In a 17‑year‑old with a week of hoarseness and odynophonia, a negative streptococcal test and no fever, stridor, drooling, unilateral neck swelling, dysphagia, or respiratory distress, should I obtain neck imaging and consider a dose of dexamethasone?

Management of One-Week Hoarseness in a 17-Year-Old

In this 17-year-old with isolated hoarseness for one week, no fever, negative strep test, and no red-flag symptoms (stridor, drooling, dysphagia, respiratory distress), you should NOT obtain imaging and should NOT prescribe dexamethasone—instead, continue observation and consider laryngoscopy only if symptoms persist beyond 4 weeks or worsen. 1

Why Imaging Is Not Indicated

Clinicians should not obtain CT or MRI for patients with a primary voice complaint prior to visualization of the larynx. 1 The American Academy of Otolaryngology guidelines explicitly recommend against imaging before laryngoscopy because:

• Laryngoscopy is the primary diagnostic modality for hoarseness 1
• Most hoarseness is self-limited or caused by pathology identifiable only by direct visualization 1
• Imaging is reserved for specific findings after laryngoscopy, such as vocal fold paralysis or suspected malignancy 1
• Pre-laryngoscopy imaging exposes patients to unnecessary radiation and cost without diagnostic benefit 1

Why Dexamethasone Is Not Indicated

Clinicians should not routinely prescribe corticosteroids in patients with dysphonia prior to visualization of the larynx. 1 The evidence strongly argues against empiric steroid use:

• Systematic reviews found no studies supporting corticosteroids as empiric therapy for hoarseness except in special circumstances (croup, allergic laryngitis in performers, or patients acutely dependent on their voice) 1
• Corticosteroids carry significant side effects even with short-term use 1
• Most acute laryngitis is self-limited, with improvement in 7-10 days without treatment 1
• The preponderance of evidence shows harm over benefit for routine steroid use 1

This 17-year-old has none of the special circumstances that might justify steroids: no croup symptoms, no documented allergic laryngitis, and no professional voice demands requiring urgent intervention 1.

When Laryngoscopy Becomes Necessary

Clinicians should perform laryngoscopy when dysphonia fails to resolve or improve within 4 weeks, or irrespective of duration if a serious underlying cause is suspected. 1 At one week, this patient has not yet reached the threshold for mandatory evaluation 1.

Red Flags That Would Prompt Earlier Laryngoscopy

The following would warrant immediate laryngoscopy regardless of duration 1:

• History of tobacco or alcohol use
• Concomitant neck mass
• Hemoptysis, dysphagia, odynophagia, or otalgia
• Airway compromise (stridor, respiratory distress)
• Unexplained weight loss
• Worsening symptoms
• Recent intubation or neck surgery

This patient has NONE of these red flags 1. The negative strep test, absence of fever, and lack of stridor, drooling, dysphagia, or respiratory distress all point away from serious bacterial infection or airway emergency 2.

Appropriate Management at This Stage

Symptomatic Treatment Only

• Offer ibuprofen or acetaminophen for symptom relief 2
• Reassure that most viral laryngitis resolves within 7-10 days 1
• Advise voice rest and adequate hydration (general medical knowledge)

Observation Timeline

• Continue observation through week 4 1
• If symptoms persist or worsen before 4 weeks, consider earlier laryngoscopy 1
• If symptoms resolve, no further workup is needed 1

Common Pitfalls to Avoid

Do not order imaging based on symptom duration alone—this violates evidence-based guidelines and exposes the patient to unnecessary radiation and cost 1. The one-week timeframe is well within the expected self-resolution period for viral laryngitis 1.

Do not prescribe steroids empirically for hoarseness—the evidence shows no benefit and potential harm, and this patient lacks any of the narrow indications (croup, documented allergic laryngitis, professional voice user with urgent performance) 1.

Do not confuse hoarseness with stridor—stridor indicates upper airway obstruction and requires urgent evaluation 3, 4, but this patient has isolated hoarseness without respiratory compromise 1.

Special Considerations for Adolescents

While children under 3 years with hoarseness warrant earlier evaluation for congenital anomalies 1, and professional voice users may justify earlier intervention 1, a 17-year-old with uncomplicated hoarseness follows the standard adult algorithm: 4-week observation period before mandatory laryngoscopy 1.

The negative strep test effectively rules out Group A Streptococcal pharyngitis as a cause 2, and the absence of fever, systemic symptoms, and respiratory compromise makes bacterial tracheitis or other serious infections extremely unlikely 5.