A 56-year-old man comes to the office due to a 3-week history of hoarseness. The patient is a school teacher and has never had similar symptoms during his 20-year career. He has had no recent upper respiratory illness, cough, shortness of breath, or difficulty swallowing but has been having vague right ear discomfort. The patient takes lisinopril for hypertension and over-the-counter antacids for occasional heartburn. He has smoked a pack of cigarettes daily for 30 years but does not use alcohol or illicit drugs.
Blood pressure is 122/72 mm Hg, pulse is 78/min, and BMI is 28 kg/m². His voice sounds hoarse. On examination, there is no nasal discharge, the tympanic membranes appear normal, and the oropharyngeal mucous membranes are pink with no abnormal lesions. The remainder of the physical examination is normal.
Which of the following is the most appropriate next step in management of this patient's symptoms?

Question

Quizplus · Accepted Answer

11ec193a_979e_3c39_853d_4379d3bc009b_MD0002_00 Hoarseness is a type of dysphonia characterized by coarsening of vocal quality, typically due to disorders of the larynx (especially the vibratory edge of the vocal cords). Edema, hemorrhage, laceration, or mass lesions can alter the vibratory capacity of the cords. Most causes of acute hoarseness are benign and apparent based on clinical history (eg, acute upper respiratory infection, vocal strain). Chronic hoarseness may also be benign (eg, gastroesophageal reflux disease, postnasal drip). However, hoarseness lasting >2 weeks that is not explained by an acute upper respiratory illness increases the risk for a malignant etiology and warrants evaluation by an otolaryngologist to consider laryngoscopy. Regardless of duration, patients with a history of tobacco or heavy alcohol use, systemic symptoms (eg, weight loss), stridor, dysphagia, or referred ear pain also require consideration for laryngoscopy. Imaging (CT scan or MRI) may also be indicated to evaluate specific etiologies of hoarseness after laryngoscopy. (Choice A) Proton pump inhibitor therapy is appropriate for patients with hoarseness in the setting of chronic gastroesophageal reflux. However, this patient has risk factors for malignancy that should be excluded first. (Choice B) ACE inhibitors (eg, lisinopril) can cause a chronic, dry cough, which may contribute to hoarseness. However, this patient has not had a cough and his antihypertensive therapy is unlikely to be the cause of his symptoms. (Choices D and E) Voice therapy focuses on behavioral factors associated with hoarseness and may effectively treat some vocal disorders. Vocal rest is useful for hoarseness due to overuse, acute laryngitis, or laryngeal edema or hemorrhage. These interventions could be considered if laryngoscopy establishes a benign etiology. Educational objective: Hoarseness is characterized by coarsening of vocal quality and is typically due to abnormalities in the larynx (eg, edema, hemorrhage, laceration, mass lesions). Most causes of acute hoarseness are benign. However, patients with symptoms lasting >2 weeks or with a history of tobacco or heavy alcohol use, systemic symptoms, stridor, dysphagia, or referred ear pain require referral for consideration of laryngoscopy. __________ References: Hoarseness in adults. (http://www.ncbi.nlm.nih.gov/pubmed/19678604) Clinical practice guideline: hoarseness (dysphonia). (http://www.ncbi.nlm.nih.gov/pubmed/19729111)

A 56-Year-Old Man Comes to the Office Due to a 3-Week