Key Points
Table 1. Summary of Guideline Key Action Statements (KAS)
| Statement | Action | Strength |
|---|---|---|
| Diagnosis | ||
| 1. Identification of Abnormal Voice | Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces QOL. | R-C |
| 2. Identifying Underlying Cause of Dysphonia | Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. | R-C |
| 3. Escalation of Care | 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 he/she is a professional voice user. | S-B |
| 4a. Laryngoscopy and Dysphonia | Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. | O-C |
| 4b. Need for Laryngoscopy in Persistent Dysphonia | 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. | R-C |
| 5. Imaging | Clinicians should NOT obtain computed tomography (CT) or magnetic resonance imaging (MRI) in patients with a primary voice complaint prior to visualization of the larynx. | R-C against |
| Treatment | ||
| 6. Anti-Reflux Medication and Dysphonia | 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. | R-B against |
| 7. Corticosteroid Therapy | Clinicians should NOT routinely prescribe corticosteroids in patients with dysphonia prior to visualization of the larynx. | R-B against |
| 8. Antimicrobial Therapy | Clinicians should NOT routinely prescribe antibiotics to treat dysphonia. | S-A against |
| 9a. Laryngoscopy Prior to Voice Therapy | 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. | R-C |
| 9b. Advocating for Voice Therapy | Clinicians should advocate voice therapy in patients with dysphonia from a cause amenable to voice therapy. | S-A |
| 10. Surgery | Clinicians should advocate for surgery as a therapeutic option in 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. | R-B |
| 11. Botulinum Toxin | 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. | R-B |
| 12. Education/ Prevention | Clinicians should inform patients with dysphonia about control/preventive measures. | R-C |
| 13. Outcomes | Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in quality of life in patients with dysphonia after treatment or observation. | R-C |
Figure 1. Key Action Statement (KAS) Algorithm
Table 2. Definition of Common Terms
Term | Definition |
|---|---|
Dysphonia | Altered vocal quality, pitch, loudness, or vocal effort that impairs communication as assessed by a clinician and/or affects quality of life. |
Hoarseness | A symptom of altered voice quality reported by patients. |
Worsened Voice-related Quality of Life (QOL) | Self-perceived decrement in function; or a decline in economic status, as a result of voice-related dysfunction. |
Dysarthria | A speech disorder due to impaired movement of the structures used for speech production, including the lips, tongue, and complex musculature involved in articulation. |
Dyspnea | Difficult or labored breathing, shortness of breath. |
Dysphagia | Disordered or impaired swallowing. |
Laryngoscopy | Term used to describe visualization of larynx. Unless otherwise specified, its use in this guideline refers to indirect laryngoscopy (visualization of the larynx), which can be done by several methods including mirror examination, rigid rod-lens telescope examination, rigid rod-lens telescope, flexible fiber optic or flexible distal chip scopes. Each laryngoscopy technique has specific diagnostic indications. |
Stroboscopy | Advanced laryngeal imaging designed to visualize vocal fold vibratory abnormalities that cannot be appreciated using continuous light laryngoscopy. It uses a synchronized flashing light that passes through a laryngoscope. |
- Dysphonia (which causes hoarseness) is a very common complaint affecting nearly one-third of the population at some point in their lives.
- Dysphonia can affect patients of all ages and genders but has an increased prevalence in teachers, older adults, and other persons with significant vocal demands.
- Of dysphonia-related ICD-9 diagnoses, the most commonly used by physicians were acute laryngitis, non-specific dysphonia, benign vocal fold lesions (e.g., cysts, polyps, nodules), and chronic laryngitis.
- More serious conditions that cause dysphonia include:
- Neurological (e.g., vocal fold paralysis, spasmodic dysphonia, essential tremor, Parkinson’s disease, amyotropic lateral sclerosis, multiple sclerosis)
- Gastrointestinal (e.g., reflux, eosinophilic esophagitis)
- Rheumatologic/autoimmune (e.g., rheumatic arthritis, Sjogren’s, sarcoidosis, amyloidosis, granulomatosis with polyangiitis)
- Allergic, pulmonary (e.g., chronic obstructive pulmonary disease)
- Musculoskeletal (e.g., muscle tension dysphonia, fibromyalgia, cervicalgia)
- Psychological (functional voice disorders)
- Traumatic (e.g., laryngeal fracture, inhalational injury, iatrogenic injury, blunt/penetrating trauma)
- Infectious (e.g., candidiasis)
Diagnosis
Table 3. Etiologies of Dysphonia and Examples* from Each Category
Etiologic Category | Examples |
|---|---|
Surgery | Thyroidectomy or Parathyroidectomy Anterior Spine Surgeries Thoracic and Cardiac Surgeries Neurosurgery and Skull Base Surgery |
Inflammatory | Tobacco Use Polypoid Corditis Allergy |
Autoimmune | Granulomatosis with Polyangiitis Sarcoidosis Amyloidosis Rheumatoid Arthritis |
Infectious | Viral Upper Respiratory Infection Bacterial Infection Laryngeal Candidiasis |
Neurological | Laryngeal Dystonia (e.g., Spasmodic Dysphonia) Vocal Fold Paralysis Essential Tremor Parkinson Disease |
Endocrinological | Hypothyroidism Diabetes Menopause Androgen Supplementation |
Neoplastic | Laryngeal Squamous Cell Carcinoma Recurrent Respiratory Papillomatosis Metastatic Disease Other Neoplasms (e.g., chondromas, lymphoma) |
Congenital | Laryngeal Web Vocal Fold Cyst Laryngeal Cleft |
Traumatic | Laryngeal Fracture Posterior Glottic Stenosis Intubation Injury |
Behavioral | Vocal Fold Nodules Vocal Fold Cyst Vocal Fold Polyp Vocal Fold Vascular Lesion |
Musculoskeletal | Muscle Tension Dysphonia Cervicalgia |
Gastrointestinal | Reflux |
* Not a comprehensive list of etiologic examples. | |
Table 4. Medications That May Cause Dysphonia*
| Medication | Mechanism of impact on voice |
|---|---|
| Coumadin, thrombolytics, Phosphodiesterase-5 inhibitors | Vocal fold hematoma |
| Bisphosphonates | Chemical laryngitis |
| Angiotensin-converting enzyme inhibitors | Cough |
| Antihistamines, diuretics, anticholinergics | Drying effect on mucosa |
| Danocrine, testosterone | Sex hormone production/utilization Alteration |
| Antipsychotics, atypical antipsychotics | Laryngeal dystonia |
| Inhaled steroids | Dose dependent mucosal irritation Fungal laryngitis |
| * Note: This is not intended to be an exhaustive list of all medication that could cause dysphonia. | |
Table 5. Examples of Pertinent Questions in the Assessment of a Patient with Dysphonia*
Voice specific questions: | |
|---|---|
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Symptoms | |
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Medical history relevant to dysphonia | |
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Acute conditions | |
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Chronic conditions | |
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* Note: These are example considerations and list is not comprehensive of all pertinent parameters that may need to be assessed. | |
Treatment
Table 6. Documented Side Effects of Short and Long-term Steroid Therapy
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