Practice Rational Imaging

Investigating the hoarse voice

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a1726 (Published 08 October 2008) Cite this as: BMJ 2008;337:a1726
  1. Pieter M Pretorius, consultant neuroradiologist1,
  2. Chris A Milford, consultant ear, nose, and throat surgeon2
  1. 1Department of Neuroradiology, John Radcliffe Hospital, Oxford Radcliffe NHS Trust, Oxford OX3 9DU
  2. 2Department of ENT Surgery, John Radcliffe Hospital
  1. Correspondence to: P M Pretorius pieter.pretorius{at}orh.nhs.uk
  • Accepted 6 May 2008

This article explores the radiological approaches available to investigate the causes of a hoarse voice

Learning points

  • Any patient with unexplained hoarseness persisting for more than 3 weeks should be referred to an ear, nose, and throat surgeon for investigation

  • Clinical examination including laryngoscopy is required to identify the small minority of patients with hoarseness who require imaging

  • Depending on the findings at laryngoscopy, imaging is aimed at (a) characterising and staging laryngeal or pharyngeal tumours or (b) identifying a cause for vocal cord paralysis

  • Computed tomography or magnetic resonance can be used for either indication, but MRI is preferable if pathology is expected in the brain stem, skull base, or suprahyoid neck whereas CT is better for imaging pathology in the infrahyoid neck and mediastinum

  • In an adult smoker with a recurrent laryngeal nerve palsy a chest radiograph can be used to decide on the most appropriate form of CT scan to be performed

The patient

A 74 year old man presented with a hoarse voice and difficulty swallowing that had developed over a few months. He also gave a long history of left sided hearing loss. Examination revealed a left vocal cord palsy and a mild left hypoglossal nerve palsy. A vascular mass was noted behind the left tympanic membrane.

What are the next investigations?

Hoarseness is usually caused by excessive voice use, laryngitis, or other self limiting conditions. Referral to an ear, nose, and throat surgeon and imaging investigations are not indicated in patients with a history of hoarseness shorter than three weeks unless it is associated with other symptoms and signs of serious underlying pathology such as unexplained shortness of breath, stridor, dysphagia, haemoptysis, a neck lump, or lower cranial nerve palsies as in this case.1

Clinical examination should include indirect laryngoscopy (with a mirror) or flexible nasolaryngoscopy. This will usually identify the underlying …

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