New Clinical Guideline for Hoarseness Offers Assessment and Treatment Advice

A new clinical practice guideline offers advice to physicians assessing and treating dysphonia, or hoarseness, a condition that affects a substantial number of individuals at some point in life.

The guideline, created by an expert panel assembled by the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) Foundation, seeks to offer evidence-based recommendations for managing dysphonia and to raise public awareness of the condition's prevalence and its treatment options (Schwartz SR et al. Otolaryngol Head Neck Surg. 2009;141[3]:S1-S31). According to the guideline, only about 6% of individuals seek treatment for dysphonia, which is more common in women, children, and older adults. Certain occupations have high prevalence rates, including telemarketers (31%), aerobics instructors (44%), and teachers (58%).

For many individuals, an encounter with dysphonia may be little more than a brief nuisance, or a time-limited adverse effect of an upper respiratory tract infection. But it can also be a warning signal of something more serious.

“For the general public, an important message in the guideline is a lot of hoarseness can be benign, and a little hoarseness can be a sign of a bigger problem, like cancer,” said Richard M. Rosenfeld, MD, MPH, a coauthor of the document and chair of otolaryngology at the Long Island College Hospital in Brooklyn, NY. In putting together the guideline, Rosenfeld joined experts representing neurology, family medicine, pulmonology, geriatric medicine, internal medicine, otolaryngology–head and neck surgery, pediatrics, nursing, speech-language pathology, professional voice teaching, and consumers.

The document is the sixth published by the AAO-HNS and joins guidelines for benign paroxysmal positional vertigo, cerumen impaction, adult sinusitis, acute otitis externa, and otitis media with effusion. “Guidelines have evolved based on big-ticket inpatient conditions such as cardiac disease and stroke, but some of the outpatient conditions that may be ubiquitous may fall under the radar,” Rosenfeld said. He added that the Centers for Medicare & Medicaid Services (CMS) care about such conditions “because they represent big bucks.”

The dysphonia guideline should please the CMS because it downplays use of several high-cost assessments and treatments. The guideline authors said that based on observational studies, physicians should not obtain computed tomography or magnetic resonance imaging of a patient with a primary complaint of dysphonia prior to visualizing the larynx either by sight or by laryngoscopy. The authors also recommend, based on randomized controlled trials, against the routine prescribing of oral corticosteroids or antibiotics to treat dysphonia.

Another frequently used therapy rejected by the guideline authors is use of antireflux medications for the treatment of hoarseness unless the patient has signs or symptoms of gastroesophageal reflux disease. “Use of the antireflux medications in the management of hoarseness has become the chic prescription,” Rosenfeld said. “The problem is that the evidence supporting this use is nonexistent, and there is no reason it should be encouraged or considered—especially with some of the side effects these medications have when taken long-term.”

The guideline strongly recommends voice therapy for patients whose dysphonia reduces voice-related quality of life. “Voice therapy is vastly underused in managing hoarseness—very few people pursue it, and it is not often mentioned as a therapy option by primary care clinicians,” Rosenfeld said. Surgery is recommended only for patients with dysphonia and a suspected laryngeal malignancy, benign laryngeal soft tissue lesions, or glottic insufficiency.

For primary care physicians, who tend to be the first to see patients with dysphonia, the guideline should improve management of the condition, said Karen K. O’Brien, MD, a coauthor representing the American Academy of Family Physicians' Commission on Health of the Public and Science. “I think it will help them prioritize when to visualize the larynx, with laryngoscopy, either in their own offices or by an otolaryngologist,” said O’Brien, who is also a command surgeon with the US Army Training and Doctrine Command at Fort Monroe in Virginia. “It also highlights some potentially reversible conditions.” Such a condition could be the use of inhaled corticosteroids for treating asthma which could have hoarseness as a side effect.

And while research on reducing the risk of hoarseness has not been rigorous, the guideline suggests clinicians may choose to educate or counsel patients on measures to control or prevent the condition. “The article reinforces the importance of preventive measures such as good hydration, use of microphones to amplify the voice, avoidance of irritants, and the use of voice training in individuals who rely heavily upon their voice quality in their occupations and lives,” O’Brien said.