Eduovisual
Special Senses & Otolaryngology
Acute laryngitis and chronic hoarseness workup
— Acute (<2 weeks): Usually viral URI, vocal abuse (shouting, singing), or post-extubation. Self-limited, supportive care only.
— Chronic (>2–4 weeks): Requires laryngoscopy. Broad differential including reflux (LPR), smoking-related Reinke edema, vocal nodules/polyps, neurogenic causes (RLN palsy), malignancy, fungal (post-inhaled steroid), and systemic (hypothyroidism, GPA, sarcoid, RA cricoarytenoid arthritis).
— Hoarseness >3 weeks in a smoker >40
— Dysphagia, odynophagia, otalgia (referred via CN X), neck mass, hemoptysis
— Stridor, weight loss, prior head/neck radiation
Board pearl: Persistent hoarseness >2 weeks in any adult — especially smoker — mandates flexible laryngoscopy referral to ENT, regardless of how benign the history sounds. This is one of the most tested ambulatory decisions on Step 3 and the threshold to refer is intentionally low because early laryngeal cancer is curable (>90% 5-yr).
— Hypothyroidism: Low, hoarse voice + fatigue, cold intolerance, weight gain
— GPA (Wegener): Subglottic stenosis, saddle nose, hemoptysis, sinusitis
— Sarcoid: Supraglottic edema, lupus pernio, hilar LAD
— RA: Cricoarytenoid arthritis → morning hoarseness + known RA
Key distinction: Hoarseness that fluctuates with voice use → benign mucosal lesion (nodule/polyp/cyst). Hoarseness that is constant and progressive → think neurogenic palsy, mass, or fixation. Hoarseness that is worse in the morning → LPR. This temporal pattern alone reorganizes the differential before laryngoscopy.
— Breathy: Glottic gap → vocal cord paralysis, atrophy (presbylarynx), large polyp
— Strained/strangled: Spasmodic dysphonia (adductor type), muscle tension dysphonia
— Rough/raspy: Mass lesion, edema, Reinke
— Diplophonic (two pitches): Asymmetric cord vibration → unilateral lesion
— Aphonia with normal cough: Functional/psychogenic dysphonia (intact reflexive phonation)
— Inspect oropharynx for thrush (ICS use, immunocompromise), tonsillar asymmetry
— Palpate neck for thyroid nodules/goiter, cervical/supraclavicular LAD, laryngeal crepitus on rocking (loss may suggest postcricoid mass)
— Cranial nerves IX, X, XI, XII — palatal elevation, gag, shoulder shrug, tongue protrusion (skull-base lesions)
Step 3 management: In the outpatient stem, a hoarse patient with new Horner syndrome or supraclavicular adenopathy gets urgent CT chest with contrast before (or alongside) ENT referral — the larynx exam may be normal because the lesion is along the RLN course, not in the larynx itself. Ordering laryngoscopy alone and stopping there is the trap answer.
— No labs, no imaging, no scope
— Symptomatic care; reassess at 2 weeks
— TSH if features of hypothyroidism or chronic unexplained hoarseness
— CBC if systemic symptoms or suspected infection
— ANCA, ANA, RF/anti-CCP, ACE level only when vasculitis/autoimmune suspected
— HIV if oral candidiasis or atypical infections
— CT neck + chest with contrast: Indicated when laryngoscopy shows vocal cord paralysis (to trace the entire RLN from skull base to mediastinum), or when malignancy/mass suspected
— MRI brain/skull base: If high vagal lesion (paralysis + other CN deficits, palatal weakness)
— Barium swallow/modified barium swallow: When aspiration or Zenker diverticulum suspected
— Stroboscopy (videostroboscopy): Slows mucosal wave for subtle lesion detection — done by ENT/SLP, gold standard for benign mucosal pathology
— Acoustic analysis and Voice Handicap Index (VHI-10) for severity/follow-up
Board pearl: AAO-HNS explicitly states clinicians should NOT prescribe antireflux medications empirically for isolated dysphonia without GERD symptoms and without prior laryngoscopy. The empirical PPI trial in chronic hoarseness is a tested wrong answer.
— Definitive evaluation when an office scope reveals a suspicious lesion (leukoplakia, ulcer, mass, asymmetric fixation)
— Allows biopsy, excision of nodules/polyps/cysts, sampling for AFB and fungal stains
— Suspected SCC → H&E + HPV/p16 (esp. supraglottic/oropharyngeal extension)
— Granulomatous lesions → AFB, GMS/PAS (TB, histoplasma, blastomyces, candida), tissue culture
— Vasculitis suspicion → adequate tissue for vasculitis pathology; pair with ANCA serology
— Absent mucosal wave over a cord segment = scar or invasion (concerning for malignancy)
— Phase asymmetry without lesion = paresis
— Distinguishes vocal fold paralysis (denervation, fibrillations) from mechanical fixation (cricoarytenoid arthritis, scar, posterior glottic stenosis)
— Prognostic for recovery in idiopathic RLN palsy at 4–6 months
— Reserved for LPR cases refractory to PPI + lifestyle who are being considered for fundoplication, or to confirm reflux when diagnosis is equivocal
— Speech-language pathology (SLP): Diagnostic + therapeutic — voice therapy is first-line for nodules, muscle tension dysphonia, presbylarynx
— Pulmonology: Suspected subglottic stenosis, GPA, sarcoid
— Gastroenterology: Refractory LPR, dysphagia
— Neurology: Spasmodic dysphonia, essential tremor of voice, parkinsonian dysphonia
Key distinction: Vocal fold paralysis (neural injury — flaccid, foreshortened cord, atrophy on EMG) vs vocal fold fixation (mechanical — cricoarytenoid joint, scar, posterior glottic stenosis — normal EMG). Surgical planning differs substantially; both look immobile on routine scope, hence the role of laryngeal EMG before any medialization procedure.
— <2 weeks + viral context + no red flags: Symptomatic management, no workup, reassess
— ≥2 weeks OR any red flag at any time: Laryngoscopy
— Smoker >40, tobacco/alcohol use
— Hemoptysis, otalgia, dysphagia, odynophagia, weight loss
— Neck mass, supraclavicular adenopathy
— Stridor, dyspnea
— Recent neck/thoracic surgery (RLN injury)
— Hoarseness in a professional voice user impairing livelihood
— Immunocompromise (HIV, transplant, chronic steroids)
— History of head/neck cancer or radiation
— Normal larynx + reflux symptoms: 8–12 week trial of lifestyle + PPI BID; reassess
— Benign mucosal lesion (nodule, polyp, cyst, Reinke): SLP voice therapy first; phonomicrosurgery if persistent
— Vocal fold paralysis: Image RLN course (CT skull base to mediastinum); voice therapy; injection medialization if symptomatic; framework surgery if persistent >9–12 months
— Leukoplakia/suspicious lesion: Direct laryngoscopy + biopsy under GA
— Granulomas (contact/intubation): Voice rest, PPI, treat cough; rarely excise
— Functional/psychogenic: SLP, address triggers
Step 3 management: In the ambulatory setting, the correct sequence for an adult presenting at week 3 of hoarseness — even one who feels otherwise fine — is (1) flexible laryngoscopy referral, (2) targeted workup based on findings, (3) NOT empiric PPI, NOT empiric antibiotic, NOT "wait another month." Delayed referral is the most common deviation from guideline care and a frequent Step 3 vignette pitfall.
— No antibiotics (AAO-HNS strong recommendation against). Even if bacterial superinfection is suspected, evidence shows no benefit on dysphonia outcomes.
— Analgesia: acetaminophen or NSAIDs
— Humidified air, hydration, voice rest, avoid whispering and throat clearing
— Lozenges with menthol/benzocaine for symptomatic relief
— Brief (3–5 day) oral steroids (prednisone 40–60 mg) for professional voice users with urgent performance commitments, severe edema on scope, or supraglottitis (with airway monitoring)
— Not routine for community-acquired acute laryngitis
— PPI BID (omeprazole 20 mg, esomeprazole 20 mg, pantoprazole 40 mg) 30–60 min before breakfast and dinner × 8–12 weeks, then reassess
— H2 blocker at bedtime (famotidine 20–40 mg) as adjunct if nocturnal breakthrough
— Alginates (Gaviscon Advance) post-meal and bedtime — useful adjunct
— Lifestyle is co-equal: weight loss, elevate head of bed, avoid meals 3 h before sleep, limit alcohol/caffeine/tobacco/chocolate/peppermint
— Deprescribe PPI if no benefit at 12 weeks — chronic PPI risks (C. difficile, fracture, hypomagnesemia, B12 deficiency, CKD, pneumonia) are testable
— Switch to MDI + spacer, rinse mouth after dosing, treat candidiasis with nystatin swish-and-swallow or oral fluconazole
— Lowest effective ICS dose; consider DPI swap
Board pearl: The classic wrong-answer cluster in acute laryngitis stems: amoxicillin, azithromycin, dexamethasone, and empiric PPI. The right answer in pure viral acute laryngitis is supportive care + voice rest + reassess in 2 weeks.
— Injection laryngoplasty (medialization): Temporary (collagen, hyaluronic acid, carboxymethylcellulose — 1–3 months) or longer-lasting (calcium hydroxyapatite — 12–18 months). Indicated for symptomatic unilateral vocal cord paralysis to restore glottic closure and improve voice/swallow/cough.
— In-office KTP/PDL laser: For dysplasia, papillomatosis (recurrent respiratory papillomatosis — HPV 6/11), vascular lesions.
— Botox injection: Spasmodic dysphonia, vocal tremor.
— Microsuspension direct laryngoscopy with phonomicrosurgery: Removal of polyps, cysts, Reinke edema (cordotomy + suction), papillomas. Cold instruments preferred over CO2 laser for benign lesions to preserve mucosal wave.
— Laryngeal framework surgery (medialization thyroplasty, Isshiki type I): Permanent silastic or Gore-Tex implant via thyroid cartilage window — for persistent unilateral paralysis after observation period (often 9–12 months from onset to allow spontaneous recovery), or earlier if known nerve transection.
— Arytenoid adduction: Added when large posterior glottic gap persists.
— Reinnervation (ansa cervicalis-to-RLN): Younger patients with cut nerve, restores tone and bulk.
— Acute supraglottitis/epiglottitis with stridor: Awake fiberoptic intubation in OR with surgical airway backup. Cefotaxime/ceftriaxone + vancomycin; dexamethasone.
— Bilateral vocal fold paralysis with airway compromise: Tracheostomy; later cordotomy or arytenoidectomy to enlarge airway (trading voice for airway).
CCS pearl: If your CCS case is a patient with stridor and muffled voice after recent thyroidectomy, don't order a CT — order STAT ENT consult and flexible laryngoscopy at bedside, prepare OR for possible reintubation/tracheostomy. Bilateral RLN injury is a post-thyroidectomy emergency on the order of an hour, not a day.
— Bilateral bowing of cords, spindle-shaped glottic gap on phonation
— Symptoms: breathy weak voice, vocal fatigue, reduced loudness, aspiration with thin liquids
— Voice therapy is first-line — evidence-based (LSVT-LOUD program borrowed from Parkinson protocols)
— Injection augmentation or medialization if therapy insufficient
— Higher prevalence of laryngeal SCC — lower threshold for biopsy of leukoplakia
— Parkinson disease: hypokinetic dysarthria with reduced loudness, monotone — refer neurology
— Essential tremor of voice — propranolol or primidone may help
— Stroke: sudden dysphonia + dysphagia → urgent neuro workup
— Anticholinergics (TCAs, oxybutynin, 1st-gen antihistamines) → mucosal dryness → vocal fatigue
— Diuretics → dehydration → dryness
— Inhaled steroids → candidiasis, TA myopathy
— ACE inhibitors → cough → mechanical phonotrauma; consider switching to ARB
— Bisphosphonates → reflux esophagitis mimicking LPR
— PPIs: No dose adjustment needed for renal function, but observational link to AKI/CKD progression — use shortest effective course
— Famotidine: Reduce dose if CrCl <50; dose-related confusion in elderly with renal impairment
— Fluconazole: Reduce dose 50% if CrCl <50
— Avoid NSAIDs if CKD stage ≥3
— Fluconazole: Hepatotoxicity — monitor LFTs in prolonged courses
— Acetaminophen: Cap at 2 g/day in advanced liver disease
— Most PPIs metabolized hepatically (omeprazole CYP2C19) — lower dose in severe cirrhosis
Step 3 management: In an elderly patient with chronic breathy voice, mild aspiration, and bilateral cord bowing on scope, the first intervention is referral to SLP for voice therapy, NOT immediate injection augmentation. Procedures are reserved for therapy non-responders, and trying therapy first is both guideline-concordant and the test answer.
— Hormonal vocal fold edema and increased reflux are common; voice changes peak in 3rd trimester
— Acute laryngitis treatment: Supportive only. Acetaminophen is preferred analgesic. Avoid NSAIDs especially after 20 weeks (oligohydramnios) and after 30 weeks (premature ductal closure)
— PPI/H2 if reflux: Famotidine and most PPIs (omeprazole, pantoprazole) are considered acceptable in pregnancy; antacids (calcium carbonate) first-line; avoid magnesium trisilicate and sodium bicarbonate
— Defer elective laryngeal surgery to postpartum if possible
— Fluconazole: Avoid high-dose in 1st trimester (teratogenicity); topical antifungals preferred
— Acute laryngitis in young child rare in isolation — think croup (parainfluenza, barking cough, inspiratory stridor, age 6 mo–6 yr). Treat with dexamethasone 0.6 mg/kg once; nebulized racemic epinephrine if stridor at rest
— Epiglottitis (rare post-Hib vaccine): high fever, drooling, tripoding, muffled voice — OR airway management
— Recurrent respiratory papillomatosis (RRP): HPV 6/11, vertical transmission; progressive hoarseness in toddler/young child; serial laser excision; HPV vaccination reduces incidence
— Vocal nodules: Common in school-age children, especially boys; voice therapy is mainstay — do not operate on pediatric nodules, they often resolve at puberty
— Lower threshold for laryngoscopy, even at <2 weeks, especially before performances
— Voice rest, hydration, humidification core
— Short-course oral steroids selectively for urgent performance commitments (acknowledge ethics — "performance enhancement" should not mask serious pathology)
— Refer to dedicated voice clinics; coordinate with vocal coach + SLP + ENT
Board pearl: Hoarseness with stridor in a child >3 years who is unvaccinated against Hib and toxic-appearing → epiglottitis until proven otherwise — keep the child calm with caregiver, avoid IV/exam, transport to OR for controlled airway. Lateral neck XR ("thumbprint sign") only if airway stable and child cooperative.
— Laryngeal SCC: Delay in diagnosis upstages disease — T1 glottic SCC has >90% 5-year survival; T4 drops below 50%. Voice quality and survival both at stake.
— Vocal cord paralysis complications: Aspiration pneumonia (incompetent glottic closure), weight loss from dysphagia, ineffective cough
— Bilateral RLN palsy: Acute airway obstruction post-thyroidectomy; subacute presentation with exertional stridor in median position
— Chronic LPR: Subglottic stenosis, granulomas, contact ulcers, Barrett esophagus risk (when concomitant GERD), and rarely esophageal adenocarcinoma
— Untreated benign lesions: Polyp → permanent dysphonia; Reinke edema → airway narrowing in advanced cases
— Recurrent respiratory papillomatosis: Airway obstruction; rare malignant transformation
— PPI long-term: C. difficile colitis, community-acquired pneumonia, hypomagnesemia, B12 deficiency, hip/spine fracture risk, CKD progression, rebound acid hypersecretion on withdrawal
— Systemic corticosteroids: Hyperglycemia, hypertension, mood lability, insomnia, AVN with repeated courses
— Injection laryngoplasty: Overinjection → strained voice, dysphagia; migration; rare airway compromise
— Thyroplasty: Implant extrusion, infection, undercorrection/overcorrection, airway edema
— Microlaryngoscopy: Dental injury (>1% — informed consent point), tongue paresthesia from tongue base pressure, postoperative dysphonia from mucosal disruption
— Tracheostomy (for bilateral palsy): Stomal infection, tracheal stenosis, accidental decannulation, loss of natural voice
— Job loss in professional voice users; depression, anxiety; social isolation
— Voice Handicap Index (VHI-10) ≥11 = clinically significant impact
Key distinction: Aspiration in unilateral cord paralysis is typically with thin liquids and managed with diet modification + voice therapy + injection augmentation; aspiration in bilateral palsy or high vagal lesion is more severe and may require gastrostomy and tracheostomy.
— Stridor at rest, tripoding, drooling, "hot potato" voice → supraglottitis/epiglottitis
— Post-thyroidectomy stridor or aphonia → bilateral RLN palsy or expanding neck hematoma (look for tense neck swelling — open wound at bedside)
— Acute angioedema involving larynx (ACE inhibitor, hereditary) → epinephrine IM, airway, C1 esterase replacement or icatibant for HAE
— Anaphylaxis with laryngeal edema
— Caustic ingestion with hoarseness
— Hoarseness ≥2 weeks
— Suspected malignancy (neck mass, smoker, hemoptysis, otalgia, dysphagia)
— New vocal cord paralysis without obvious explanation
— Suspected RRP in child
— Professional voice user with significant impairment
— Speech-language pathology: Nearly all benign mucosal lesions, muscle tension dysphonia, presbylarynx, post-stroke dysphonia
— Pulmonology: Suspected subglottic stenosis, GPA, sarcoid, chronic cough
— Gastroenterology: Refractory LPR/GERD, dysphagia
— Oncology/radiation oncology: Confirmed laryngeal cancer — multidisciplinary tumor board
— Neurology: Spasmodic dysphonia, parkinsonian voice, ALS suspicion (fasciculations, dysarthria, weakness)
— Endocrinology: Hypothyroid-related voice change refractory to euthyroid state
— Airway concern (any stridor, accessory muscle use)
— Inability to manage secretions/aspiration with weight loss
— Severe systemic vasculitis requiring induction therapy
CCS pearl: When a CCS case features a hoarse patient with supraclavicular adenopathy, order flexible laryngoscopy + CT neck and chest with contrast + ENT consult in the same advance-clock block, then move forward. Sequential ordering wastes simulated time and downgrades efficiency scoring. Combine workup steps when the clinical picture demands parallel evaluation.
Key distinction: Nodules are bilateral and symmetric; polyps and cysts are typically unilateral. Nodules respond to voice therapy alone; polyps and cysts usually require phonomicrosurgery. The unilateral-vs-bilateral cue on a scope image is a frequent Step 3 visual identifier.
— Stroke (brainstem, particularly lateral medullary/Wallenberg) — ipsilateral cord paralysis, palatal weakness, Horner, ataxia
— Parkinson disease — hypophonic monotone, festinating speech; LSVT-LOUD
— Multiple sclerosis — scanning speech, intention tremor of voice
— Myasthenia gravis — fatigable dysphonia worse at end of day
— ALS — progressive bulbar weakness, fasciculations, mixed UMN/LMN
— Essential tremor of voice
— Spasmodic dysphonia (focal dystonia)
— Hypothyroidism — myxedematous infiltration of cords → low, hoarse voice
— Acromegaly — soft tissue hypertrophy
— RA — cricoarytenoid arthritis, morning hoarseness
— GPA — subglottic stenosis, saddle nose
— Sarcoidosis — supraglottic edema, "turban epiglottis"
— Relapsing polychondritis — auricular and laryngeal cartilage inflammation
— Amyloidosis — submucosal deposition
— SLE — rare; cricoarytenoiditis
— Lung apex (Pancoast) → left or right RLN compression
— Thyroid carcinoma with extracapsular extension
— Mediastinal lymphoma, esophageal cancer, aortic aneurysm
— Skull base tumors (glomus jugulare, schwannoma) → high vagal palsy
— Post-thyroidectomy RLN injury (~1% unilateral, <0.5% bilateral)
— Post-anterior cervical discectomy/fusion — retraction injury
— Post-CABG (left RLN stretch)
— Post-intubation granuloma, ulcer, posterior glottic stenosis
— Inhaled corticosteroid-induced dysphonia, candidiasis, myopathy
— Radiation-induced fibrosis/laryngeal edema
Board pearl: Isolated left vocal cord paralysis in a 60-year-old smoker is lung cancer until proven otherwise — image the entire RLN course (skull base to aortopulmonary window) with CT chest with contrast, even if the chest exam and CXR are unremarkable. The recurrent laryngeal nerve dips into the mediastinum, and small AP-window nodes will be missed by plain film.
— Smoking cessation: Single highest-yield intervention — reduces laryngeal SCC, Reinke edema, chronic laryngitis, LPR; offer pharmacotherapy (varenicline, bupropion, NRT) and behavioral support; quitlines (1-800-QUIT-NOW)
— Alcohol moderation: Synergistic with tobacco for SCC
— Hydration: ≥1.5–2 L water daily for mucosal lubrication
— Humidification: Especially in heated/air-conditioned environments
— Vocal hygiene: Avoid throat clearing (use silent swallow), avoid whispering during recovery, warm up the voice before extended use, minimize screaming, manage allergies
— Sustained weight loss if BMI elevated (most powerful intervention)
— Elevate head of bed 6–8 inches (blocks under bedposts; pillows ineffective)
— No food/drink within 3 hours of bedtime
— Limit trigger foods (chocolate, peppermint, citrus, tomato, caffeine, alcohol, fatty/fried foods)
— Step down PPI to lowest effective dose; consider H2RA or on-demand therapy
— Amplification devices for teachers
— Headset microphones
— Voice rest blocks built into work schedule
— Annual ENT/SLP check-ins
— Surveillance scope and imaging per NCCN: q1–3 mo year 1, q2–6 mo year 2, q4–8 mo years 3–5, then annually
— Smoking and alcohol cessation reduce second primary risk
— TSH q6–12 mo if neck radiation (hypothyroidism in 30–50%)
— Swallowing rehabilitation, voice prosthesis care (post-laryngectomy)
— HPV vaccination counseling for prevention in eligible patients
Step 3 management: Every patient with hoarseness who smokes leaves the office with (1) a brief tobacco cessation counseling note (5 A's), (2) pharmacotherapy offered, and (3) follow-up scheduled. Missing the cessation intervention is a deduction in both real-world quality metrics (MIPS) and on test items emphasizing comprehensive ambulatory care.
— Reassess at 2 weeks (in person or telehealth)
— If unresolved at 2 weeks → ENT referral
— Document smoking status, voice use, reflux symptoms
— Voice therapy course: 4–8 sessions over 2–3 months
— SLP outcome measures: VHI-10, GRBAS scale, acoustic parameters
— Repeat scope at end of therapy course; advance to surgery if persistent symptomatic lesion
— Reassess at 8–12 weeks with Reflux Symptom Index (RSI)
— If improved: continue 8–12 more weeks then step down
— If unimproved: laryngoscopy if not already done, pH/impedance probe, consider GI
— Observation period 6–12 months for spontaneous recovery (idiopathic, post-viral)
— Interim injection medialization for symptomatic patients
— Repeat scope and laryngeal EMG at 4–6 months for prognosis
— Permanent surgery (thyroplasty) if no recovery by 9–12 months
— Strict voice rest 3–7 days
— Follow-up scope at 2 and 6 weeks
— Resume voice therapy after mucosal healing
— Long-term PPI: serum magnesium annually, B12 every 1–2 years, bone density per age/risk, renal function annually
— Inhaled steroids: oral exam, voice check at each visit
— Botulinum toxin: voice diary, retreatment q3–4 months
— Natural history and timeline of recovery
— When to return (worsening, stridor, dysphagia, hemoptysis)
— Voice hygiene handout
— Smoking/alcohol cessation
— Reflux precautions
CCS pearl: For a CCS chronic hoarseness case, schedule the follow-up visit before advancing the clock past the diagnostic step — "Schedule clinic follow-up in 2 weeks" is a graded action. Skipping follow-up scheduling on outpatient cases is a common point-loss item that has nothing to do with diagnostic accuracy.
— Microlaryngoscopy: explicitly discuss dental injury (1–6%), tongue numbness/dysgeusia, postoperative dysphonia, airway risk, need for repeat procedure
— Thyroplasty: voice may be worse before better; implant infection/extrusion; rare airway edema requiring observation
— Botulinum toxin: temporary breathy voice and dysphagia for thin liquids 1–2 weeks post-injection — counsel choking risk
— Post-thyroidectomy RLN injury must be disclosed promptly; the surgeon is obligated to inform, document, and arrange ENT evaluation. Concealment violates ethical and legal standards
— Sentinel event reporting if airway compromise requires unplanned tracheostomy
— Teachers, performers, broadcasters with chronic dysphonia may qualify for FMLA, ADA accommodations (amplification, modified duties), or workers' compensation when occupational
— Document objective measures (VHI-10, stroboscopy) for disability claims
— Discharge after thyroid/parathyroid/cervical spine/CABG surgery should include explicit instructions to seek care for new hoarseness, stridor, or aspiration — and the discharge summary should communicate any documented RLN risk to the PCP
— Pending biopsy results from microlaryngoscopy must have a closed-loop follow-up system — failure to communicate a positive biopsy is a leading source of malpractice claims in laryngology
— Screen for intimate partner violence in suspicious laryngeal/neck trauma (strangulation injuries — petechiae, voice change, neck bruising). Document the exam; strangulation is a high-risk marker for future homicide; offer safety planning and resources (National DV Hotline 1-800-799-7233). Mandatory reporting laws vary by state but child and elder abuse reporting is universal when injury is suspected
— Total laryngectomy involves permanent loss of natural voice — informed consent must include discussion of TEP prosthesis, electrolarynx, esophageal speech; involve SLP preoperatively; ensure decision-making capacity and consider patient values
Board pearl: A patient with hoarseness, neck bruising, and subconjunctival hemorrhage after a "fall" — suspect strangulation/IPV. Document, image (CT angio neck for vascular injury), screen for safety, offer resources, and follow your state's reporting requirements. This vignette appears on Step 3 with increasing frequency.
Key distinction: Curtain sign (palate deviation away from a vagal lesion) localizes to CN X above the RLN takeoff — i.e., a high vagal lesion (skull base) rather than an isolated RLN lesion. Imaging extends to skull base in this scenario, not just to mediastinum.
— 56-year-old smoker, hoarseness for 3 weeks, no other symptoms, normal oropharynx. Best next step? → Flexible laryngoscopy referral. Distractors: empiric PPI, amoxicillin, CXR, observation.
— 62-year-old smoker, hoarseness, new ptosis and miosis on the left. Scope shows left vocal cord paralysis. Next step? → CT chest with contrast (and ENT continues care). Look for apical lung mass.
— Patient 2 hours post-thyroidectomy develops stridor and aphonia. Action? → Bedside flexible laryngoscopy, prepare for intubation/tracheostomy. Bilateral RLN injury vs neck hematoma — examine the wound.
— 28-year-old with URI and hoarseness × 4 days. Treatment? → Supportive care, voice rest, hydration. Distractor: azithromycin, prednisone, omeprazole.
— Morning hoarseness, throat clearing, globus, no heartburn. Scope shows posterior laryngeal erythema and arytenoid edema. Management? → PPI BID + lifestyle × 8–12 weeks.
— Unvaccinated 4-year-old, fever 39°C, drooling, tripoding, muffled voice. First step? → Do not agitate, call OR, ENT/anesthesia for airway in controlled setting; ceftriaxone after airway secured.
— 18-month-old, barking cough, hoarseness, mild stridor at rest. Treatment? → Dexamethasone 0.6 mg/kg PO/IM, racemic epinephrine nebulized if moderate-severe.
— Asthmatic on fluticasone develops hoarseness; oropharynx shows white plaques. Cause and management? → Oral candidiasis from ICS; nystatin swish/swallow, spacer, mouth rinsing after dosing.
— Hoarseness, petechiae, neck bruising after "fall." Workup? → CT angio neck, document, screen for IPV, offer resources, mandatory reporting per state law.
— Strained, strangled voice for years; whispering and singing spared. Treatment? → Botulinum toxin to thyroarytenoid.
Step 3 management: When the stem includes smoker + hoarseness + weeks of duration, the highest-yield single answer across question variants is laryngoscopy referral (or CT chest if cord paralysis is already shown). Resist the urge to pick "empiric PPI" or "trial of antibiotics" — both are explicit guideline-against options.
Acute hoarseness <2 weeks in a URI context is viral, needs only supportive care and voice rest; any hoarseness ≥2 weeks — and any red flag at any time — mandates flexible laryngoscopy, with the workup branching by what the scope shows.
Board pearl — the single highest-yield Step 3 rule for this topic: Hoarseness ≥2 weeks → flexible laryngoscopy referral. No empiric antibiotics. No empiric PPI in the absence of GERD symptoms or scope findings. No waiting another month. Earlier referral catches early-stage laryngeal SCC when cure rates exceed 90%, and it is the consistently correct ambulatory management answer across question variants.