The single most consequential error in voice practice is treating a hoarse patient empirically and reviewing them in a few weeks. Reflux therapy, a course of steroids, antibiotics and voice rest all buy time that a laryngeal cancer uses.
So hold two thresholds firmly. Any hoarseness persisting beyond about four weeks warrants visualising the larynx, and any hoarseness at all in a patient with risk factors — tobacco, alcohol, a neck lump, otalgia with a normal ear, dysphagia, stridor, or a history of head and neck cancer — warrants it now, whatever the duration. Imaging is not a substitute: a CT does not exclude an early glottic lesion, and ordering one before laryngoscopy delays the examination that would have made the diagnosis.
And do not prescribe voice therapy before the larynx has been seen. Therapy for a lesion that has not been diagnosed is a delay dressed as a treatment.
- Visualise the larynx for any hoarseness beyond about four weeks
- Scope immediately, regardless of duration, with tobacco or alcohol use, neck lump, otalgia with a normal ear, dysphagia or stridor
- Do not order imaging before laryngoscopy — it delays rather than substitutes
- Avoid empiric antireflux therapy, steroids or antibiotics as a reason to defer examination
- Do not start voice therapy until the larynx has been seen
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