Clinical Practice Guidelines for management of Dysphonia

Dysphonia or impaired voice production is a clinical condition characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life.

This is a very common complaint affecting nearly one-third of the population at some point in its life. It can affect patients of all ages and sex but most commonly affects teachers, older adults, and other persons with significant vocal demands.

Recently in March 2018, American Academy of Otolaryngology and Head & Neck Surgery (AAO-HNS) has published updated clinical practice guidelines for management of dysphonia.

These guidelines are contributed by a panel of experts representing the fields of laryngology, neurology, otolaryngology–head and neck surgery, advanced practice nursing, consumer advocacy, family medicine, geriatric medicine, internal medicine, pediatrics, professional voice, pulmonology, and speech-language pathology.

The panel believes that the updated clinical practice guidelines will provide an evidence-based framework in decision-making strategies for the practicing otolaryngologists / primary care physicians who are dealing with patients with a change in voice. The updates are applicable to patients of all age groups.

Action statements by the panel

Following are the key action statements made by the panel in the guidelines for management of dysphonia:

Strong recommendations for

  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; the presence of concomitant neck mass; respiratory distress or stridor; a 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.

Recommendations for

  1. Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces the 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 worsening symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation.

Optional recommendations for

  1. Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.

Strong recommendations against

  1. Clinicians should not routinely prescribe antibiotics to treat dysphonia.
  2. 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.
  3. Clinicians should not prescribe anti-reflux 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.
  4. Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx.

References

  1. Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis CC, Smith LJ. Clinical practice guideline: hoarseness (dysphonia)(update). Otolaryngology–Head and Neck Surgery. 2018 Mar;158(1_suppl):S1-42.

Meet the author

Dr Sanu P Moideen is an Indian-born oto-rhino-laryngologist (ENT) based in Cochin, Kerala, India. He is currently working as Post-Doctoral Fellow in Head and Neck Oncology at Regional Cancer Center, Trivandrum, Kerala.

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