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Hoarseness

8/13/18 in Blog Posts

Nearly one-third of people experience hoarseness at some point in their lives. 1 in 13 adults have a voice-related problem yearly.

Hoarseness is a symptom describing altered voice quality. When physicians evaluate a patient with hoarseness, the clinical term used to describe impaired voice production is dysphonia. Dysphonia can affect anyone but is more common in individuals with high voice demand such as teachers, speakers, and singers. Many causes of dysphonia, like an infection resolve on their own, but some persist and warrant further investigation. Individuals with head and neck cancer may present with dysphonia first.

Dysphonia can manifest due to neurologic issues (Parkinson’s disease, essential tremor), gastrointestinal problems (eosinophilic esophagitis, gastroesophageal reflux), autoimmune disorders (rheumatoid arthritis, sarcoidosis), or medication side effects (steroid inhalers, anti-hypertensives).

The American Academy of Otolaryngology-Head and Neck Surgery publishes Clinical Practice Guidelines to help all clinicians including pediatricians, internists, family practitioners, and general otolaryngologists diagnose and treat patients with dysphonia appropriately. The original Guidelines were published in 2009. This year updated Guidelines were published due to new studies and reviews suggesting a change in recommendations. The guidelines consist of 13 key action statements.

  1. Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces 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 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.

Clinicians need to be able to identify patients with dysphonia. An adult with a breathy voice may have idiopathic vocal fold paralysis, while an infant with a strained voice may have recurrent respiratory papillomatosis. Discussion with a proxy when available may be helpful. According to a study, 52% of patients with vocal fold cancer believed their voice changes were harmless and delayed seeking care. Understanding the duration of dysphonia and chronic underlying medical problems will help in obtaining timely care. Smoking history is especially critical in assessing risk for malignancy and need for laryngoscopy evaluation, as it increases the odds of head and neck cancer 2 to 3 fold.

 

    1. Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphoni
    2. 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.

 

Early laryngoscopy can avoid misdiagnosis or delayed diagnosis. Viral laryngitis typically self resolves in 1 to 3 weeks. Dysphonia that persists raises concerns for other pathologies. A previous study revealed that most patients with dysphonia wait between 88 and 119 days before seeking treatment. A recent survey of primary care providers found that 64% preferred to treat rather than refer a patient with chronic dysphonia (>6 weeks). After referral to an otolaryngologist, the use of advanced laryngeal visualization technology (eg, stroboscopy) resulted in a change of the primary care physician’s diagnosis to a different and more accurate diagnosis in 56% of cases. Delaying otolaryngology referral by over 3 months has been shown to more than double the patient’s health care costs ($271 increased to $711).

  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.
  4. Clinicians should NOT routinely prescribe antibiotics to treat dysphonia.

Imaging and medication intervention should only be considered after the larynx has been directly visualized. Laryngoscopy is the primary diagnostic modality for evaluating patients with dysphonia. The benefit of anti-reflux treatment and antibiotics for isolated dysphonia without laryngoscopy support is inconclusive. The literature does not support using steroids in isolated dysphonia, but does support its use for recurrent croup or airway compromise with associated laryngitis.

    1. 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).
    2. Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy.
  1. 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.
  2. 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.

Voice therapy is an effective technique for problems such as primary muscle tension dysphonia, Parkinson’s disease-related dysphonia, paradoxical vocal fold dysfunction, and cough. However, it is important to rule out diseases that are not amenable to therapy such as laryngeal cancer or papilloma. Laryngoscopy can make the diagnosis in many cases. If the diagnosis is still not clear after continuous light laryngoscopy, stroboscopy may help clarify this. When conservative treatments like voice therapy or medications are ineffective, surgery should be considered.

  1. Clinicians should inform patients with dysphonia about control/preventive measures.
  2. Clinicians should document resolution, improvement, or worsened symptoms of dysphonia or change in QOL among patients with dysphonia after treatment or observation.

Vocal hygiene is critical in preventing voice problems. In a study of 422 teachers, there was a 60% higher risk of dysphonia with poor water intake. One should have at least 60-80 ounces of water daily. Voice users should take at least 10-15 minute vocal breaks hourly to recuperate. If you ever have questions or concerns about a person’s voice, have them see one our Voice & Swallowing experts for an evaluation.

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