an explicit indication for immediate visualization regardless of duration. 1

Special Considerations

• If the patient has a history of tobacco or alcohol use, the suspicion for malignancy is significantly elevated and warrants expedited evaluation. 1
• If the patient uses inhaled corticosteroids, consider laryngeal candidiasis as a potential cause, but this would not explain the palpable mass or unilateral symptoms. 1
• If the patient has undergone recent neck surgery or intubation, vocal fold paralysis from recurrent laryngeal nerve injury should be considered. 1