Clinical practice guidelines for treatment of hoarseness updated

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The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published the Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). The updated guideline provides some substantially revised, evidence-based recommendations for healthcare providers when treating patients with hoarseness, a very common complaint that affects nearly one-third of the population at some point in their life.

Hoarseness is responsible for frequent healthcare visits and several billion dollars in lost productivity annually from work absenteeism. With such a prevalence of occurrence, there are several important takeaways from the updated guideline that healthcare providers should be aware of when treating patients with hoarseness, including recommendations for escalation of care, the need for laryngoscopy for persistent hoarseness, and treatment.

The 2018 update provides an algorithm for healthcare providers to determine when acceleration of care is needed. These include but are not limited to recent surgical procedures involving the head, neck, or chest; presence of a neck mass; respiratory distress; history of tobacco use; or whether the patient is a professional voice user. In addition, the update shortens the timeframe that hoarseness can be managed conservatively, from 90 days to four weeks, before evaluation of the larynx is recommended to determine the underlying cause.

“One of the goals of the update is to provide clarity to healthcare providers on circumstances where early referral to an otolaryngologist for visualisation of the larynx is necessary,” said Dr David O Francis, guideline development group assistant chair. “Hoarseness is often caused by benign conditions, like the common cold, voice overuse, age-related changes, and others; however, it may also be a symptom of a more serious condition, like head and neck cancer. Failure to evaluate the larynx can delay cancer diagnosis, resulting in the need for more aggressive treatment and reduced survival.”

Voice problems affect one in 13 adults annually, however, it can affect patients of all ages and sex. There is an increased prevalence in singers, teachers, call-centre operators, older adults, and other persons with significant vocal demands. The guideline also provides recommendations on treating patients presenting with isolated hoarseness.

“An important component of this update are the recommendations that patients with isolated hoarseness should not be empirically treated with anti-reflux, antibiotic, or steroid medications before visualising the larynx,” said Francis. “Physicians have an obligation to be good stewards when prescribing medication. There is very little evidence of benefit in treating isolated hoarseness with these medications, and in fact, they can offer more harm than good. The updated guideline provides physicians with the resources and tools to educate patients about prevention of hoarseness and how to manage it conservatively, without the use of unnecessary medication.”

The update is endorsed by American Academy of Otolaryngic Allergy; Society of Otorhinolaryngology and Head-Neck Nurses; National Association of Teachers of Singing; National Spasmodic Dysphonia Association; American Broncho-Esophagological Association; American Laryngological Association; American Speech-Language-Hearing Association; American Society of Paediatric Otolaryngology; American Academy of Paediatrics; American College of Chest Physicians; and American Academy of Physical Medicine and Rehabilitation. An Affirmation of Value for the guideline update was received from the American Academy of Family Physicians.

Objective: This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.
Purpose: The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm.
For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.
Action Statements: The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy.
The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation.
The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx.
The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.
Disclaimer: This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem.

Differences from Prior Guideline
(1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply
(2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials
(3) Inclusion of a consumer advocate on the guideline update group
(4) Changes to 9 KASs from the original guideline
(5) New KAS 3 (escalation of care) and KAS 13 (outcomes)
(6) Addition of an algorithm outlining KASs for patients with dysphonia

Robert J Stachler; David O Francis; Seth R Schwartz; Cecelia C Damask; German P Digoy; Helene J Krouse; Scott J McCoy; Daniel R Ouellette; Rita R Patel; Charles (Charlie) W Reavis; Libby J Smith; Marshall Smith; Steven W Strode; Peak Woo; Lorraine C Nnacheta

American Academy of Ortolaryngology–Head and Neck Surgery material

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