Case Challenge: Diagnosing and Managing Dysphonia

Gordon H. Sun, MD, MS

Disclosures

June 19, 2018

Management of Dysphonia

The AAO-HNSF clinical practice guideline update for dysphonia/hoarseness does not recommend CT or MRI for patients with a primary voice complaint prior to visualizing the larynx.[1] There are several effective ways to visualize the larynx, including laryngeal mirror examination, flexible or rigid laryngoscopy, and videostroboscopy. If the evaluating clinician lacks the equipment or expertise to perform a laryngoscopic exam, referral to an otolaryngologist (or another specialist with the requisite practice skills) is appropriate.

Imaging studies carry a number of risks ranging from contrast dye-related allergic reactions and radiation-induced malignancies associated with CT to renal toxicity from gadolinium contrast and device malfunctions, burns, and artifacts associated with MRI. As most cases of dysphonia are self-limiting and can be identified with laryngoscopy, the risks associated with imaging are generally outweighed by any perceived benefits.[1]

The AAO-HNSF does not recommend treating isolated cases of dysphonia with antireflux medications without first visualizing the larynx for signs consistent with gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux.[1] While the American College of Gastroenterology recommends empiric treatment with a PPI for patients who have typical GERD symptoms (eg, heartburn, regurgitation),[2] the patient in this case had none of these symptoms.

The AAO-HNSF does not recommend routine use of corticosteroids for isolated dysphonia prior to visualizing the larynx and establishing a diagnosis. In fact, the AAO-HNSF does not recommend corticosteroid therapy for dysphonia because of a significant lack of supporting data.[1]

Hoarseness and Sore Throat After a Cold

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A 21-year-old previously healthy college student presented to a nurse practitioner (NP) at the university health clinic for evaluation of a 1-day history of sore throat and hoarseness. She reported that several days earlier she had developed nasal congestion, rhinorrhea, and a cough, which are now resolved. Sore throat and hoarseness began after these other symptoms resolved. She denied fever or chills. She also denied tobacco use, but did report drinking two to three beers per month. She was not taking any prescription or over-the-counter medications and had no known drug allergies.

Vital signs were all normal. On examination, she appeared nontoxic and in no acute distress. Notable exam findings included erythema of the oropharynx and a hoarse voice. The NP subsequently diagnosed the patient with acute laryngitis stemming from a recent upper respiratory infection. The young woman requested a prescription for antibiotics, stating that she had upcoming midterm examinations and was concerned she would not be well enough to study for or take the tests.

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