Patterns in the evaluation of hoarseness: time to presentation, laryngeal visualization, and diagnostic accuracy.

OBJECTIVES/HYPOTHESIS Controversial recommendations regarding the evaluation of dysphonia have been made in the absence of evidence related to clinical practice. This study aims to describe existing patterns of care for dysphonia to generate data for potential systemic improvement and provide a baseline for dysphonia recommendations. STUDY DESIGN Retrospective review. METHODS Information regarding the current complaint, including duration of hoarseness; inciting factors; number and type of previous physicians seen; Voice Handicap Index-10; and details of prior evaluation, diagnosis, and treatment was collected from patient records. RESULTS A total of 259 patients complaining of hoarseness were evaluated. Of those, 35.1% presented directly to subspecialty care, whereas 61% were previously evaluated by another otolaryngologist. Median times (in months) from symptom onset to evaluation were as follows: initial evaluation, 3.0; laryngoscopy, 3.0; stroboscopic exam, 5.8; subspecialty evaluation, 6.6. A total of 64.5% of patients had at least one incoming diagnosis; 45% of all incoming diagnoses were revised on re-evaluation. Diagnoses most commonly revised included "no abnormality," edema or laryngopharyngeal reflux disease (LPR), infection or allergy, and muscle tension dysphonia (MTD) or behavioral disorders. Final diagnoses that most frequently differed from incoming diagnoses were paresis; MTD or behavioral disorders; malignancy; and sulcus, atrophy, or scar. CONCLUSIONS Patients received prompt laryngeal visualization. However, we observed high rates of diagnostic error. Initial diagnoses of LPR, edema, infection, and allergy appear to be particularly likely to be revised on further evaluation; and scar, sulcus, atrophy, and paresis are likely to be overlooked.