When should I consider referring a patient with hoarseness for specialist evaluation, and what criteria should guide this decision?

Consider referring a patient with hoarseness for specialist evaluation if the hoarseness is persistent and unexplained, especially in adults aged 45 and over. This should prompt a suspected cancer pathway referral to assess for possible laryngeal cancer.

Additional criteria guiding referral include:

• Hoarseness that is isolated and unexplained after excluding structural abnormalities or malignancy by an ear, nose, and throat (ENT) examination, to consider assessment for laryngeal dystonia.
• Persistent dysphonia that may be a presenting symptom of neurological conditions such as Parkinson's disease, warranting further evaluation.

In summary, persistent, unexplained hoarseness in adults over 45 years is the key trigger for urgent specialist referral, primarily to exclude malignancy.

These recommendations align with NICE guidance on suspected cancer and neurological conditions.