Rule out Cancer Early.

The authors deserve thanks for their comprehensive overview of the wide range of possible causes of hoarseness (1). Apart from histologically benign organic lesions, functional and other causes, especially malignancies, such as cancer of the larynx and hypopharynx as well as apical lung cancer, should always be addressed early in the workup, even in the absence of risk factors. The most common head and neck cancers are located in the larynx and the only early symptom in patients with glottic cancer is dysphonia. Fortunately, this often leads to early diagnosis and initiation of treatment, contributing largely to the good to very good prognosis of these tumors. Thus, it is vital to avoid any unnecessary delay in diagnosis. The cited US guideline (2) making the (non-consensus-based) recommendation to only use indirect laryngoscopy for diagnosis in patients with hoarseness persisting for more than 3 months has been a matter of strong controversy after its publication, particularly because of the literature it is based on, and thus should be viewed critically (3). This position is supported by a large survey among members of the American Laryngological Association, the American Broncho-Esophagological Association and the European Laryngological Society, where the respondents clearly called for the use of indirect laryngoscopy in patients with persistent dysphonia during the first month after onset, for the above mentioned reasons (4).