AAO-HNSF Hoarseness (Dsphonia) Guidelines Pocket Guide & App

Hoarseness GUIDELINES Pocket Guide

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American Academy of Otolaryngology-Head and Neck Surgeons

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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.

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:
Was the onset of your hoarseness abrupt or slowly progressive? Does your voice ever return to normal or is the hoarseness constant? Did your voice change at the time or persist after an upper respiratory tract infection? Do you have pain or is there effort when talking? Does your voice deteriorate or fatigue with use? 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? Were you intubated prior to dysphonia onset? Did you have brain, spine, neck, or chest surgery prior to dysphonia onset? Did you recently take inhaled medications, antibiotics, or steroids? Do you need the voice for your occupation? Do you have significant daily voice use requirements? Do you smoke (tobacco, vape, or use recreational drugs)? Does your throat feel dry? Have you undergone radiation therapy to the head and neck region? Do you have any neurological or arthritic problems? Did you have prior trauma (physical, emotional, or psychological) preceding the voice change?
Symptoms
Globus pharyngeus (persisting sensation of lump in throat) Dysphagia Sore throat Chronic throat clearing Cough Odynophagia (pain with swallowing) Nasal drainage Post-nasal drainage Acid reflux Regurgitation Heartburn Hemoptysis Non-anginal chest pain Waterbrash (sudden appearance of salty liquid in the mouth) Halitosis (“bad breath”) Weight loss Night sweats Fever (>101.5° F Otalgia (ear pain) Dyspnea (difficulty breathing)
Medical history relevant to dysphonia
Occupation and/or avocation requiring extensive voice use (i.e., teacher, singer) Absenteeism from occupation due to dysphonia Prior episode(s) of hoarseness Relationship of instrumentation (e.g., intubation) to onset of dysphonia Relationship of prior neck or chest surgery to onset of dysphonia Cognitive impairment (requirement for proxy historian) Anxiety, depression, stress
Acute conditions
Infection of the throat and/or larynx: viral, bacterial, fungal Foreign body in larynx, trachea, or esophagus Neck or laryngeal trauma
Chronic conditions
Stroke Diabetes Parkinson’s disease Parkinson-plus syndromes (e.g., progressive supranuclear palsy) Myasthenia gravis Multiple sclerosis Amyotrophic lateral sclerosis (ALS) Essential tremor Testosterone deficiency Allergic rhinitis Chronic rhinitis Hypertension (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 (because of use of inhaled steroids or effect on respiratory function) COPD (because of use of inhaled steroids or effect on respiratory function) Aneurysm of thoracic aorta (rare cause) Laryngeal cancer Lung cancer (or metastasis to the lung) Thyroid cancer Hypothyroidism and other endocrinopathies Vocal fold nodules Vocal fold paralysis Vocal abuse Infective laryngitis Chemical laryngitis Chronic tobacco use Sjögren syndrome Alcohol (moderate to heavy use or abuse) Menopause

* 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

Lipodystrophy
Hypertension
Cardiovascular disease
Cerebrovascular disease
Osteoporosis
Impaired wound healing
Myopathy
Cataracts
Peptic ulcers

Infection
Mood disorder
Ophthalmologic disorders
Skin disorders and alopecia
Menstrual disorders, and hormonal changes
Avascular necrosis (femur, humerus, long bones)
Pancreatitis
Diabetogenesis

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Key Points

Table 1. Summary of Guideline Key Action Statements (KAS)

Figure 1. Key Action Statement (KAS) Algorithm

Table 2. Definition of Common Terms

Diagnosis

Table 3. Etiologies of Dysphonia and Examples* from Each Category

Table 4. Medications That May Cause Dysphonia*

Table 5. Examples of Pertinent Questions in the Assessment of a Patient with Dysphonia*

Treatment

Table 6. Documented Side Effects of Short and Long-term Steroid Therapy

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