AAO-HNSF to issue the first guideline for helping physicians manage dysphonia

American Academy of Otolaryngology -- Head and Neck SurgerySep 1 2009

New recommendations from ENT doctors on the management of a common voice problem in adults and children

The American Academy of Otolaryngology - Head and Neck Surgery Foundation (AAO-HNSF) will issue the first--and only--national clinical practice guideline to help healthcare practitioners identify and manage patients with hoarseness, also known as dysphonia. The guideline emphasizes evidence-based management of hoarseness by clinicians, and educates patients on the prevalence of this common vocal health issue.

"Hoarseness affects approximately 20 million people in the U.S. at any given time, and about one in three individuals will become hoarse at some point in their life," said Richard M. Rosenfeld, MD, MPH, an author of the guideline and chair of the AAO-HNSF Guideline Development Task Force. "In addition to the impact on health and quality of life, hoarseness leads to frequent healthcare visits and several billion dollars in lost productivity annually from work absenteeism."

The terms hoarseness and dysphonia are often used interchangeably, however, hoarseness is a symptom of altered voice quality and dysphonia is a diagnosis. Hoarseness (dysphonia) is defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life. Hoarseness may affect newborns, infants, children, and adults of any age. Individuals with hoarseness have impaired communication with their family and peers, which may result in depression, social isolation, missed work, lost wages, or reduced quality of life.

"Most hoarseness is caused by benign or self-limiting conditions, but it may also be the presenting symptom of a more serious or progressive condition requiring prompt diagnosis and management," said Seth R. Schwartz, MD, MPH, chair of the Hoarseness Guideline Panel. "This new guideline is intended to enhance diagnosis, promote appropriate therapy, improve outcomes, and to expand counseling and education for prevention."

Hoarseness is more common in women (50% higher than men), children (peak range 8-14 years), the elderly, and professional voice users (e.g., teachers, performers, telemarketers, aerobics instructors). In spite of how common the condition is, a recent survey by the AAO-HNS revealed that many Americans are unfamiliar with the possible causes and appropriate treatment for hoarseness. The survey revealed that almost half of adults are not aware that persistent hoarseness may be a symptom of cancer. Separate research cited in the guideline also found that only 5.9 percent of those with hoarseness seek treatment.

Recognizing that patients who do seek care may see many different types of healthcare providers, the guidelines are intended for all clinicians who are likely to diagnose and manage patients with hoarseness.

Key features of the new guideline include:

• Most, but not all, hoarseness is the result of benign underlying or self-limiting factors; however, clinicians should consider the possibility of a serious underlying condition (growth or tumor of the larynx) or medication side effects as a cause.
• Laryngoscopy is an office procedure to visualize the larynx (voice box and vocal cords) that should be performed if hoarseness persists or if the cause is uncertain.
• Imaging studies, such as a CT or MRI scans, should not be obtained for a primary complaint of hoarseness prior to visualizing the larynx; laryngoscopy is the primary diagnostic modality and should be done first.
• Anti-reflux medicines should not be prescribed for hoarseness unless there are (a) signs or symptoms of gastroesophageal reflex disease (GERD), such as heartburn or regurgitation, or (b) signs of inflammation of the larynx seen during laryngoscopy.
• Steroids or antibiotics given by mouth are not recommended for hoarseness and should not be used routinely.
• Voice therapy is a well-established intervention for hoarseness that can be performed at any age. Laryngoscopy should be performed prior to voice therapy and results communicated to the speech-language pathologist. Therapy for hoarseness usually includes one to two sessions per week for four to eight weeks.
• Surgery is not the primary treatment for most hoarseness, but may be indicated for suspected cancer, other tumors or growths, abnormal movement of the vocal cords, or abnormal tone of the vocal cord muscles.
• The risk of hoarseness may be reduced by preventive measures such as staying well-hydrated, avoiding irritants (especially tobacco smoke), voice training, and amplification during heavy voice use.

"In an era of health reform and comparative effectiveness research, well-crafted guidelines help improve quality, promote optimal outcomes, minimize harm, and reduce inappropriate variations in care," says Dr. Rosenfeld. "It is hoped that these guidelines will give clinicians the tools they need to spot an issue early, avoid poor outcomes, and reduce healthcare costs."

The guideline was created by a multidisciplinary panel representing neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology - head and neck surgery, pediatric medicine, and consumers.