Guideline Issued for Evaluation and Management of Hoarseness

Laurie Barclay, MD

September 03, 2009

September 3, 2009 — The American Academy of Otolaryngology–Head and Neck Surgery Foundation (AAO-HNSF) has issued the first, and thus far the only, national clinical practice guideline to help healthcare practitioners diagnose and treat patients with hoarseness or dysphonia.

The complete guidelines are available on the Otolaryngology–Head and Neck Surgery Web site.

The new evidence-based recommendations, which also aim to educate patients regarding the prevalence and causes of this common problem, are published in the September issue of Otolaryngology–Head and Neck Surgery. Because hoarseness may be a presenting symptom in many different practice settings, the guideline targets all clinicians who are likely to diagnose and manage patients with hoarseness.

"Hoarseness affects approximately 20 million people in the U.S. at any given time, and about one in three individuals will become hoarse at some point in their life," guideline coauthor Richard M. Rosenfeld, MD, MPH, who is also chair of the AAO-HNSF Guideline Development Task Force, said in a news release. "In addition to the impact on health and quality of life, hoarseness leads to frequent healthcare visits and several billion dollars in lost productivity annually from work absenteeism."

Although hoarseness and dysphonia are sometimes used interchangeably, hoarseness properly refers to the symptom of changed voice quality and dysphonia to the corresponding diagnosis. Characteristics of this disorder are altered vocal quality, pitch, volume, or vocal effort that hinders communication or decreases voice-related quality of life. Impaired communication with family and peers may lead to depression, social isolation, lost time from work or school, loss of wages or productivity, and/or decreased quality of life.

"Most hoarseness is caused by benign or self-limiting conditions, but it may also be the presenting symptom of a more serious or progressive condition requiring prompt diagnosis and management," said Seth R. Schwartz, MD, MPH, chair of the Hoarseness Guideline Panel. "This new guideline is intended to enhance diagnosis, promote appropriate therapy, improve outcomes, and to expand counseling and education for prevention."

Hoarseness may develop in newborns, infants, children, and adults of all ages. Prevalence in women is 50% higher than men. Other groups at increased risk include children, especially at ages 8 through 14 years; the elderly population; and professional voice users such as teachers, performers, telemarketers, and aerobics instructors.

Despite the high prevalence of dysphonia, many people in the United States lack knowledge of the possible causes and appropriate treatment of hoarseness, according to results from a recent survey by the AAO-HNSF. Nearly half of adults are unaware that persistent hoarseness may be a red flag indicating cancer. Only 5.9% of individuals with hoarseness seek treatment, according to findings from other studies reviewed by the guideline authors.

A multidisciplinary panel including consumers, as well as clinicians specializing in neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatrics, nursing, internal medicine, otolaryngology–head and neck surgery, and pediatrics developed this guideline.

Recommendations to Diagnose/Treat Hoarseness (Dysphonia)

Specific recommendations include the following:

  • The clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, volume, or vocal effort that impairs communication or decreases voice-related quality of life.

  • History and/or physical examination of the patient with hoarseness should look for factors that modify management, such as recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiotherapy to the neck, history of tobacco abuse, and occupation as a singer or vocal performer.

  • The cause of nearly all cases of hoarseness is benign underlying or self-limiting conditions. Other causes to be ruled out include laryngeal tumor or other serious underlying condition, or adverse effects from medication.

  • If hoarseness persists for more than 3 months or if the underlying cause is not readily diagnosed or thought to be serious, laryngoscopy should be performed to visualize the larynx, either by the examining physician or through a referral. This procedure, which can be done in the office, is considered the primary diagnostic modality and should be performed before any other imaging procedures.

  • For a primary complaint of hoarseness, imaging studies, such as computed tomography or magnetic resonance imaging scans, should not be performed before visualizing the larynx with laryngoscopy.

  • Hoarseness should not be treated with antireflux medications unless there are signs or symptoms of significant gastroesophageal reflux disease, such as heartburn or regurgitation, or laryngoscopic findings of laryngeal inflammation.

  • The clinician should not routinely prescribe antibiotics to treat hoarseness (strong recommendation).

  • Oral corticosteroids are not recommended for hoarseness and should not be routinely prescribed.

  • The clinician should recommend voice therapy for patients diagnosed with hoarseness that reduces voice-related quality of life (strong recommendation). Voice therapy is a well-established intervention for hoarseness and may be indicated for patients of all ages. The usual therapeutic regimen is 1 to 2 sessions per week for 4 to 8 weeks. Before voice therapy is started, laryngoscopy should be performed and the findings communicated to the speech-language pathologist.

  • Although surgery is not the primary treatment of most causes of hoarseness, it may be indicated for suspected cancer, other tumors or growths, abnormal vocal cord movement, or abnormal vocal cord muscle tone.

  • The clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections to treat hoarseness caused by adductor spasmodic dysphonia.

Additional Suggested Tips

The guideline also offered the following options:

  • Laryngoscopy may be performed at any time in a patient with hoarseness, either by the treating physician or by referral to a specialist.

  • Patients with hoarseness and signs of chronic laryngitis may be treated with antireflux medication.

  • The clinician may educate and counsel patients with hoarseness regarding control and preventive measures that may decrease the risk for hoarseness, such as good hydration, avoidance of tobacco smoke and other irritants, voice training, and amplification during periods of heavy voice use.

"In an era of health reform and comparative effectiveness research, well-crafted guidelines help improve quality, promote optimal outcomes, minimize harm, and reduce inappropriate variations in care," Dr. Rosenfeld said. "It is hoped that these guidelines will give clinicians the tools they need to spot an issue early, avoid poor outcomes, and reduce healthcare costs."

The AAO-HNSF funded development of this guideline. Some of the guideline authors have disclosed various financial or other relationships with TAP Pharmaceuticals, Bioform, Kramer Patient Education, Restore Medical (Medtronic), Alcon, Schering-Plough, Pfizer, Boehringer Ingelheim, Forest, Novartis, GlaxoSmithKline, Central AR Veterans Healthcare System, American Academy of Family Physicians, E.Doc America, KayPentax, and/or Plural Publishing.

Otolaryngol Head Neck Surg. 2009;141:S1-S31.