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Practice

Hoarseness of unclear origin in adults

Angus P. Morgan and Matthew H. Rigby
CMAJ January 22, 2018 190 (3) E80; DOI: https://doi.org/10.1503/cmaj.170660
Angus P. Morgan
Division of Otolaryngology – Head and Neck Surgery, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS
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Matthew H. Rigby
Division of Otolaryngology – Head and Neck Surgery, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS
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  • For correspondence: mhrigby@dal.ca
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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.

Box 1:

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.

References

  1. ↵
    1. Cohen SM,
    2. Kim J,
    3. Roy N,
    4. et al
    . Prevalence and causes of dysphonia in a large treatment-seeking population. Laryngoscope 2012;122:343–8.
    OpenUrlCrossRefPubMed
  2. ↵
    1. Ruiz R,
    2. Jeswani S,
    3. Andrews K,
    4. et al
    . Hoarseness and laryngopharyngeal reflux: a survey of primary care physician practice patterns. JAMA Otolaryngol Head Neck Surg 2014;140:192–6.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Schwartz SR,
    2. Cohen SM,
    3. Dailey SH,
    4. et al
    . Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg 2009;141:S1–31.
    OpenUrlCrossRefPubMed
  4. ↵
    1. Kerr P,
    2. Taylor SM,
    3. Rigby M,
    4. et al
    . Oncologic and voice outcomes after treatment of early glottic cancer: transoral laser microsurgery versus radiotherapy. J Otolaryngol Head Neck Surg 2012;41:381–8.
    OpenUrl
  5. ↵
    1. Brandstorp-Boesen J,
    2. Sorum Falk R,
    3. Boysen M,
    4. et al
    . Impact of stage, management and recurrence on survival rates in laryngeal cancer. PLoS One 2017;12:e0179371.
    OpenUrl
  6. ↵
    1. Teppo H,
    2. Hyrynkangas K,
    3. Koivunen P,
    4. et al
    . Impact of patient and professional diagnostic delays on the risk of recurrence in laryngeal carcinoma. Clin Otolaryngol 2005;30:157–63.
    OpenUrlPubMed
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Canadian Medical Association Journal: 190 (3)
CMAJ
Vol. 190, Issue 3
22 Jan 2018
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Hoarseness of unclear origin in adults
Angus P. Morgan, Matthew H. Rigby
CMAJ Jan 2018, 190 (3) E80; DOI: 10.1503/cmaj.170660

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Hoarseness of unclear origin in adults
Angus P. Morgan, Matthew H. Rigby
CMAJ Jan 2018, 190 (3) E80; DOI: 10.1503/cmaj.170660
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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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