Guideline Updates Recommendations for Persistent Hoarseness

Diana Phillips

March 06, 2018

For patients presenting with persistent hoarseness, early visualization of the larynx and vocal folds can expedite a diagnosis and should be conducted before empirical treatment for gastroesophageal reflux disease, infection, or inflammation, according to a revised clinical practice document from the American Academy of Otolaryngology—Head and Neck Surgery Foundation.

Although dysphonia or hoarseness often resolves spontaneously, persistent cases may be a symptom of serious underlying disease, such as head and neck cancer. Therefore, the benefits of immediate laryngoscopy outweigh the risks, Robert J. Stachler, MD, from Wayne State University, Detroit, Michigan, and colleagues write in the updated clinical practice guideline, published March 1 in a supplement to Otolaryngology—Head and Neck Surgery.

Dysphonia, defined in the guideline as "altered vocal quality, pitch, loudness, or vocal effort that impairs communication or affects quality of life," is often used interchangeably with "hoarseness." The updated guideline uses the colloquial term because "it's a symptom that patients and families understand," Stachler said in an interview with Medscape Medical News. This was important, he explained, "because we wanted to make sure the guideline met the needs of all stakeholders, including clinicians and patients."

The objective for the new guideline is to improve the quality of care and quality of life for patients with dysphonia by reducing variation in care, preventing unnecessary diagnostic and treatment delays, and improving education among all health providers about the management of this condition. The document also fills evidence gaps by incorporating research conducted after the publication of the previous guideline in 2009.

As in the prior version, the revised guideline recommends that clinicians conduct a thorough clinical examination and history of patients with dysphonia to identify underlying causes and plan management of the condition.

Because of the physiological complexity of the larynx, "potential etiologies of dysphonia are very broad and include traumatic, infectious, inflammatory, neurologic, metabolic, neoplastic, congenital, and behavioral factors," the authors write. "Careful evaluation allows the clinician to (1) categorize dysphonia severity, (2) develop a treatment plan, and (3) prioritize patients who may need escalated care." The physical exam should include a through head and neck assessment, perceptual evaluation of the voice, palpation of the neck for masses or lesions, and when possible, indirect mirror laryngoscopy, they state.

Regarding the timing of laryngeal evaluation, both the old and new versions of the guideline indicate that clinicians may perform laryngoscopy at any time in a patient with dysphonia, regardless of the duration of the symptom or other considerations. Unlike the earlier document, however, which allowed for up to 3 months before performing a diagnostic laryngoscopy in patients with persistent hoarseness and no additional significant concerns, the update recommends that clinicians perform the procedure, or refer the patient to another provider who can perform it, "when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected."

The language around laryngoscopy timing in the previous version of the guideline was vague and led to some confusion, Stachler said. "The revised guideline uses more specific language and makes it clear that earlier evaluation of the larynx in all patients with dysphonia is beneficial."

As the principal method for refining the differential diagnosis for a patient with dysphonia, visualization of the larynx allows for appropriately directed treatment, the authors write. "Most important, its expedient performance will prevent delay in diagnosis of malignancy or other morbid conditions."

Because most dysphonia is self-limited or caused by pathology that can be identified by laryngoscopy alone, computed tomography and magnetic resonance imaging are usually not necessary and not recommended for patients with a primary voice complaint before larynx evaluation.

The guideline also advises against routine use of antireflux, antibiotic, or steroid medications for the treatment of isolated hoarseness before visualizing the larynx because of lack of sufficient evidence supporting their use in these patients.

With respect to gastroesophageal reflux disease, or laryngopharyngeal reflux in particular, "we made it clear that you should not prescribe proton pump inhibitors without first looking at the larynx," Stachler said. "This is a change from the older guideline, which indicated that antireflux medications could be prescribed without or before visualization."

Although empiric proton pump inhibitor treatment for dysphonia is common among primary care physicians, there are no data indicating that it's more effective than placebo, the authors explain. "Moreover, such an approach is often associated with missed/inaccurate diagnosis and delay in appropriate treatment."

Another action statement in the new guideline describes the appropriate escalation of care in patients whose hoarseness occurs in conjunction with certain specific risk indicators, such as a neck mass; a recent surgical procedure involving the head, neck, or chest; recent endotracheal intubation; respiratory distress; a history of tobacco use; or professional voice use. Such factors warrant expedited laryngeal evaluation, the authors note.

In addition to the above recommendations, the guideline also recommends treatment paths depending on patient presentation and the results of the larynx assessment. For example, after diagnostic laryngoscopy, clinicians should:

  • educate patients about and advocate for voice therapy in patients who have dysphonia from a cause amenable to such therapy;

  • consider surgery for patients with suspected laryngeal malignancy, benign laryngeal soft tissue lesions, or glottic insufficiency; and

  • consider botulism toxin injections to treat spasmodic dysphonia and other types of laryngeal dystonia.

To improve uptake and understanding of the revised guidance document among clinicians, the guideline includes a supplemental algorithm of the key action statements. The algorithm provides a clear, logical progression of diagnostic considerations and recommended actions, the authors write.

In preparing the updated guideline, the authors identified several areas in which additional research is needed. Specifically, they point to the need for a better definition of the warning signs that should prompt early referral for diagnostic laryngoscopy, as well as education and communication around those indications. They also call for

  • a "gold standard" definition of laryngopharyngeal reflux "to reduce heterogeneity among comparative studies";

  • a better understanding of the variation and overuse of antibiotics and steroids for acute laryngitis;

  • insight into which benign lesions are amenable to surgery, as well as the benefits and harms of less-invasive treatments;

  • a better understanding of the pathophysiology of laryngeal dystonia to develop more effective treatments;

  • research into ways to reduce the burden of disease through the identification of preventive factors and education; and

  • standardized outcome measures and assessment tools to enable treatment comparisons and define disease severity.

"The update provides evidence-based recommendations that answer a lot of questions that were left unanswered after the publication of the first guideline, but obviously there's a lot more we need to know to continue to improve the quality of care for patients with voice problems," Sachler said.

Members of the Clinical Practice Guideline development panel disclosed multiple competing interests: Patient Centered Outcomes Research Institute, National Institute on Deafness and Other Communication Disorders, Cochlear Americas, Oticon Medical, Cochlear Corporation, Audigy Medical, Teva Respiratory, ALK, American Academy of Otolaryngology—Head and Neck Surgery Foundation, Society of Otorhinolaryngology and Head-Neck Nurses, Cardeas Pharmaceuticals, American College of Chest Physicians, American Speech Language-Hearing Association, National Spasmodic Dysphonia Association, and American Academy of Family Physicians.

Otolaryngol Head Neck Surg. 2018;158:S1-S42. Full text

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