Hoarseness is a common cause of primary care visits
In primary care, 1% of visits are for hoarseness, most commonly self-limited laryngitis. However, laryngeal cancers account for 1% to 2% of principal diagnoses associated with hoarseness.1
Primary care providers often treat chronic hoarseness of unclear origin empirically
Sixty-four percent of primary care providers who responded to a US survey reported that they treated chronic hoarseness of unknown cause medically, despite a lack of evidence for this practice.2 The most common medications they prescribed in this context were antireflux agents, antihistamines and antibiotics.2 This practice should be avoided as it can delay the diagnosis of serious disease.3
The larynx should be visualized in a patient with a three-month duration of hoarseness of unclear origin4
Over half of laryngeal squamous cell carcinomas originate on the vocal folds and present with hoarseness as an early sign of disease. These cancers are identifiable by laryngoscopy, requiring referral to an otolaryngologist.
Referral should be considered earlier for patients with red flags
If red flags (Box 1) are present, the threshold to refer should be lower. The most important risk factor for laryngeal squamous cell carcinoma is a history of smoking.
Red flags that should lower the threshold to refera patient with hoarseness to otolaryngology3
History of smoking (10 pack-years or more)
Enlarged cervical lymph nodes
Progression of hoarseness without fluctuation
Referred otalgia
Dysphagia or aspiration
Odynophagia or throat pain
Hemoptysis
Stridor or dyspnea
Unexplained weight loss
Alcohol consumption exceeding low-risk levels
Outcomes for laryngeal squamous cell carcinomas are correlated with stage and time to diagnosis
Early-stage disease can be treated by either radiation or larynx-preserving surgery with good outcomes for oncology, voice and swallowing.5 Advanced local disease is generally treated with chemoradiation or total laryngectomy; however, these patients often have substantial impairment of function after treatment and decreased survival compared with patients with early-stage disease (five-year disease-specific survival 54%–66% v. 85%–95%), respectively.3 Even in early-stage disease, delays of 12 months or longer in referral for diagnosis of laryngeal squamous cell carcinoma have been associated with an increased risk of local and/or regional recurrence (adjusted hazard ratios 4.6 and 9.5, respectively, p < 0.02).6
Footnotes
Competing interests: None declared.
This article has been peer reviewed.
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- Hoarseness is a common cause of primary care visits
- Primary care providers often treat chronic hoarseness of unclear origin empirically
- The larynx should be visualized in a patient with a three-month duration of hoarseness of unclear origin4
- Referral should be considered earlier for patients with red flags
- Outcomes for laryngeal squamous cell carcinomas are correlated with stage and time to diagnosis
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