In the case of a smoker presenting with cough, stridor, and hoarseness, what is the next best step?

• A. Chest X-ray
• B. Flexible laryngoscopy
• C. Bronchoscopy
• D. CT scan of the neck

Answer: (B)

In a patient with a history of smoking who presents with cough, stridor, and hoarseness, flexible laryngoscopy is the next best step. This procedure allows for direct visualization of the larynx and surrounding structures, which is crucial in evaluating the potential causes of stridor and hoarseness. Given the patient's smoking history, there is a concern for malignancy of the larynx, vocal cords, or surrounding tissues, and flexible laryngoscopy is particularly effective in identifying lesions, tumors, or other abnormalities in the upper airway.

Flexible laryngoscopy is a minimally invasive procedure that can provide immediate and valuable information about the condition of the vocal cords and other laryngeal structures. Early evaluation of these symptoms is critical, especially in smokers, as they are at increased risk for laryngeal cancers.

While imaging studies such as a CT scan of the neck could provide further anatomical detail, they would not be the immediate step in assessing the laryngeal structure. A chest X-ray and bronchoscopy serve different purposes and may follow if indicated after laryngoscopy findings, but they are not best suited for identifying issues specifically in the larynx at this initial stage.