What is the recommended otolaryngology (ear, nose, and throat) workup for a patient presenting with hoarseness?

Otolaryngology Workup for Hoarseness

Immediate Laryngoscopy Required for Red Flags

Any patient with hoarseness and red-flag features requires same-day or next-day laryngoscopy, not observation or empiric treatment. 1, 2

Red flags mandating immediate laryngoscopy include:

• Tobacco or alcohol use – increases head and neck cancer risk 2- to 3-fold 3, 1
• Concomitant neck mass, hemoptysis, dysphagia, odynophagia, or otalgia – may represent advanced disease 1, 2
• Recent neck/chest surgery or endotracheal intubation – 50% of anterior cervical spine cases and 17-31% of cardiac surgery cases develop postoperative hoarseness 1
• Respiratory distress, stridor, or airway compromise – constitutes an emergency 1, 2
• Professional voice users (teachers, singers, call center workers, attorneys) – livelihood depends on voice function 3, 1
• Unexplained weight loss or progressive worsening – concerning for malignancy 1, 2
• Immunocompromised status 1, 2
• Hoarseness in a neonate – may signal birth trauma, Arnold-Chiari malformation, or mediastinal disease 4

Timing of Laryngoscopy for Non-Emergent Cases

Laryngoscopy must be performed within 4 weeks if hoarseness persists, and no patient should wait longer than 3 months. 1, 2 Delaying beyond 3 months more than doubles healthcare costs ($271 to $711) and significantly worsens outcomes for malignancy, leading to higher disease stage and poorer survival. 1, 2

Observation is appropriate only for acute hoarseness with concurrent upper respiratory symptoms (rhinitis, fever >101.5°F), as viral laryngitis typically resolves within 7-10 days. 1 If symptoms persist beyond 1-3 weeks, laryngoscopy is mandatory. 1

Essential History Components

Obtain a targeted voice-specific history including:

• Onset pattern – sudden versus gradual, relation to infection or intubation 3, 1
• Voice characteristics – breathy quality suggests vocal fold paralysis; strained voice with pitch breaks suggests spasmodic dysphonia 1
• Constancy – whether voice is ever normal, fatigue with use 3, 1
• Associated symptoms – dysphagia, odynophagia, globus sensation, chronic throat clearing, cough 3
• Occupational impact – missed work days, voice demands of profession 1

Critical medication review is mandatory, as multiple drugs cause hoarseness:

• Inhaled corticosteroids – dose-dependent mucosal irritation and fungal laryngitis 3, 1
• ACE inhibitors – chronic cough 3, 1
• Antihistamines, diuretics, anticholinergics – drying effect on mucosa 3, 1
• Anticoagulants, thrombolytics, PDE-5 inhibitors – vocal fold hematoma 3, 1
• Bisphosphonates – chemical laryngitis 3, 1

Physical Examination

• Perceptual voice assessment – evaluate quality, pitch, loudness, vocal effort 1
• Neck palpation – assess for masses or lymphadenopathy 3, 1
• Observation for respiratory distress or swallowing difficulty 1

Laryngoscopy Technique and Findings

Multiple techniques are acceptable:

• Transnasal flexible fiberoptic laryngoscopy 2
• Transoral rigid endoscopy 2
• Stroboscopy – for detailed mucosal wave assessment 2

Assess for:

• Vocal fold mobility – paralysis or paresis 2
• Mucosal lesions – nodules, polyps, masses 2
• Structural abnormalities – edema, erythema, leukoplakia 2
• Signs of inflammation 2

What NOT to Do Before Laryngoscopy

The American Academy of Otolaryngology-Head and Neck Surgery issues strong recommendations against empiric treatment without visualization: 1, 2

• No antibiotics – systematic reviews show no benefit for acute laryngitis, as most cases are viral 1
• No systemic corticosteroids – no high-quality trials support routine use; risks include hypertension, diabetes, osteoporosis, infection 1
• No anti-reflux medications – unless concurrent GERD symptoms are present 1

This prohibition exists because 56% of primary care diagnoses change after specialist laryngoscopy, meaning empiric treatment delays accurate diagnosis and risks missing laryngeal cancer or vocal fold paralysis. 2

Imaging Guidelines

Do not order imaging before laryngoscopy. 2 Imaging should only follow direct visualization and is indicated when:

• Vocal fold paralysis is identified – requires CT with contrast from skull base to thoracic inlet to evaluate the entire recurrent laryngeal nerve path 2
• Laryngeal tumor is visualized – for staging 2
• Unexplained findings require further anatomic evaluation 2

Treatment Based on Laryngoscopy Findings

Voice therapy is first-line treatment with Level 1a evidence for functional or benign organic dysphonia. 1, 2 It improves voice quality in nonorganic dysphonia and treats benign pathologic vocal cord lesions (nodules, polyps). 1

Before prescribing voice therapy:

• Laryngoscopy must be performed first 1
• Document and communicate findings to the speech-language pathologist 1

Counsel all patients on vocal hygiene:

• Voice rest (avoid whispering) 1
• Adequate hydration 1
• Avoidance of tobacco smoke and irritants 1

Common Pitfalls

• Assuming hoarseness is benign based on duration alone – 52% of laryngeal cancer patients thought their hoarseness was harmless and delayed care; 40% waited ≥3 months before seeking attention 1
• Treating as "laryngitis" or "reflux" without confirmation 2
• Failing to recognize that patients minimize dysphonia – 16.7% only sought treatment after family encouragement; proxy input may be necessary, especially in older adults 1
• Overlooking occupational voice demands – >50% of teachers experience dysphonia from voice overuse, and 20% miss work because of it 1