Waiting longer increases the risk that significant pathology might be missed, said Mark Courey, MD, director of laryngology and the medical director of the UCSF Voice and Swallowing Center. “Unpublished data suggests that when a patient’s referral for laryngoscopy is delayed and they have remained dysphonic for three to six months, they are significantly more likely to have a diagnosis of cancer made on their initial visit to an otolaryngologist,” he added. “I see probably one patient every other month whose referral was delayed a year, and now I’m taking out their larynx as opposed to treating an early cancer and preserving their larynx.”
Explore This IssueJuly 2013
Delaying laryngoscopic evaluation may also contribute unnecessarily to patients’ decreased quality of life. “Voice problems are not cosmetic,” Dr. Cohen said. “Even if cancer isn’t the cause, people with dysphonia suffer work disability, can’t communicate and become socially isolated. We wouldn’t expect somebody with back pain, for example, to wait three months before an evaluation.”
Performing laryngoscopy earlier allows for appropriate treatment and may decrease medication-related morbidity and health care costs. “Compare what a laryngoscopy costs, which through Medicare is about $200, versus a single month prescription of Nexium, which is often prescribed for supposed acid reflux and costs a few hundred dollars. Some patients are put on three or four months of Nexium or a proton pump inhibitor, so that’s a significant difference,” Dr. Amin said.
While most otolaryngologists understand that laryngoscopy is always preferable to computed tomography (CT) or magnetic resonance imaging (MRI) for initial visualization of the larynx, some health care practitioners still order CT scans or MRIs before referring patients for laryngoscopy. Otolaryngologists can help primary care doctors understand that “CT scans are terrible for looking at laryngeal pathology,” Dr. Amin said. “You get a much more sensitive view with a laryngoscope.”
If laryngoscopy reveals a blatantly obvious cause for a patient’s voice problems, “you can stop there,” Dr. Rosen said. But if there is no obvious cause for the problem, videostroboscopy may be warranted.
However, videostroboscopy is not routinely performed as the next step in the evaluation of voice disorders. A 2012 study of the practice patterns of 982 otolaryngologists revealed that 57.9 percent obtained stroboscopy for adult dysphonic patients with no vocal fold lesions and normal vocal fold mobility, 58.6 percent prescribed a proton pump inhibitor, 63 percent initiated a referral to speech pathology, 11.7 percent referred to a laryngologist and 9.2 percent prescribed an oral steroid (respondents were allowed to select more than one answer) (Otolaryngol Head Neck Surg. 2012;147:289-294).