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http://oto.sagepub.com/content/141/3_suppl/S1The online version
of this article can be found at:
DOI: 10.1016/j.otohns.2009.06.744
2009 141: S1Otolaryngology -- Head and Neck SurgeryStemple, J.
Paul Willging, Terrie Cowley, Scott McCoy, Peter G. Bernad and
Milesh M. Patel
R. Ouellette, Barbara J. Messinger-Rapport, Robert J. Stachler,
Steven Strode, Dana M. Thompson, Joseph C.Granieri, Edie R. Hapner,
C. Eve Kimball, Helene J. Krouse, J. Scott McMurray, Safdar Medina,
Karen O'Brien, Daniel Seth R. Schwartz, Seth M. Cohen, Seth H.
Dailey, Richard M. Rosenfeld, Ellen S. Deutsch, M. Boyd Gillespie,
Evelyn
Clinical Practice Guideline: Hoarseness (Dysphonia)
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Otolaryngology–Head and Neck Surgery (2009) 141, S1-S31
GUIDELINE
Clinical practice guideline: Hoarseness (Dysphonia)
Seth R. Schwartz, MD, MPH, Seth M. Cohen, MD, MPH,Seth H.
Dailey, MD, Richard M. Rosenfeld, MD, MPH,Ellen S. Deutsch, MD, M.
Boyd Gillespie, MD,Evelyn Granieri, MD, MPH, MEd, Edie R. Hapner,
PhD, C. Eve Kimball, MD,Helene J. Krouse, PhD, RN, ANP-BC, J. Scott
McMurray, MD,Safdar Medina, MD, Karen O’Brien, MD, Daniel R.
Ouellette, MD,Barbara J. Messinger-Rapport, MD, PhD, Robert J.
Stachler, MD,Steven Strode, MD, MEd, MPH, Dana M. Thompson,
MD,Joseph C. Stemple, PhD, J. Paul Willging, MD, Terrie
Cowley,Scott McCoy, DMA, Peter G. Bernad, MD, MPH, and Milesh M.
Patel, MS,Seattle, WA; Durham, NC; Madison, WI; Brooklyn, NY;
Wilmington, DE; Charleston,SC; New York, NY; Atlanta, GA; Reading,
PA; Detroit, MI; Uxbridge, MA;Fort Monroe, VA; Cleveland, OH;
Little Rock, AR; Rochester, MN; Lexington, KY;
Cincinnati, OH; Milwaukee, WI; Princeton, NJ; Washington, DC;
and Alexandria, VA
Sponsorships or competing interests that may be relevant to
con-tent are disclosed at the end of this article.
ABSTRACT
OBJECTIVE: This guideline provides evidence-based
recom-mendations on managing hoarseness (dysphonia), defined as
adisorder characterized by altered vocal quality, pitch, loudness,
orvocal effort that impairs communication or reduces
voice-relatedquality of life (QOL). Hoarseness affects nearly
one-third of thepopulation at some point in their lives. This
guideline applies to allage groups evaluated in a setting where
hoarseness would beidentified or managed. It is intended for all
clinicians who arelikely to diagnose and manage patients with
hoarseness.PURPOSE: The primary purpose of this guideline is to
improvediagnostic accuracy for hoarseness (dysphonia), reduce
inappropriateantibiotic use, reduce inappropriate steroid use,
reduce inappropriateuse of anti-reflux medications, reduce
inappropriate use of radio-graphic imaging, and promote appropriate
use of laryngoscopy, voicetherapy, and surgery. In creating this
guideline the American Acad-emy of Otolaryngology—Head and Neck
Surgery Foundation se-lected a panel representing the fields of
neurology, speech-languagepathology, professional voice teaching,
family medicine, pulmonol-ogy, geriatric medicine, nursing,
internal medicine, otolaryngology–head and neck surgery,
pediatrics, and consumers.RESULTS: The panel made strong
recommendations that 1) theclinician should not routinely prescribe
antibiotics to treat hoarse-ness and 2) the clinician should
advocate voice therapy for patientsdiagnosed with hoarseness that
reduces voice-related QOL. The
Received June 26, 2009; accepted June 26, 2009.
0194-5998/$36.00 © 2009 American Academy of Otolaryngology–Head
and Necdoi:10.1016/j.otohns.2009.06.744
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panel made recommendations that 1) the clinician should
diagnosehoarseness (dysphonia) in a patient with altered voice
quality,pitch, loudness, or vocal effort that impairs communication
orreduces voice-related QOL; 2) the clinician should assess
thepatient with hoarseness by history and/or physical examination
forfactors that modify management, such as one or more of
thefollowing: recent surgical procedures involving the neck or
affect-ing the recurrent laryngeal nerve, recent endotracheal
intubation,radiation treatment to the neck, a history of tobacco
abuse, andoccupation as a singer or vocal performer; 3) the
clinician shouldvisualize the patient’s larynx, or refer the
patient to a clinician whocan visualize the larynx, when hoarseness
fails to resolve by amaximum of three months after onset, or
irrespective of durationif a serious underlying cause is suspected;
4) the clinician shouldnot obtain computed tomography or magnetic
resonance imagingof the patient with a primary complaint of
hoarseness prior tovisualizing the larynx; 5) the clinician should
not prescribe anti-reflux medications for patients with hoarseness
without signs orsymptoms of gastroesophageal reflux disease; 6) the
clinicianshould not routinely prescribe oral corticosteroids to
treat hoarse-ness; 7) the clinician should visualize the larynx
before prescribingvoice therapy and document/communicate the
results to thespeech-language pathologist; and 8) the clinician
should prescribe,or refer the patient to a clinician who can
prescribe, botulinumtoxin injections for the treatment of
hoarseness caused by adductorspasmodic dysphonia. The panel offered
as options that 1) theclinician may perform laryngoscopy at any
time in a patient withhoarseness, or may refer the patient to a
clinician who can visu-alize the larynx; 2) the clinician may
prescribe anti-reflux medi-
k Surgery Foundation. All rights reserved.
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cation for patients with hoarseness and signs of chronic
laryngitis;and 3) the clinician may educate/counsel patients with
hoarsenessabout control/preventive measures.DISCLAIMER: This
clinical practice guideline is not intendedas a sole source of
guidance in managing hoarseness (dysphonia).Rather, it is designed
to assist clinicians by providing an evidence-based framework for
decision-making strategies. The guideline isnot intended to replace
clinical judgment or establish a protocol forall individuals with
this condition, and may not provide the onlyappropriate approach to
diagnosing and managing this problem.
© 2009 American Academy of Otolaryngology–Head and NeckSurgery
Foundation. All rights reserved.
Nearly one-third of the population has impaired voiceproduction
at some point in their lives.1,2 Hoarse-ness is more prevalent in
certain groups, such as teachersand older adults, but all age
groups and both genders can beaffected.1-6 In addition to the
impact on health and quality oflife (QOL),7,8 hoarseness leads to
frequent health care visitsand several billion dollars in lost
productivity annually fromwork absenteeism.9 Hoarseness is often
caused by benign orself-limited conditions, but may also be the
presentingsymptom of a more serious or progressive condition
requir-ing prompt diagnosis and management.
The terms hoarseness and dysphonia are often used
in-terchangeably, although hoarseness is a symptom of alteredvoice
quality and dysphonia is a diagnosis. Dysphonia maybe broadly
defined as an alteration in the production ofvoice that impairs
social and professional communication.In contrast, hoarseness is a
coarse or rough quality to thevoice. Although the two terms are not
synonymous, theguideline working group decided to use the term
hoarsenessfor this guideline because it is more recognized and
under-stood by patients, most clinicians, and the lay press.
The target patient for this guideline is anyone presentingwith
hoarseness (dysphonia).
● Hoarseness (dysphonia) is defined as a disorder charac-terized
by altered vocal quality, pitch, loudness, or vocaleffort that
impairs communication or reduces voice-re-lated QOL.
● Impaired communication is defined as a decreased orlimited
ability to interact vocally with others.
● Reduced voice-related QOL is defined as a
self-perceiveddecrement in physical, emotional, social, or
economicstatus as a result of voice-related dysfunction.
This working definition, developed by the guidelinepanel,
assumes that hoarseness affects people differently.Some individuals
may have altered voice quality, vocaleffort, pitch, or loudness;
others may experience problemswith communication and diminished
voice-related QOL.
The guideline is intended for all clinicians who are likelyto
diagnose and manage patients with hoarseness and ap-plies to any
setting in which hoarseness would be identified,monitored, treated,
or managed. The guideline does notapply to patients with hoarseness
with the following condi-
tions: history of laryngectomy (total or partial),
craniofacial
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anomalies, velopharyngeal insufficiency, and dysarthria(impaired
articulation). However, the guideline will discussthe relevance of
these conditions in managing patients withhoarseness.
There are a number of patients with modifying factorsfor whom
many of the recommendations of the guidelinemay not apply. There is
some discussion of these factors andhow they might modify
management. A partial list includesprior laryngeal surgery, recent
surgical procedures involv-ing the neck or affecting the recurrent
laryngeal nerve,recent endotracheal intubation, radiation treatment
to theneck, and patients who are singers or performers.
GUIDELINE PURPOSE
The primary purpose of this guideline is to improve thequality
of care for patients with hoarseness based on currentbest evidence.
Expert consensus to fill evidence gaps, whenused, is explicitly
stated, and is supported with a detailedevidence profile for
transparency. Specific objectives of theguideline are to reduce
inappropriate variations in care,produce optimal health outcomes,
and minimize harm.
The guideline is intended to focus on a limited number ofquality
improvement opportunities, deemed most importantby the working
group, and is not intended to be a compre-hensive, general guide
for managing patients with hoarse-ness. In this context, the
purpose is to define actions thatcould be taken by clinicians,
regardless of discipline, todeliver quality care. Conversely, the
statements in thisguideline are not intended to limit or restrict
care providedby clinicians based on assessment of individual
patients.
While there is evidence to guide management of certaincauses of
hoarseness, there are currently no evidence-basedclinical practice
guidelines. There are variations in the useof the laser, voice
therapy, steroids, and postoperative voicerest and in the treatment
of reflux-related laryngitis.10-13
Differences in training, preference, and resource
availabilityinfluence management decisions. A guideline is
necessarygiven this practice variation and the significant public
healthburden of hoarseness.
This guideline addresses the identification,
diagnosis,treatment, and prevention of hoarseness (dysphonia)
(Table1). In addition, it highlights needs and management optionsin
special populations or in patients who have modifyingfactors.
Furthermore, this guideline is intended to enhancethe accurate
diagnosis of hoarseness (dysphonia), promoteappropriate
intervention in patients with hoarseness, high-light the need for
evaluation and intervention in specialpopulations, promote
appropriate therapeutic options withoutcomes assessment, and
improve counseling and educa-tion for prevention and management of
hoarseness. Thisguideline may also be suitable for deriving a
performance
measure on hoarseness.
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BURDEN OF HOARSENESS
Hoarseness has a lifetime prevalence of 29.9 percent
(per-centage of people affected at some point in their life) and
apoint prevalence of 6.6 percent (percent of people affectedat a
given point in time) in adults aged 65 years or under.1
Other cross-sectional studies have found a similar highlifetime
prevalence of voice complaints of 28.8 percent inthe general
population.2 Higher prevalence rates of hoarse-ness have been shown
in telemarketers (31%),4 aerobicsinstructors (44%),5 and teachers
(58%).2,6 Women are morefrequently affected than men, with a 60:40
F:M ratio.1,3,14
Hoarseness may affect all age groups. Among children,prevalence
rates vary from 3.9 percent to 23.4 percent,15-17
with the most affected age range of 8 to 14 years.18
Voiceproblems persist four years or longer after identification
in38 percent of children with a voice disorder, suggesting
anopportunity for early intervention.19 In addition, olderadults
are also at particular risk,3 with a point prevalence of29
percent20 and a lifetime incidence up to 47 percent.20,21
Hoarseness has significant public health implications.Patients
suffer social isolation, depression, and reduced dis-ease-specific
and general QOL.1,8,22,23 For example, pa-tients with hoarseness
caused by neurologic disorders (Par-kinson disease, spasmodic
dysphonia, vocal tremor, orvocal fold paralysis) reported severe
levels of voice handi-cap and reduced general health-related QOL,
comparable toimpairments observed in patients with congestive heart
fail-ure, angina, and chronic obstructive pulmonary disease.7,8
Hoarseness may also impair work-related function.Approximately
28 million US workers have occupationsthat require use of voice.9
In the general population, 7.2percent of individuals surveyed
missed work for one ormore days within the preceding year because
of a problem
Table 1Interventions considered in hoarseness
guidelinedevelopment
Diagnosis Targeted historyPhysical
examinationLaryngoscopyStroboscopyComputed tomography (CT)Magnetic
resonance imaging (MRI)
Treatment Watchful waiting/observationEducation/informationVoice
therapyAnti-reflux medicationsAntibioticsSteroidsSurgeryBotulinum
toxin (BOTOX)
Prevention Voice trainingVocal hygieneEducationEnvironmental
measures
with their voice.1 Among teachers this rate increases to 20
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percent,6,14 resulting in a $2.5 billion loss among US
adultsbecause of missed work annually.9
Medical, surgical, and behavioral treatment options existfor
managing hoarseness. Among the general population,however, only 5.9
percent of those with hoarseness soughttreatment.1 Similarly, only
14.3 percent of teachers hadconsulted a physician or
speech-language pathologist forhoarseness, even though voice
function is essential to theirprofession.2 In some circumstances,
complete resolution ofhoarseness may not be achieved and the
clinician’s respon-sibilities will include minimizing hoarseness
and optimizingpatient function as well as assisting the patient in
develop-ing understanding and realistic expectations.
Lack of awareness about hoarseness and its causes arepotential
barriers to appropriate care. Among older adults,individuals
commonly attribute their hoarseness to advanc-ing age. Such
assumptions may prevent or delay those withhoarseness from
obtaining treatment. Improved educationamong all health
professionals24 and efficient medical careare essential for
reducing the health burden of hoarseness.25
Inadequate insurance coverage has been cited as a cause
offailure to seek treatment for both functional voice problems,as
seen in singers,25 and life-threatening ones, as seen incancer
patients.26
The primary outcomes considered in this guideline areimprovement
in vocal function and change in voice-relatedQOL. Secondary
outcomes include complications and ad-verse events. Economic
consequences, adherence to ther-apy, global QOL, return to work,
improved communicationfunction, and return health care visits were
also considered.The high prevalence, significant individual and
societal im-plications, diversity of interventions, and lack of
consensusmake this an important condition for an up-to-date,
evi-dence-based practice guideline.
GENERAL METHODS AND LITERATURESEARCH
The guideline was developed using an explicit and trans-parent a
priori protocol for creating actionable statementsbased on
supporting evidence and the associated balanceof benefit and
harm.27,28 The multidisciplinary guidelinedevelopment panel was
chosen to represent the fields ofneurology, speech-language
pathology, professional voiceteaching, family medicine,
pulmonology, geriatric medi-cine, nursing, internal medicine,
otolaryngology–head andneck surgery, pediatric medicine, and
consumers. Severalgroup members had significant prior experience in
develop-ing clinical practice guidelines.
Several initial literature searches were performedthrough
November 17, 2008 by AAO-HNSF staff usingMEDLINE, The National
Guidelines Clearinghouse (NGC)(www.guideline.gov), The Cochrane
Library, GuidelinesInternational Network (GIN), The Cumulative
Index to
Nursing and Allied Health Literature (CINAHL), and
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EMBASE. The initial broad MEDLINE search using “hoarse-ness[mh]”
or “dysphonia[tw]” or “voice disorders[mh]” inany field showed 6032
potential articles:
1) Clinical practice guidelines were identified by a GIN,NGC,
and MEDLINE search using “guideline” as apublication type or title
word. The search identified eightguidelines with a topic of
hoarseness or dysphonia. Aftereliminating articles that did not
have hoarseness or dys-phonia as the primary focus, no guidelines
met qualitycriteria of being produced under the auspices of a
med-ical association or organization and having an explicitmethod
for ranking evidence and linking evidence torecommendations.
2) Systematic reviews were identified in MEDLINE using
avalidated filter strategy.29 That strategy initially yielded92
potential articles. The final data set included 14 sys-tematic
reviews or meta-analyses (including two Co-chrane systematic
reviews) on hoarseness or dysphoniathat were distributed to the
panel members.
3) Randomized controlled trials were identified through
theCochrane Library (Cochrane Controlled Trials Register)and
totaled 256 trials with “hoarseness” or “dysphonia”in any
field.
4) Original research studies were identified by limiting
theMEDLINE, CINAHL, and EMBASE search to articleson humans
published in English. The resulting data setof 769 articles yielded
262 related to therapy, 256 todiagnosis, 205 to etiology, and 46 to
prognosis.
Results of all literature searches were distributed toguideline
panel members at the first meeting, includingelectronic listings
with abstracts (if available) of thesearches for randomized trials,
systematic reviews, andother studies. This material was
supplemented, as needed,with targeted searches to address specific
needs identified inwriting the guideline through February 8,
2009.
In a series of conference calls, the working group definedthe
scope and objectives of the proposed guideline. Duringthe nine
months devoted to guideline development ending in2009, the group
met twice, with interval electronic reviewand feedback on each
guideline draft to ensure accuracy ofcontent and consistency with
standardized criteria for re-porting clinical practice
guidelines.30
AAO-HNSF staff used GEM-COGS,31 the GuidelineImplementability
Appraisal and Extractor, to appraise ad-herence of the draft
guideline to methodological standards,to improve clarity of
recommendations, and to predict po-tential obstacles to
implementation. Guideline panel mem-bers received summary
appraisals in April 2009 and mod-ified an advanced draft of the
guideline.
The final draft practice guideline underwent
extensive,multidisciplinary, external peer review. Comments
werecompiled and reviewed by the group chairpersons, and amodified
version of the guideline was distributed and ap-proved by the
development panel. The recommendations
contained in the practice guideline are based on the best
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available published data through February 2009. Wheredata were
lacking, a combination of clinical experience andexpert consensus
was used. A scheduled review process willoccur at five years from
publication, or sooner if new com-pelling evidence warrants earlier
consideration.
Classification of Evidence-Based StatementsGuidelines are
intended to reduce inappropriate variationsin clinical care, to
produce optimal health outcomes forpatients, and to minimize harm.
The evidence-based ap-proach to guideline development requires that
the evidencesupporting a policy be identified, appraised, and
summa-rized and that an explicit link between evidence and
state-ments be defined. Evidence-based statements reflect boththe
quality of evidence and the balance of benefit and harmthat is
anticipated when the statement is followed. Thedefinitions for
evidence-based statements32 are listed inTables 2 and 3.
Guidelines are never intended to supersede professionaljudgment;
rather, they may be viewed as a relative con-straint on individual
clinician discretion in a particular clin-ical circumstance. Less
frequent variation in practice isexpected for a “strong
recommendation” than might beexpected with a “recommendation.”
“Options” offer themost opportunity for practice variability.33
Cliniciansshould always act and decide in a way that they believe
willbest serve their patients’ interests and needs, regardless
ofguideline recommendations. They must also operate withintheir
scope of practice and according to their training.Guidelines
represent the best judgment of a team of expe-rienced clinicians
and methodologists addressing the scien-tific evidence for a
particular topic.32
Making recommendations about health practices in-volves value
judgments on the desirability of various out-comes associated with
management options. Values appliedby the guideline panel sought to
minimize harm and dimin-ish unnecessary and inappropriate therapy.
A major goal ofthe committee was to be transparent and explicit
about howvalues were applied and to document the process.
Financial Disclosure and Conflicts of InterestThe cost of
developing this guideline, including travel ex-penses of all panel
members, was covered in full by theAAO-HNS Foundation. Potential
conflicts of interest for allpanel members in the past five years
were compiled anddistributed before the first conference call.
After review anddiscussion of these disclosures,34 the panel
concluded thatindividuals with potential conflicts could remain on
thepanel if they: 1) reminded the panel of potential
conflictsbefore any related discussion, 2) recused themselves from
arelated discussion if asked by the panel, and 3) agreed not
todiscuss any aspect of the guideline with industry
beforepublication. Lastly, panelists were reminded that conflicts
ofinterest extend beyond financial relationships and may in-clude
personal experiences, how a participant earns a living,and the
participant’s previously established “stake” in an
issue.35
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S5Schwartz et al Clinical practice guideline: Hoarseness
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HOARSENESS (DYSPHONIA) GUIDELINEACTION STATEMENTS
Each action statement is organized in a similar
fashion:statement in boldface type, followed by an italicized
state-ment on the strength of the recommendation. Several
para-graphs then discuss the evidence base supporting the
state-ment, concluding with an “evidence profile” of
aggregateevidence quality, benefit-harm assessment, and statement
ofcosts. Lastly, there is an explicit statement of the
valuejudgments, the role of patient preferences, and a
repeatstatement of the strength of the recommendation. An over-view
of evidence-based statements in the guideline and
theirinterrelationship is shown in Table 4.
The role of patient preference in making decisions de-serves
further clarification. For some statements the evi-dence base
demonstrates clear benefit, which would mini-mize the role of
patient preference. If the evidence is weakor benefits are unclear,
however, not all informed patientsmight opt to follow the
suggestion. In these cases, thepractice of shared decision making,
where the managementdecision is made by a collaborative effort
between the
Table 2Guideline definitions for evidence-based statements
Statement Definition
Strong recommendation A strong recommendation mof the
recommended apprexceed the harms (or thatexceed the benefits, in
thenegative recommendationquality of the supporting eexcellent
(Grade A or B*).identified circumstances, srecommendations may
belesser evidence when highis impossible to obtain anbenefits
strongly outweigh
Recommendation A recommendation means texceed the harms (or
thatthe benefits, in the case orecommendation), but theevidence is
not as strongIn some clearly identifiedrecommendations may belesser
evidence when highis impossible to obtain anbenefits outweigh the
har
Option An option means either thaevidence that exists is susor
that well-done studiesC*) show little clear advanapproach vs
another.
*See Table 3 for definition of evidence grades.
clinician and the informed patient, becomes more useful.
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Factors related to patient preference include (but are
notlimited to) absolute benefits (number needed to treat), ad-verse
effects (number needed to harm), cost of drugs ortests, frequency
and duration of treatment, and desire to takeor avoid antibiotics.
Comorbidity can also impact patientpreferences by several
mechanisms, including the potentialfor drug-drug interactions when
planning therapy.
STATEMENT 1. DIAGNOSIS: Clinicians should diag-nose hoarseness
(dysphonia) in a patient with alteredvoice quality, pitch,
loudness, or vocal effort that im-pairs communication or reduces
voice-related QOL.Recommendation based on observational studies
with apreponderance of benefit over harm.
Supporting TextThe purpose of this statement is to promote
awareness ofhoarseness (dysphonia) by all clinicians as a condition
thatmay require intervention or additional investigation.
Theproposed diagnosis (dysphonia) is based on strictly
clinicalcriteria, and does not require testing or additional
investi-gations. Hoarseness is a symptom reported by the patient
or
Implication
the benefitsclearlyarms clearlyof a strongthat thece is
me clearly
e based onity evidenceanticipatedharms.
Clinicians should follow a strongrecommendation unless a clear
andcompelling rationale for analternative approach is present.
nefitsarms exceedgativety ofe B or C*).
stances,e based onity evidenceanticipated
Clinicians should also generally followa recommendation, but
shouldremain alert to new information andsensitive to patient
preferences.
uality ofGrade D*)
e A, B, orto one
Clinicians should be flexible in theirdecision making
regardingappropriate practice, although theymay set bounds on
alternatives;patient preference should have asubstantial
influencing role.
eansoachthe hcase
) andvidenIn sotrongmad-qual
d thethe
he bethe h
f a nequali
(Gradcircummad-qual
d thems.t the qpect (
(Gradtage
proxy, identified by the clinician, or both.
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Some patients with objectively minor changes may beunable to
work and have a significant decrement in QOL.Others with
significant disease such as malignancy mayhave minimal functional
impairment of their voice. Of pa-tients with laryngeal cancer, 52
percent thought theirhoarseness was harmless and delayed seeing a
physician.36
Accordingly, patients with minimal objective voice changeand
significant complaints as well as patients with limited
Table 3Evidence quality for grades of evidence
Grade Evidence quality
A Well-designed randomized controlled trialsor diagnostic
studies performed on apopulation similar to the guideline’starget
population
B Randomized controlled trials or diagnosticstudies with minor
limitations;overwhelmingly consistent evidencefrom observational
studies
C Observational studies (case-control andcohort design)
D Expert opinion, case reports, reasoningfrom first principles
(bench research oranimal studies)
X Exceptional situations where validatingstudies cannot be
performed and thereis a clear preponderance of benefit overharm
Table 4Outline of guideline action statements
Hoarseness (dysphonia) (statement number)
I. Diagnosisa. Diagnosis (Statement 1)b. Modifying factors
(Statement 2)c. Laryngoscopy and hoarseness (Statement 3A)d.
Indications for laryngoscopy
(Statement 3B)e. Imaging prior to laryngoscopy (Statement 4)
II. Medical therapya. Anti-reflux therapy for hoarseness in the
absence
or chronic laryngitis (Statement 5A)b. Anti-reflux therapy with
chronic laryngitis (Statemc. Corticosteroid therapy (Statement 6)d.
Antimicrobial therapy (Statement 7)
III. Voice therapya. Laryngoscopy prior to beginning (Statement
8A)b. Advocating for
(Statement 8B)IV. Invasive therapies
a. Advocating surgery in selected patients (Statemenb. Botulinum
toxin for adductor spasmodic dysphon
(Statement 10)V. Prevention (Statement 11)
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complaints but with objective alterations of voice
qualitywarrant evaluation.
Patients with hoarseness may experience discomfort withspeaking,
increased phonatory effort, and weak voice, aswell as altered
quality such as wobbly or shaky voice,breathiness, and
raspiness.20,37,38 While a breathy voicemay signify vocal fold
paralysis or another cause of incom-plete vocal fold closure, a
strained voice with altered pitchor pitch breaks is common in
spasmodic dysphonia.39
Changes in voice quality may be limited to the singing voiceand
not affect the speaking voice. Among infants and youngchildren, an
abnormal cry may signify underlying pathologyincluding vocal fold
paralysis, laryngeal papilloma, or othersystemic conditions.
Listening to the voice (perceptual evaluation) in a criticaland
objective manner may provide important diagnosticinformation.
Characterizing the patient’s complaint andvoice quality is
important for assessing hoarseness severityand for differentiating
among specific causes of hoarseness,such as muscle tension
dysphonia and spasmodic dyspho-nia.40,41
Hoarseness may impair communication. Difficulty beingheard and
understood while using the telephone has beenreported in the
geriatric population.20,38 Trouble beingheard in groups and
problems being understood are alsocommon complaints among hoarse
patients.37 Conse-quently, patients describe less confidence,
decreased social-ization, and impaired work-related
function.1,37
Hoarseness may lead to decreased voice-related QOLand a
decrement in physical, social, and emotional aspects
Statement strength
RecommendationRecommendationOptionRecommendation
Recommendation against
RD Recommendation against
) OptionRecommendation againstStrong recommendation against
RecommendationStrong recommendation
RecommendationRecommendation
Option
of GE
ent 5B
t 9)ia
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of global QOL similar to those associated with other
chronicdiseases, such as congestive heart failure and chronic
ob-structive pulmonary disease.7,8
Clinicians should consider input from proxies when di-agnosing
hoarseness (dysphonia). Of patients with vocalfold cancer, 40
percent waited three months before seekingmedical attention for
their hoarseness. Furthermore, 16.7percent only sought treatment
after encouragement fromother people.36 These data highlight the
fact that hoarsenessmay not be recognized by the patient.
Children and patients with cognitive impairment or se-vere
emotional burden may be unaware or unable to recog-nize and report
on their own hoarseness.42 QOL studies inolder adults have required
proxy input in approximately 25percent of the geriatric
population.43 While self-report mea-sures for hoarseness are
available, patients may be unable tocomplete them.44-46 In these
cases, proxy judgments bysignificant others about QOL are a good
alternative.42 Mod-erate agreement has been shown between adult
patients andtheir communication partners on the Voice Handicap
Index.Parent proxy self-report measures have also been validatedfor
use in the pediatric population.38,47
When evaluating a patient with hoarseness, the clini-cian should
obtain a detailed medical history (Table 5)and review current
medications (Table 6) as this infor-mation may identify the cause
of the hoarseness (dyspho-nia) or an alternative underlying
condition that may war-rant attention.
Evidence profile for Statement 1: Diagnosis
● Aggregate evidence quality: Grade C, observational stud-
Table 5continued
Allergic rhinitisChronic rhinitisHypertension (because of
certain medications used
for this condition)Schizophrenia (because of anti-psychotics
used for
mental health problems)Osteoporosis (because of certain
medications used
for this condition)Asthma, chronic obstructive pulmonary
disease
(because of use of inhaled steroids)Aneurysm of thoracic aorta
(rare cause)Laryngeal cancerLung cancer (or metastasis to the
lung)Thyroid cancerHypothyroidism and other endocrinopathiesVocal
fold nodulesVocal fold paralysisVocal abuseChemical
laryngitisChronic tobacco useSjögren syndromeAlcohol (moderate to
heavy use or abuse)
Table 5Pertinent medical history for assessing a patientwith
hoarseness48-50
Voice-specific questionsDid your problem start suddenly or
gradually?Is your voice ever normal?Do you have pain when
talking?Does your voice deteriorate or fatigue with use?Does it
take more effort to use your voice?What is different about the
sound of your voice?Do you have a difficult time getting loud
or
projecting?Have you noticed changes in your pitch or range?Do
you run out of air when talking?Does your voice crack or break?
SymptomsGlobus pharyngeus (persisting sensation of lump
in throat)DysphagiaSore throatChronic throat
clearingCoughOdynophagia (pain with swallowing)Nasal
drainagePost-nasal drainageNon-anginal chest painAcid
refluxRegurgitationHeartburnWaterbrash (sudden appearance of salty
liquid in
the mouth)Halitosis (“bad breath”)FeverHemoptysisWeight
lossNight sweatsOtalgia (ear pain)Difficulty breathing
Medical history relevant to hoarsenessOccupation and/or
avocation requiring extensive
voice use (ie, teacher, singer)Absenteeism from occupation due
to hoarsenessPrior episode(s) of hoarsenessRelationship of
instrumentation (intubation, etc) to
onset of hoarsenessRelationship of prior surgery to neck or
chest to
onset of hoarsenessCognitive impairment (requirement for
proxy
historian)Anxiety
Acute conditionsInfection of the throat and/or larynx:
viral,
bacterial, fungalForeign body in larynx, trachea, or
esophagusNeck or laryngeal trauma
Chronic conditionsStrokeDiabetesParkinson’s diseaseDiseases from
the Parkinson’s Plus family
(progressive supranuclear palsy, etc)Myasthenia gravisMultiple
sclerosisAmyotrophic lateral sclerosis (ALS)Testosterone
deficiency
ies for symptoms with one systematic review of QOL in
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voice disorders and two systematic reviews on medica-tion side
effects
● Benefit: Identify patients who may benefit from treatmentor
from further investigation to identify underlying con-ditions that
may be serious, promote prompt recognitionand treatment, and
discourage the perception of hoarse-ness as a trivial condition
that does not warrant attention
● Harm: Potential anxiety related to diagnosis● Cost: Time
expended in diagnosis, documentation, and
discussion● Benefits-harm assessment: Preponderance of
benefits
over harm● Value judgments: None● Role of patient preference:
Limited● Intentional vagueness: None● Exclusions: None● Policy
Level: Recommendation
STATEMENT 2. MODIFYING FACTORS: Cliniciansshould assess the
patient with hoarseness by historyand/or physical examination for
factors that modifymanagement such as one or more of the following:
re-cent surgical procedures involving the neck or affectingthe
recurrent laryngeal nerve, recent endotracheal intu-bation,
radiation treatment to the neck, a history oftobacco abuse, and
occupation as a singer or vocal per-former. Recommendation based on
observational studieswith a preponderance of benefit over harm.
Supporting TextThe term “modifying factors” as used in this
recommenda-tion refers to details elicited by history taking or
physicalexamination that provide a clue to the presence of an
im-
Table 6Medications that may cause hoarseness
MedicationMechanism of impact
on voice
Coumadin, thrombolytics,phosphodiesterase-5inhibitors
Vocal fold hematoma51-53
Biphosphonates Chemical laryngitis54
Angiotensin-convertingenzyme inhibitors
Cough55
Antihistamines, diuretics,anticholinergics
Drying effect onmucosa56,57
Danocrine, testosterone Sex hormone production/utilization
alteration58,59
Antipsychotics, atypicalantipsychotics
Laryngeal dystonia60,61
Inhaled steroids Dose-dependent mucosalirritation,62
fungallaryngitis
portant underlying etiology of hoarseness (dysphonia) that
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may lead to a change in management. The history andphysical
examination of the patient with hoarseness mayprovide insight into
the nature of the patient’s conditionprior to the initiation of a
more in-depth evaluation.
Surgery on the cervical spine via an anterior approachhas been
associated with a high incidence of voice prob-lems. Recurrent
laryngeal nerve paralysis has been reportedto range from 1.27
percent to 2.7 percent.63-65 Assessmentwith laryngoscopy suggests
an even higher incidence.66 Theincidence of hoarseness immediately
following anterior cer-vical spine surgery may be as high as 50
percent.67 Hoarse-ness resulting from anterior cervical spine
surgery may ormay not resolve over time.68,69
Thyroid surgery has been associated with voice disor-ders.
Patients with thyroid disease requiring surgery mayhave hoarseness
and identifiable abnormalities on indirectlaryngoscopy prior to
surgery.70 Thyroidectomy may causehoarseness as a result of
recurrent laryngeal nerve paralysisin up to 2.1 percent of
patients.71 Surgery in the anteriorneck can also lead to injury to
the superior laryngeal nervewith resulting voice alteration,
although this is uncom-mon.72
Carotid endarterectomy is frequently associated
withpostoperative voice problems73 and may result in
recurrentlaryngeal nerve damage in up to 6 percent of
patients.74,75
Surgery to achieve an urgent airway or on the larynx directlymay
alter its structure, resulting in abnormal voice.76,77
Surgical procedures not involving the neck may alsoresult in
hoarseness (dysphonia). Hoarseness following car-diac surgery is a
common problem, occurring in 17 percentto 31 percent of
patients.78,79 Hoarseness may result fromchanges in position or
manipulation of the endotracheal tubeor from lengthy procedures.78
Recurrent laryngeal nerveinjury occurs in about 1.4 percent of
patients during cardiacsurgery.78 The left recurrent laryngeal
nerve is damagedmore commonly than the right as it extends into the
chestand loops under the arch of the aorta. Damage may resultfrom
direct physical injury to the nerve or hypothermicinjury due to
cold cardioplegia.80
Surgery for esophageal cancer frequently results in dam-age to
the recurrent laryngeal nerve with subsequent hoarse-ness. In one
study, 51 of 141 patients undergoing esopha-gectomy for cancer had
laryngeal nerve paralysis, with 30 ofthese patients having
persistent paralysis one year followingsurgery.81 The implantation
of vagal nerve stimulators forintractable seizures has been
associated with hoarseness inas many as 28 percent of
patients.82
Prolonged endotracheal intubation has been associatedwith
hoarseness. Direct laryngoscopy of patients intubatedfor more than
four days (mean nine days) demonstrates that94 percent of patients
have laryngeal injury.83 The injurypatterns seen in the patients
with prolonged intubation in-clude laryngeal edema and posterior
and medial vocal foldulceration. As many as 44 percent of patients
with pro-longed intubation may develop vocal fold granulomas
within four weeks of being extubated. In this study, 18
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percent of patients had prolonged true vocal fold immobilityfor
at least four weeks after extubation.84 Another studyfollowing a
large group of patients for several years foundchronic phonatory
dysfunction in many patients after long-term intubation.85
Short-term intubation for general anesthesia may resultin
hoarseness and vocal fold pathology in over 50 percent ofcases.86
While most symptoms resolved after five days,prolonged symptoms may
result from vocal fold granuloma.If hoarseness persists, the
remoteness of the index eventmay confound the evaluating clinician.
Use of a laryngealmask airway may reduce postsurgical complaints of
dis-comfort, but does not objectively reduce hoarseness.87
Long-term intubation of neonates may result in voiceproblems
related to arytenoid and posterior commissureulceration and
cartilage erosion.88 Children with a history ofprolonged intubation
may have long-term complications ofhoarseness and arytenoid
dysfunction.
Voice disorders are common in older adults and signif-icantly
affect the QOL in these patients.21 Vocal fold atro-phy with
resulting hoarseness (dysphonia) is a commondisorder of older
adults and is frequently undiagnosed byprimary care providers.89,90
Hoarseness resulting from neu-rologic disorders such as cerebral
vascular accident andParkinson disease is also more common in
elderly pa-tients.91-94 Multiple sclerosis can lead to hoarseness
in pa-tients of any age.95
Chronic hoarseness (dysphonia) is quite common inyoung children
and has an adverse impact on QOL.96 Prev-alence ranges from 15
percent to 24 percent of the popula-tion.17,97 In one study, 77
percent of hoarse children hadvocal fold nodules.17 These may
persist into adolescence ifnot properly treated.98 Craniofacial
anomalies such as oro-facial clefts are associated with abnormal
voice,99 but theseare frequently resonance disorders requiring very
differenttherapies than for hoarse children with normal
anatomicaldevelopment.
Hoarseness or dysphonia in infants may be recognizedonly by an
abnormal cry, and suspicion of such symptomsshould prompt
consultation with an otolaryngologist.100
When infants do present with hoarseness, underlying etiol-ogies
such as birth trauma, an intracranial process such asArnold-Chiari
malformation or posterior fossa mass, or me-diastinal pathology
should be considered.101
Hoarseness in tobacco smokers is associated with anincreased
frequency of polypoid vocal fold lesions and headand neck
cancer.102 Accordingly, this requires an expedientassessment for
malignancy as the potential cause of hoarse-ness. In addition, in
patients treated with external beamradiation for glottic cancer,
radiation treatment is associatedwith hoarseness in about 8 percent
of cases.103,104
Patients who use inhaled corticosteroids for the treatmentof
asthma or chronic obstructive pulmonary disease maypresent to a
clinician with hoarseness that is a side effect oftherapy either
from direct irritation or from a fungal infec-
tion of the larynx.105
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Singers or vocal performers should be identified by theclinician
when eliciting a history from the hoarse patient.These patients
have significant impairment with symptomsthat may be subclinical in
other patients. They may be moresubject to voice over-use or have a
different etiology fortheir symptoms, and hoarseness may have a
more significantimpact on their QOL or ability to earn income. For
example,while hoarseness is relatively rare following thyroid
sur-gery, there are objective, measurable changes in the voice
ofmost patients that could affect pitch and the ability tosing.106
Singers are also prone to develop microvascularectasias that affect
voice and require specific therapy.107
To a slightly lesser degree, individuals in a number ofother
occupations or avocations, such as teachers andclergy, depend on
voice use. As an example, over 50 percentof teachers have
hoarseness, and vocal overuse is a com-mon, but not exclusive,
etiologic factor.108 Cliniciansshould inquire about an individual’s
voice use in order todetermine the degree to which altered voice
quality mayimpact the individual professionally.
Evidence profile for Statement 2: Modifying Factors
● Aggregate evidence quality: Grade C, observationalstudies
● Benefit: To identify factors early in the course of
man-agement that could influence the timing of
diagnosticprocedures, choice of interventions, or provision of
fol-low-up care
● Harm: None● Cost: None● Benefits-harm assessment:
Preponderance of benefit over
harm● Value judgments: Importance of history taking and
iden-
tifying modifying factors as an essential component ofproviding
quality care
● Role of patient preferences: Limited or none● Intentional
vagueness: None● Exclusions: None● Policy level: Recommendation
STATEMENT 3A. LARYNGOSCOPY AND HOARSE-NESS: Clinicians may
perform laryngoscopy, or mayrefer the patient to a clinician who
can visualize thelarynx, at any time in a patient with hoarseness.
Optionbased on observational studies, expert opinion, and a
bal-ance of benefit and harm.
STATEMENT 3B. INDICATIONS FOR LARYNGOS-COPY: Clinicians should
visualize the patient’s larynx,or refer the patient to a clinician
who can visualize thelarynx, when hoarseness fails to resolve by a
maximumof three months after onset, or irrespective of duration ifa
serious underlying cause is suspected. Recommendationbased on
observational studies, expert opinion, and a pre-
ponderance of benefit over harm.
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Supporting TextThe purpose of these statements is to highlight
the importantrole of visualizing the larynx and vocal folds in
managing apatient with hoarseness, especially if the hoarseness
fails toimprove within three months of onset (Statement 3B).
Pa-tients with persistent hoarseness may have a serious under-lying
disorder (Table 7) that would not be diagnosed unlessthe larynx was
visualized. This does not, however, implythat all patients must
wait three months before laryngoscopyis performed, because, as
outlined below, early assessmentof some patients with hoarseness
may improve manage-ment. Therefore, clinicians may perform
laryngoscopy, orrefer to a clinician for laryngoscopy, at any time
(Statement3A) if deemed appropriate based on the patient’s
specificclinical presentation and modifying factors.
Laryngoscopy and HoarsenessVisualization of the larynx is part
of a comprehensive eval-uation for voice disorders. While not all
clinicians have thetraining and equipment necessary to visualize
the larynx,those who do may examine the larynx of a patient
present-ing with hoarseness at any time if considered
appropriate.Although most hoarseness is caused by benign or
self-limited conditions, early identification of some disordersmay
increase the likelihood of optimal outcomes.
There are a number of conditions where laryngoscopy atthe time
of initial assessment allows for timely diagnosisand management.
Laryngoscopy can be used at the bedsidefor patients with hoarseness
after surgery or intubation toidentify vocal fold immobility,
intubation trauma, or othersources of postsurgical hoarseness.
Laryngoscopy plays acritical role in evaluating laryngeal patency
after laryngealtrauma where visualization of the airway allows for
assess-ment of the need for surgical intervention and for
followingpatients in whom immediate surgery is not
required.109,110
Laryngoscopy is used routinely for diagnosing laryngeal
Table 7Conditions leading to suspicion of a “seriousunderlying
cause”
Hoarseness with a history of tobacco or alcohol useHoarseness
with concomitant discovery of a neck
massHoarseness after traumaHoarseness associated with
hemoptysis, dysphagia,
odynophagia, otalgia, or airway compromiseHoarseness with
accompanying neurologic
symptomsHoarseness with unexplained weight lossHoarseness that
is worseningHoarseness in an immunocompromised hostHoarseness and
possible aspiration of a foreign bodyHoarseness in a
neonateUnresolving hoarseness after surgery (intubation or
neck surgery)
cancer. The usefulness of laryngoscopy for establishing the
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diagnosis and the benefit of early detection have led theBritish
medical system to employ fast-track screening clin-ics for
laryngeal cancer that mandate laryngoscopy within14 days of
suspicion of laryngeal cancer.111,112 Fungal lar-yngitis from
inhalers and other causes is best diagnosedwith laryngoscopy and
must be distinguished from malig-nancy.113
Unilateral vocal fold paralysis causes breathy hoarsenessand is
often caused by thoracic, cervical, or brain tumorsthat either
compress or invade the vagus nerve or itsbranches that innervate
the larynx. Stroke may also presentwith hoarseness due to vocal
fold paralysis. Vocal foldparalysis is routinely identified,
characterized, and followedby laryngoscopy.79,114
In patients with cranial nerve deficits or neuromuscularchanges,
laryngoscopy is useful to identify neurologiccauses of vocal
dysfunction.115 Benign vocal fold lesionssuch as vocal fold cysts,
nodules, and polyps are readilydetected on laryngoscopy.
Visualization of the larynx mayalso provide supporting evidence in
the diagnosis of laryn-gopharyngeal reflux.116
Hoarseness caused by neurologic or motor neuron dis-ease such as
Parkinson disease, amyotrophic lateral sclero-sis, and spasmodic
dysphonia may have laryngoscopic find-ings that the clinician can
identify to initiate management ofthe underlying disease.117 Office
laryngoscopy is also acritical tool in the evaluation of the aging
voice.
Neonates with hoarseness should undergo laryngoscopyto identify
vocal fold paralysis,118 laryngeal webs,119 orother congenital
anomalies that might affect their ability toswallow or
breathe.120
Hoarseness in children is rarely a sign of a serious un-derlying
condition and is more likely the result of a benignlesion of the
larynx such as a vocal fold polyp, nodules, orcyst.121 However,
determining if laryngeal papilloma is theetiology of hoarseness in
a child is particularly importantgiven the high potential for
life-threatening airway obstruc-tion and the potential for
malignant transformation.122 Ahoarse child with other symptoms such
as stridor, airwayobstruction, or dysphagia may have a serious
underlyingproblem such as a Chiari malformation,123
hydrocephalus,skull base tumors, or a compressing neck or
mediastinalmass. Persistent hoarseness in children may be a
symptomof vocal fold paralysis with underlying etiologies that
in-clude neck masses, congenital heart disease, or
previouscardiothoracic, esophageal, or neck surgery.124
Indications for LaryngoscopyLaryngoscopy is indicated for the
assessment of hoarsenessif symptoms fail to improve or resolve
within three months,or at any time the clinician suspects a serious
underlyingdisorder. In this context “serious” describes an etiology
thatwould shorten the lifespan of the patient or otherwise
reduceprofessional viability or voice-related QOL. If the
clinicianis concerned that hoarseness may be caused by a
serious
underlying condition, the optimal way to address this con-
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cern is by visualization of the vocal folds with
laryngos-copy.
The major cause of community-acquired hoarseness isviral.
Symptoms from viral laryngitis typically last 1 to 3weeks.125,126
Symptoms of hoarseness persisting beyondthis time warrant further
evaluation to insure that no malig-nancy or morbid conditions are
missed and to allow furthertreatment to be initiated based on
specific benign patholo-gies if indicated. One population-based
cohort study127 andone large case-control study128 have shown that
delays indiagnosis of laryngeal cancer lead to higher stages of
dis-ease at diagnosis and worse prognosis. In the cohort
study,delay longer than three months led to poorer survival.
The expediency of laryngoscopy also depends on
patientconsiderations. Singers, performers, and patients
whoselivelihood depends upon their voice will not be able to
waitseveral weeks for their hoarseness to resolve as they may
beunable to work in the interim. In fact, a number of
profes-sionals with high vocal demands may benefit from imme-diate
evaluation.
Even in the absence of serious concern or patient
con-siderations indicating immediate laryngoscopy,
persistenthoarseness should be evaluated to rule out significant
pa-thology such as cancer or vocal fold paralysis. In the ab-sence
of immediate concern, there is little guidance from theliterature
on the proper length of time a hoarse patient canor should be
observed before visualization of the larynx ismandated. The working
group weighed the risk of delayeddiagnosis against the potential
over-utilization of resourcesand selected a fairly long window of
three months prior tomandating laryngoscopy. This safety net
approach, based onexpert opinion, was designed to address the main
concern ofthe working group that many patients with
persistenthoarseness are currently experiencing delayed diagnosis
orare not undergoing laryngoscopy at all.
Techniques for Visualizing the LarynxDifferent techniques are
available for laryngoscopy andconfer varying levels of risk. The
working group does nothave recommendations as to the preferred
method. Choiceof method is at the discretion of the evaluating
clinician.
Office laryngoscopy can be performed transorally with amirror or
rigid endoscope, transnasally with a flexible fi-beroptic or
distal-chip laryngoscope, and with either halo-gen light or
stroboscopic light application.129 The surfaceand mobility of the
vocal folds are well assessed with thesetools.
Stroboscopy is used to visualize the vocal folds as theyvibrate,
allowing for an assessment of both anatomy andfunction during the
act of phonation.130 When hoarsenesssymptoms are out of proportion
to the laryngoscopic exam-ination, stroboscopy should be
considered. The addition ofstroboscopic light allows for an
assessment of the pliabilityof the vocal folds, making additional
pathologies such asvocal fold scar easy to identify. Stroboscopy
has resulted inaltered diagnosis in 47 percent of cases,131 and
stroboscopic
parameters aid in the differentiation of specific vocal fold
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pathology, such as polyps and cysts.132 Surgical endoscopywith
magnification (microlaryngoscopy) is utilized moreoften when more
detailed examination, manipulation, orbiopsy of the structures is
required.133
In the adult, visualization by indirect mirror examinationmay be
limited by patient tolerance and photo documenta-tion is not
possible. Discomfort in transnasal laryngoscopyis usually mitigated
by the application of topical deconges-tant and/or anesthetic such
as lidocaine. A study of 1208patients evaluated by fiberoptic
laryngoscopy for assess-ment of vocal fold paralysis after
thyroidectomy showed nosignificant adverse events.134 No other
reports of significantrisks of fiberoptic laryngoscopy were found
in a detailedMEDLINE search using key words: laryngoscopy,
compli-cations, risk, and adverse events. Transoral examinations
ofthe larynx may be preceded by topical lidocaine to the throatand
carries similarly minimal risk.
Operative laryngoscopy carries more substantial risk
butgenerally allows for ease of tissue manipulation and
biopsy.Risks associated with direct laryngoscopy with general
an-esthesia, include airway distress; dental trauma; oral
cavity,oropharyngeal, and hypopharyngeal trauma; tongue
dyses-thesia; taste changes; and cardiovascular risk.135-137
Thecost of direct laryngoscopy is substantially greater than thatof
office-based laryngoscopy due to the additional costs ofstaff,
equipment, and additional care required.138-140
Special consideration is given to children for whomlaryngoscopy
requires either advanced skill or a specializedsetting. With the
advent of small-diameter flexible laryngo-scopes, awake, flexible
laryngoscopy can be employed inthe clinic in children as young as
newborns but is subject tothe skill of the clinician and comfort
with children. Theadvantage is that this examination allows for
evaluation ofboth anatomy and function of the larynx in the hoarse
child.Direct laryngoscopy under anesthesia with or without
amicroscope may be used to verify flexible fiberoptic find-ings,
manage laryngeal papillomas or other vocal fold le-sions, and
further define laryngeal pathology such as con-genital anomalies of
the larynx. Intraoperative palpation ofthe cricoarytenoid joint may
also help differentiate betweenvocal fold paralysis and
fixation.
Evidence profile for Statement 3A: Laryngoscopy
andHoarseness
● Aggregate evidence quality: Grade C, based on observa-tional
studies
● Benefit: Visualization of the larynx to improve
diagnosticaccuracy and allow comprehensive evaluation
● Harm: Risk of laryngoscopy, patient discomfort● Cost:
Procedural expense● Benefits-harm assessment: Balance of benefit
and harm● Value judgments: Laryngoscopy is an important tool
for
evaluating voice complaints and may be performed at anytime in
the patient with hoarseness
● Intentional vagueness: None
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● Role of patient preferences: Substantial; the level of
pa-tient concern should be considered in deciding when toperform
laryngoscopy
● Exclusions: None● Policy level: Option
Evidence profile for Statement 3B: Indications for
La-ryngoscopy
● Aggregate evidence quality: Grade C, observational stud-ies on
the natural history of benign laryngeal disorders;grade C for
observational studies plus expert opinion ondefining what
constitutes a serious underlying condition
● Benefit: Avoid missed or delayed diagnosis of
seriousconditions in patients without additional signs or symp-toms
to suggest underlying disease; permit prompt assess-ment of the
larynx when serious concern exists
● Harm: Potential for up to a three-month delay in diagno-sis;
procedure-related morbidity
● Cost: Procedural expense● Benefits-harm assessment:
Preponderance of benefit over
harm● Value judgments: A need to balance timely diagnostic
intervention with the potential for over-utilization
andexcessive cost. The guideline panel debated on the max-imum
duration of hoarseness prior to mandated evalua-tion and opted to
select a “safety net approach” with agenerous time allowance (three
months), but options toproceed promptly based on clinical
circumstances
● Intentional vagueness: The term “serious underlying con-cern”
is subject to the discretion of the clinician. Someconditions are
clearly serious, but in other patients, theseriousness of the
condition is dependent on the patient.Intentional vagueness was
incorporated to allow for clin-ical judgment in the expediency of
evaluation
● Role of patient preferences: Limited● Exclusions: None● Policy
level: Recommendation
STATEMENT 4. IMAGING: Clinicians should not ob-tain computed
tomography (CT) or magnetic resonanceimaging (MRI) of the patient
with a primary complaintof hoarseness prior to visualizing the
larynx. Recommen-dation against imaging based on observational
studies ofharm, absence of evidence concerning benefit, and a
pre-ponderance of harm over benefit.
Supporting TextThe purpose of this statement is not to
discourage the use ofimaging in the comprehensive work-up of
hoarseness, butrather to emphasize that it should be used to assess
forspecific pathology after the larynx has been visualized.
Laryngoscopy is the primary diagnostic modality forevaluating
patients with hoarseness. Imaging studies, in-cluding CT and MRI,
have also been used, but are unnec-essary in most patients because
most hoarseness is self-
limited or caused by pathology that can be identified by
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laryngoscopy. The value of imaging procedures before
la-ryngoscopy is undocumented; no articles were found in
thesystematic literature review for this guideline regarding
thediagnostic yield of imaging studies prior to laryngeal
exam-ination. Conversely, the risk of imaging studies is
welldocumented.
The risk of radiation-induced malignancy from CT scansis small
but real. More than 62 million CT scans per year areobtained in the
United States for all indications, including 4million performed on
children (nationwide evaluation ofx-ray trends). In a study of
400,000 radiation workers in thenuclear industry who were exposed
to an average dose of 20mSVs (a typical organ dose from a single CT
scan for anadult), a significant association was reported between
theradiation dose and mortality from cancer in this cohort.These
risks were quantitatively similar to those reported foratomic bomb
survivors.141 Children have higher rates ofmalignancy and a longer
lifespan in which radiation-in-duced malignancies can
develop.142,143 It is estimated thatabout 0.4 percent of all
cancers in the United States may beattributable to the radiation
from CT studies.144,145 The riskmay be higher (1.5% to 2%) if we
adjust this estimate basedon our current use of CT scans.
There are also risks associated with IV contrast dye usedto
increase diagnostic yield of CT scans.146 Allergies tocontrast dye
are common (5% to 8% of the population).Severe, life-threatening
reactions, including anaphylaxis,occur in 0.1 percent of people
receiving iodinated contrastmaterial, with a death rate of up to
one in 29,500 peo-ple.147,148
While MRI has no radiation effects, it is not without risk.A
review of the safety risks of MRI149 details five mainclasses of
injury: 1) projectile effects (anything metal thatgets attracted by
the magnetic field); 2) twisting of indwell-ing metallic objects
(cerebral artery clips, cochlear implants,or shrapnel); 3) burning
(electrical conductive material incontact with the skin with an
applied magnetic field, ie,EKG electrodes or medication patches);
4) artifacts (radio-frequency effects from the device itself
simulating pathol-ogy); and 5) device malfunction (pacemakers will
fire in-appropriately or work at an elevated frequency,
thusdistorting cardiac conduction).150
The small confines of the MRI scanner may lead toclaustrophobia
and anxiety.151 Some patients, children inparticular, require
sedation (with its associated risks). Thegadolinium contrast used
for MRI rarely induces anaphy-lactic reactions,152,153 but there is
recent evidence of renaltoxicity with gadolinium in patients with
pre-existing renaldisease.154 Transient hearing loss has been
reported, but thisis usually avoided with hearing protection.155
The costs ofMRI, however, are significantly more than CT
scanning.Despite these risks and their considerable cost,
cross-sec-tional imaging studies are being used with increasing
fre-quency.156-158
After laryngoscopy, evidence does support the use of
imaging to further evaluate 1) vocal fold paralysis or 2) a
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mass or lesion of the vocal fold or larynx that
suggestsmalignancy or airway obstruction.159 If vocal fold palsy
isnoted and recent surgery can explain the cause of the pa-ralysis,
imaging studies are generally not useful. If thehealth care
provider suspects a lesion along the recurrentlaryngeal nerve,
imaging studies are indicated.
Unexplained vocal fold paralysis found on laryngoscopywarrants
imaging the skull base to the thoracic inlet/arch ofthe aorta.
Including these anatomic areas allows for evalu-ation of the entire
path of the recurrent laryngeal nerve as itloops around the arch of
the aorta on the left side. On theright, it will show any lesions
in the lung apex along thecourse of the right recurrent laryngeal
nerve as it loopsaround the subclavian artery. One study showed
that acomplete radiographic work-up improved rates of
diagno-sis,160 but there is no consensus on whether CT or MRI
isbetter for evaluating the recurrent laryngeal nerve.161,162
Lesions at the skull base and brain are best evaluated usingan
MRI of the brain and brain stem with gadolinium en-hancement. If a
patient presents with additional lower cra-nial nerve palsy, the
skull base, particularly the jugularforamen (CN IX, X, XI), should
be evaluated.159
Primary lesions of the larynx, pharynx, subglottis, thy-roid,
and any pertinent lymph node groups can also beevaluated by imaging
the entire area. Intravenous contrastmay help to distinguish
vascular lesions from normal pa-thology on CT. Due to the
substantial dose of ionizingradiation delivered to the
radiosensitive thyroid gland,163
CT examination in children is cautioned when MRI is
avail-able.
There is still significant controversy whether MRI or CTis the
preferred study to evaluate invasion of laryngealcartilage. Before
the advent of the helical CT, MRI was thepreferred method.164 The
extent of bone marrow infiltrationby malignant tumors (ie,
nasopharyngeal carcinoma) can beassessed with MRI of the skull
base.165 MRI is preferred inchildren and can easily be extended to
include the medias-tinum to help evaluate congenital and neoplastic
lesions.For those patients who have absolute contraindications
toMRI such as pacemaker, cochlear implants, heart valveprosthesis,
or aneurysmal clip, CT is a viable alternative.
Imaging studies are valuable tools in diagnosing certaincauses
of hoarseness in children. A plain chest radiographwill aid in the
diagnosis of a mediastinal mass or foreignbody. A CT scan can
elucidate more detail if the initialradiography fails to show a
lesion. A soft tissue radiographof the neck can aid in the
diagnosis of an infectious orallergic process.166 CT imaging has
been the test of choicefor congenital cysts, laryngeal webs, solid
neoplasms, andexternal trauma, as it provides adequate resolution
withouthaving to sedate the patient as may be necessary for MRI.The
risk of radiation must be weighed against these benefits.MRI is the
better option for imaging the brain stem.166
FDG-PET imaging is used increasingly to assess patientswith head
and neck cancer. PET scans may help identify
mediastinal or pulmonary neoplasms that cause vocal fold
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paralysis.167 PET scanning is very costly, however, and maygive
false-positive results in patients with vocal fold paral-ysis. FDG
activity in the normal vocal fold can be misin-terpreted as a
tumor.168
Evidence profile for Statement 4: Imaging
● Aggregate evidence quality: Grade C, observational stud-ies
regarding the adverse events of CT and MRI; noevidence identified
concerning benefits in patients withhoarseness before
laryngoscopy
● Benefit: Avoid unnecessary testing; minimize cost andadverse
events; maximize the diagnostic yield of CT andMRI when
indicated
● Harm: Potential for delayed diagnosis● Cost: None●
Benefits-harm assessment: Preponderance of benefit over
harm● Value judgments: Avoidance of unnecessary testing● Role of
patient preferences: Limited● Intentional vagueness: None●
Exclusions: None● Policy level: Recommendation against
STATEMENT 5A. ANTI-REFLUX MEDICATIONAND HOARSENESS. Clinicians
should not prescribeanti-reflux medications for patients with
hoarsenesswithout signs or symptoms of gastroesophageal
refluxdisease (GERD). Recommendation against prescribingbased on
randomized trials with limitations and observa-tional studies with
a preponderance of harm over benefit.
STATEMENT 5B. ANTI-REFLUX MEDICATIONAND CHRONIC LARYNGITIS.
Clinicians may pre-scribe anti-reflux medication for patients with
hoarse-ness and signs of chronic laryngitis. Option based
onobservational studies with limitations and a relative bal-ance of
benefit and harm.
Supporting TextThe primary intent of this statement is to limit
widespreaduse of anti-reflux medications as empiric therapy for
hoarse-ness without symptoms of GERD or laryngeal
findingsconsistent with laryngitis, given the known adverse
effectsof the drugs and limited evidence of benefit. The purpose
isnot to limit use of anti-reflux medications in managinglaryngeal
inflammation, when inflammation is seen on la-ryngoscopy (eg,
laryngitis denoted by erythema, edema,redundant tissue, and/or
surface irregularities of the inter-arytenoid mucosa, arytenoid
mucosa, posterior laryngealmucosa, and/or vocal folds). To
emphasize these dual con-siderations, the working group has split
the statement intopart A, a recommendation against empiric therapy
forhoarseness, and part B, an option to use anti-reflux therapy
in managing properly diagnosed laryngitis.
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Anti-Reflux Medications and the EmpiricTreatment of
HoarsenessThe benefit of anti-reflux treatment for hoarseness in
pa-tients without symptoms of esophageal reflux (heartburnand
regurgitation) or evidence for esophagitis is unclear. ACochrane
systematic review of 302 eligible studies thatassess the
effectiveness of anti-reflux therapy for patientswith hoarseness
did not identify any high-quality trialsmeeting the inclusion
criteria.169 For example, a nonran-domized study on treating
patients with documented refluxof stomach contents into the throat
(laryngopharyngeal re-flux) with twice-daily proton pump inhibitors
(PPIs) couldnot be included in the review because hoarseness was
onlyone component of the reflux symptom index and not anoutcome
separate from heartburn.170 One randomized, pla-cebo-controlled
trial was also not included because it didnot separate hoarseness
as an outcome from other laryngealsymptoms.171 However, the
response rate for the laryngealsymptoms was 50 percent in the PPI
group compared to 10percent in the placebo group.
A randomized trial published after the Cochrane reviewof
anti-reflux treatment for hoarseness included 145 subjectswith
chronic laryngeal symptoms (throat clearing, cough,globus, sore
throat, or hoarseness and no cardinal GERDsymptoms) and
laryngoscopic evidence for laryngitis(erythema, edema, and/or
surface irregularities of the inter-arytenoid mucosa, arytenoid
mucosa, posterior laryngealmucosa, and/or vocal folds).172 Subjects
received eitheresomeprazole 40 mg twice daily or placebo for 16
weeks.There was no evidence for benefit in symptom score
orlaryngopharyngeal reflux health-related QOL score betweenthe
groups at the end of the study. However, this studyincluded
patients with one of many possible laryngealsymptoms and excluded
patients with heartburn three ormore days per week.172
The benefits of anti-reflux medication for control ofGERD
symptoms are well documented. High-quality con-trolled studies
demonstrate that PPIs and H2RA (hista-mine-2 receptor antagonist)
improve important clinical out-comes in esophageal GERD over
placebo, with PPIsdemonstrating superior response.173,174 Response
rates foresophageal symptoms and esophagitis healing are high
(ap-proximately 80% for PPIs).173,174
In patients with hoarseness and a diagnosis of GERD,anti-reflux
treatment is more likely to reduce hoarseness.Anti-reflux treatment
given to patients with GERD (basedon positive pH probe, esophagitis
on endoscopy, or pres-ence of heartburn or regurgitation) showed
improvedchronic laryngitis symptoms, including hoarseness,
overthose without GERD.175
There is some evidence supporting the pharmacologicaltreatment
of GERD without documented esophagitis, butthe number needed to
treat tends to be higher.173 Thesestudies have esophageal symptoms
and/or mucosal healing
as outcomes, not hoarseness.
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While generally safe for therapy shorter than two
months,prolonged therapy with PPIs and H2RAs for greater thanthree
months has been associated with significant risk.H2RAs are
associated with impaired cognition in olderadults.176,177 PPI use
may increase the risk of bacterial gastro-enteritis, specifically
campylobacter and salmonella178 andpossibly clostridium
difficile.179 Epidemiological studiesalso associate PPIs with
community-acquired pneumo-nia.180,181 Although patients with
primary voice disordersmay differ from those in the above mentioned
studies, thetreating clinician needs to consider these adverse
events.Furthermore, PPIs may impair the ability of clopidogrel
toinhibit platelet aggregation activity,182 to varying
degreesdepending upon the particular PPI.
Higher doses such as the twice-daily PPI therapy maycarry a
higher risk than once-daily therapy, and older adultsmay be more
likely than younger adults to be harmed.183
Although pneumonia is more common in young childrenusing PPIs,
the prevalence of profound regurgitation andswallowing disorders is
high in that population, so it isdifficult to draw conclusions
about the effect of the drugitself.184
Use of PPI may interfere with calcium absorption andbone
homeostasis. PPI use is associated with an increasedrisk for hip
fractures in older adults.185 PPIs decrease vita-min B12
(cobalamin) absorption in a dose-dependent man-ner,186 and serum
vitamin B12 levels may underestimate theresulting serum cobalamin
deficiency.187 PPI use also de-creases iron absorption and may
cause iron deficiency ane-mia.188 Additionally, acid-suppressing
drugs (both H2RAsand PPIs) were associated with an increased risk
of pancre-atitis in a case-controlled study, not explained by
theslightly higher risk of pancreatitis seen in patients withGERD
symptoms alone.189
For patients with hoarseness and GERD, a trial ofanti-reflux
therapy may be prescribed. If hoarseness doesnot respond or if
symptoms worsen, then pharmacologi-cal therapy should be
discontinued and a search foralternative causes of hoarseness
should be initiated withlaryngoscopy.
Anti-Reflux Medications and Treatment ofChronic
LaryngitisLaryngoscopy is helpful in determining whether
anti-refluxtreatment should be considered in managing a patient
withhoarseness. Increased pharyngeal acid reflux events aremore
common in patients with vocal process granulomascompared to
controls.190 Also, erythema in the vocal folds,arytenoid mucosa,
and posterior commissure has improvedwith omeprazole treatment in
patients with sore throat,throat clearing, hoarseness, and/or
cough.191 While no dif-ferences in hoarseness improvement was seen
between threemonths of esomeprazole vs placebo, one small
randomizedcontrolled trial found that findings of erythema,
diffuse
laryngeal edema, and posterior commissure hypertrophy
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showed greater improvement in the treatment arm comparedto
placebo.192
More improvement in signs of laryngitis of the true vocalfolds
(such as erythema, edema, redundant tissue, and/orsurface
irregularities), posterior cricoid mucosa, and aryte-noid complex
were noted in patients whose laryngeal symp-toms, including
hoarseness, responded to four months ofPPI treatment compared to
nonresponders.193 Additionally,the above abnormalities of the
interarytenoid mucosa andtrue vocal folds were predictive of
improvement in laryn-geal symptoms, including hoarseness.193
Reflux of stomach contents into the laryngopharynx is
animportant consideration in the management of patients
withlaryngeal disorders. Reflux of gastric contents into the
hy-popharynx has been linked with subglottic stenosis.194
Case-control studies have shown that GERD may be a riskfactor
for laryngeal cancer,195 and that anti-reflux therapymay reduce the
risk of laryngeal cancer recurrence.196 Bet-ter healing and reduced
polyp recurrence after vocal foldsurgery in patients taking PPIs
compared to no PPIs havealso been described.197
PPI treatment may improve laryngeal lesions and ob-jective
measures of voice quality. Observational studieshave demonstrated
that vocal process granulomas, whichmay cause hoarseness, have
resolved or regressed aftertreatment with anti-reflux medication
with or withoutvoice therapy.198 Case series also have shown
improvedacoustic voice measures of voice quality after one to
twomonths of PPI therapy compared to baseline.199
Nonetheless, there are limitations of the endoscopic la-ryngeal
examination in diagnosing patients who may re-spond to PPIs. The
presence of abnormal findings, such asthe interarytenoid bar, has
been noted in normal individu-als.177 In addition, in a study of
healthy volunteers notroutinely using anti-reflux medication and
with GERDsymptoms no more than three times per month, erythema
ofthe medial arytenoid, posterior commissure hypertrophy,and
pseudosulcus were noted.200 Furthermore, the presenceof specific
findings depended upon the method of laryngos-copy (rigid vs
flexible) and the inter-rater reliability rangedfrom moderate to
poor depending on the specific finding.200
In a study of patients with hoarseness from a variety
ofdiagnoses, problems with intra- and inter-rater reliability
forfindings of edema and erythema of the vocal folds andarytenoids
have also been noted.201
Further research exploring the sensitivity, specificity,and
reliability of laryngoscopic examination findings is nec-essary to
determine which signs are associated with treat-ment response with
respect to hoarseness and which tech-niques are best to identify
them.
Evidence profile for Statement 5A: Anti-reflux Medica-tions and
Hoarseness
● Aggregate evidence quality: Grade B, randomized trials
withlimitations showing lack of benefits for anti-reflux therapy
in
patients with laryngeal symptoms, including hoarseness; ob-
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servational studies with inconsistent or inconclusive
results;inconclusive evidence regarding the prevalence of
hoarse-ness as the only manifestation of reflux disease
● Benefit: Avoid adverse events from unproven therapy;reduce
cost; limit unnecessary treatment
● Harm: Potential withholding of therapy from patientswho may
benefit
● Cost: None● Benefits-harm assessment: Preponderance of benefit
over
harm● Value judgments: Acknowledgment by the working
group of the controversy surrounding laryngopharyngealreflux,
and the need for further research before definitiveconclusions can
be drawn; desire to avoid known adverseevents from anti-reflux
therapy
● Intentional vagueness: None● Patient preference: Limited●
Exclusions: Patients immediately before or after laryn-
geal surgery and patients with other diagnosed pathologyof the
larynx
● Policy level: Recommendation against
Evidence profile for Statement 5B: Anti-reflux Medica-tion and
Chronic Laryngitis
● Aggregate evidence quality: Grade C, observationalstudies with
limitations showing benefit with laryngealsymptoms, including
hoarseness, and observationalstudies with limitations showing
improvement in signsof laryngeal inflammation
● Benefit: Improved outcomes, promote resolution of
lar-yngitis
● Harm: Adverse events related to anti-reflux medications● Cost:
Direct cost of medications● Benefits-harm assessment: Relative
balance of benefit
and harm● Value judgments: Although the topic is controversial,
the
working group acknowledges the potential role of anti-reflux
therapy in patients with signs of chronic laryngitisand recognizes
that these patients may differ from thosewith an empiric diagnosis
of hoarseness (dysphonia)without laryngeal examination
● Patient preference: Substantial role for shared
decisionmaking
● Intentional vagueness: None● Exclusions: None● Policy level:
Option
STATEMENT 6. CORTICOSTEROID THERAPY:Clinicians should not
routinely prescribe oral cortico-steroids to treat hoarseness.
Recommendation againstprescribing based on randomized trials
showing adverseevents and absence of clinical trials demonstrating
ben-efits with a preponderance of harm over benefit for ste-
roid use.
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Supporting TextOral steroids are commonly prescribed for
hoarseness andacute laryngitis, despite an overwhelming lack of
support-ing data of efficacy. A systematic search of
MEDLINE,CINAHL, EMBASE, and the Cochrane Library revealed nostudies
supporting the use of corticosteroids as empirictherapy for
hoarseness except in special circumstances asdiscussed below.
Although hoarseness is often attributed to acute inflam-mation
of the larynx, the temptation to prescribe systemic orinhaled
steroids for acute or chronic hoarseness or laryngitisshould be
avoided because of the potential for significantand serious side
effects. Side effects from corticosteroids canoccur with short- or
long-term use, although the frequencyincreases with longer
durations of therapy (Table 8).202 Addi-tionally, there are many
reports implicating long-term inhaledsteroid use as a cause of
hoarseness.208-219
Despite these side effects, there are some indications
forsteroid use in specific disease entities and patients. A
spe-cific and accurate diagnosis should be achieved, however,before
beginning this therapy. The literature does supportsteroid use for
recurrent croup with associated laryngitis inpediatric patients220
and allergic laryngitis.212,221 Patientswith chronic laryngitis and
dysphonia may have environ-mental allergy.221 In limited cases,
systemic steroids havebeen reported to provide quick relief from
allergic laryngitisfor performers.212,221 While these are not
high-quality trials,they suggest a possible role for steroids in
these selectedpatient populations. Additionally, in patients
acutely depen-dent on their voice, the balance of benefit and harm
may beshifted. The length of treatment for allergy-associated
dys-phonia with steroids has not been well defined in the
liter-ature.
Pediatric patients with croup and other associated symp-toms
such as hoarseness had better outcomes when treated
Table 8Documented side effects of short- and long-termsteroid
therapy202-207
LipodystrophyHypertensionCardiovascular diseaseCerebrovascular
diseaseOsteoporosisImpaired wound healingMyopathyCataractsPeptic
ulcersInfectionMood disorderOphthalmologic disordersSkin
disordersMenstrual disordersAvascular
necrosisPancreatitisDiabetogenesis
with systemic steroids.220 Steroids should also be consid-
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ered in patients with airway compromise to decrease edemaand
inflammation. An appropriate evaluation and determi-nation of the
cause of the airway compromise is requiredprior to starting the
steroid therapy. Steroids are also helpfulin some autoimmune
disorders involving the larynx such assystemic lupus erythematosus,
sarcoidosis, and Wegenergranulomatosis.222,223
Evidence profile for Statement 6: Corticosteroid Therapy
● Aggregate evidence quality: Grade B, randomized trialsshowing
increased incidence of adverse events associatedwith orally
administered steroids; absence of clinical tri-als demonstrating
any benefit of steroid treatment onoutcomes
● Benefit: Avoid potential adverse events associated
withunproven therapy
● Harm: None● Cost: None● Benefits-harm assessment:
Preponderance of harm over
benefit for steroid use● Value judgments: Avoid adverse events
of ineffective or
unproven therapy● Role of patient preferences: Some; there is a
role for
shared decision making in weighing the harms of steroidsagainst
the potential yet unproven benefit in specific cir-cumstances (ie,
professional or avocation voice use andacute laryngitis)
● Intentional vagueness: Use of the word “routine” to
ac-knowledge there may be specific situations, based onlaryngoscopy
results or other associated conditions, thatmay justify steroid use
on an individualized basis
● Exclusions: None● Policy level: Recommendation against
STATEMENT 7. ANTIMICROBIAL THERAPY: Cli-nicians should not
routinely prescribe antibiotics to treathoarseness. Strong
recommendation against prescribingbased on systematic reviews and
randomized trials showingineffectiveness of antibiotic therapy and
a preponderance ofharm over benefit.
Supporting TextHoarseness in most patients is caused by acute
laryngitis ora viral upper respiratory infection, neither of which
arebacterial infections. Since antimicrobials are only effectivefor
bacterial infections, their routine, empiric use in
treatingpatients with hoarseness is unwarranted.
Upper respiratory infections often produce symptoms ofsore
throat and hoarseness, which may alter voice qualityand function.
Acute upper respiratory infections caused byparainfluenza,
rhinovirus, influenza, and adenovirus havebeen linked to
laryngitis.224,225 Furthermore, acute laryngi-tis is self-limited,
with patients having improvement in 7 to10 days undergoing placebo
treatment.226 A Cochrane re-
view examining the role of antibiotics in acute laryngitis
in
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adults found only two studies meeting the inclusion criteriaand
no benefit of either penicillin or erythromycin.227 Sim-ilar
findings of no benefit for antibiotics in acute upperrespiratory
tract infections in adults and children were notedin another
Cochrane review.228
The potential harm from antibiotics must also be consid-ered.
Common adverse effects include rash, abdominalpain, diarrhea, and
vomiting and are more common in pa-tients receiving antibiotics
compared to placebo.228,229 In-teractions may also occur between
specific antibiotics andother medications.230
In addition to negative consequences from antibioticu