clinical practice guideline: hoarseness (dysphonia)

OtolaryngologyHead and Neck Surgery (2009) 141, S1-S31GUIDELINE

Clinical practice guideline: Hoarseness (Dysphonia)

Seth R. Schwartz, MD, MPH, Seth M. Cohen, MD, MPH,Seth H. Dailey, MD, Richard M. Rosenfeld, MD, MPH,Ellen S. Deutsch, MD, M. Boyd Gillespie, MD,Evelyn Granieri, MD, MPH, MEd, Edie R. Hapner, PhD, C. Eve Kimball, MD,Helene J. Krouse, PhD, RN, ANP-BC, J. Scott McMurray, MD,Safdar Medina, MD, Karen OBrien, MD, Daniel R. Ouellette, MD,Barbara J. Messinger-Rapport, MD, PhD, Robert J. Stachler, MD,Steven Strode, MD, MEd, MPH, Dana M. Thompson, MD,Joseph C. Stemple, PhD, J. Paul Willging, MD, Terrie Cowley,Scott McCoy, DMA, Peter G. Bernad, MD, MPH, and Milesh M. Patel, MS,Seattle, WA; Durham, NC; Madison, WI; Brooklyn, NY; Wilmington, DE; Charleston,SC; New York, NY; Atlanta, GA; Reading, PA; Detroit, MI; Uxbridge, MA;Fort Monroe, VA; Cleveland, OH; Little Rock, AR; Rochester, MN; Lexington, KY;

Cincinnati, OH; Milwaukee, WI; Princeton, NJ; Washington, DC; and Alexandria, VASponsorships or competing interests that may be relevant to con-tent are disclosed at the end of this article.

ABSTRACT

OBJECTIVE: This guideline provides evidence-based recom-mendations on managing hoarseness (dysphonia), defined as adisorder characterized by altered vocal quality, pitch, loudness, orvocal effort that impairs communication or reduces voice-relatedquality of life (QOL). Hoarseness affects nearly one-third of thepopulation at some point in their lives. This guideline applies to allage groups evaluated in a setting where hoarseness would beidentified or managed. It is intended for all clinicians who arelikely to diagnose and manage patients with hoarseness.PURPOSE: The primary purpose of this guideline is to improvediagnostic accuracy for hoarseness (dysphonia), reduce inappropriateantibiotic use, reduce inappropriate steroid use, reduce inappropriateuse of anti-reflux medications, reduce inappropriate use of radio-graphic imaging, and promote appropriate use of laryngoscopy, voicetherapy, and surgery. In creating this guideline the American Acad-emy of OtolaryngologyHead and Neck Surgery Foundation se-lected a panel representing the fields of neurology, speech-languagepathology, professional voice teaching, family medicine, pulmonol-ogy, geriatric medicine, nursing, internal medicine, otolaryngologyhead and neck surgery, pediatrics, and consumers.RESULTS: The panel made strong recommendations that 1) theclinician should not routinely prescribe antibiotics to treat hoarse-ness and 2) the clinician should advocate voice therapy for patientsdiagnosed with hoarseness that reduces voice-related QOL. TheReceived June 26, 2009; accepted June 26, 2009.

0194-5998/$36.00 2009 American Academy of OtolaryngologyHead and Necdoi:10.1016/j.otohns.2009.06.744

boto.sagepub.comDownloaded from panel made recommendations that 1) the clinician should diagnosehoarseness (dysphonia) in a patient with altered voice quality,pitch, loudness, or vocal effort that impairs communication orreduces voice-related QOL; 2) the clinician should assess thepatient with hoarseness by history and/or physical examination forfactors that modify management, such as one or more of thefollowing: recent surgical procedures involving the neck or affect-ing the recurrent laryngeal nerve, recent endotracheal intubation,radiation treatment to the neck, a history of tobacco abuse, andoccupation as a singer or vocal performer; 3) the clinician shouldvisualize the patients larynx, or refer the patient to a clinician whocan visualize the larynx, when hoarseness fails to resolve by amaximum of three months after onset, or irrespective of durationif a serious underlying cause is suspected; 4) the clinician shouldnot obtain computed tomography or magnetic resonance imagingof the patient with a primary complaint of hoarseness prior tovisualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs orsymptoms of gastroesophageal reflux disease; 6) the clinicianshould not routinely prescribe oral corticosteroids to treat hoarse-ness; 7) the clinician should visualize the larynx before prescribingvoice therapy and document/communicate the results to thespeech-language pathologist; and 8) the clinician should prescribe,or refer the patient to a clinician who can prescribe, botulinumtoxin injections for the treatment of hoarseness caused by adductorspasmodic dysphonia. The panel offered as options that 1) theclinician may perform laryngoscopy at any time in a patient withhoarseness, or may refer the patient to a clinician who can visu-alize the larynx; 2) the clinician may prescribe anti-reflux medi-k Surgery Foundation. All rights reserved.

y guest on March 7, 2015

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S2 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009cation for patients with hoarseness and signs of chronic laryngitis;and 3) the clinician may educate/counsel patients with hoarsenessabout control/preventive measures.DISCLAIMER: This clinical practice guideline is not intendedas a sole source of guidance in managing hoarseness (dysphonia).Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline isnot intended to replace clinical judgment or establish a protocol forall individuals with this condition, and may not provide the onlyappropriate approach to diagnosing and managing this problem.

2009 American Academy of OtolaryngologyHead and NeckSurgery Foundation. All rights reserved.

Nearly one-third of the population has impaired voiceproduction at some point in their lives.1,2 Hoarse-ness is more prevalent in certain groups, such as teachersand older adults, but all age groups and both genders can beaffected.1-6 In addition to the impact on health and quality oflife (QOL),7,8 hoarseness leads to frequent health care visitsand several billion dollars in lost productivity annually fromwork absenteeism.9 Hoarseness is often caused by benign orself-limited conditions, but may also be the presentingsymptom of a more serious or progressive condition requir-ing prompt diagnosis and management.

The terms hoarseness and dysphonia are often used in-terchangeably, although hoarseness is a symptom of alteredvoice quality and dysphonia is a diagnosis. Dysphonia maybe broadly defined as an alteration in the production ofvoice that impairs social and professional communication.In contrast, hoarseness is a coarse or rough quality to thevoice. Although the two terms are not synonymous, theguideline working group decided to use the term hoarsenessfor this guideline because it is more recognized and under-stood by patients, most clinicians, and the lay press.

The target patient for this guideline is anyone presentingwith hoarseness (dysphonia).

Hoarseness (dysphonia) is defined as a disorder charac-terized by altered vocal quality, pitch, loudness, or vocaleffort that impairs communication or reduces voice-re-lated QOL.

Impaired communication is defined as a decreased orlimited ability to interact vocally with others.

Reduced voice-related QOL is defined as a self-perceiveddecrement in physical, emotional, social, or economicstatus as a result of voice-related dysfunction.

This working definition, developed by the guidelinepanel, assumes that hoarseness affects people differently.Some individuals may have altered voice quality, vocaleffort, pitch, or loudness; others may experience problemswith communication and diminished voice-related QOL.

The guideline is intended for all clinicians who are likelyto diagnose and manage patients with hoarseness and ap-plies to any setting in which hoarseness would be identified,monitored, treated, or managed. The guideline does notapply to patients with hoarseness with the following condi-

tions: history of laryngectomy (total or partial), craniofacial

boto.sagepub.comDownloaded from anomalies, velopharyngeal insufficiency, and dysarthria(impaired articulation). However, the guideline will discussthe relevance of these conditions in managing patients withhoarseness.

There are a number of patients with modifying factorsfor whom many of the recommendations of the guidelinemay not apply. There is some discussion of these factors andhow they might modify management. A partial list includesprior laryngeal surgery, recent surgical procedures involv-ing the neck or affecting the recurrent laryngeal nerve,recent endotracheal intubation, radiation treatment to theneck, and patients who are singers or performers.

GUIDELINE PURPOSE

The primary purpose of this guideline is to improve thequality of care for patients with hoarseness based on currentbest evidence. Expert consensus to fill evidence gaps, whenused, is explicitly stated, and is supported with a detailedevidence profile for transparency. Specific objectives of theguideline are to reduce inappropriate variations in care,produce optimal health outcomes, and minimize harm.

The guideline is intended to focus on a limited number ofquality improvement opportunities, deemed most importantby the working group, and is not intended to be a compre-hensive, general guide for managing patients with hoarse-ness. In this context, the purpose is to define actions thatcould be taken by clinicians, regardless of discipline, todeliver quality care. Conversely, the statements in thisguideline are not intended to limit or restrict care providedby clinicians based on assessment of individual patients.

While there is evidence to guide management of certaincauses of hoarseness, there are currently no evidence-basedclinical practice guidelines. There are variations in the useof the laser, voice therapy, steroids, and postoperative voicerest and in the treatment of reflux-related laryngitis.10-13

Differences in training, preference, and resource availabilityinfluence management decisions. A guideline is necessarygiven this practice variation and the significant public healthburden of hoarseness.

This guideline addresses the identification, diagnosis,treatment, and prevention of hoarseness (dysphonia) (Table1). In addition, it highlights needs and management optionsin special populations or in patients who have modifyingfactors. Furthermore, this guideline is intended to enhancethe accurate diagnosis of hoarseness (dysphonia), promoteappropriate intervention in patients with hoarseness, high-light the need for evaluation and intervention in specialpopulations, promote appropriate therapeutic options withoutcomes assessment, and improve counseling and educa-tion for prevention and management of hoarseness. Thisguideline may also be suitable for deriving a performance

measure on hoarseness.



S3Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)BURDEN OF HOARSENESS

Hoarseness has a lifetime prevalence of 29.9 percent (per-centage of people affected at some point in their life) and apoint prevalence of 6.6 percent (percent of people affectedat a given point in time) in adults aged 65 years or under.1

Other cross-sectional studies have found a similar highlifetime prevalence of voice complaints of 28.8 percent inthe general population.2 Higher prevalence rates of hoarse-ness have been shown in telemarketers (31%),4 aerobicsinstructors (44%),5 and teachers (58%).2,6 Women are morefrequently affected than men, with a 60:40 F:M ratio.1,3,14

Hoarseness may affect all age groups. Among children,prevalence rates vary from 3.9 percent to 23.4 percent,15-17

with the most affected age range of 8 to 14 years.18 Voiceproblems persist four years or longer after identification in38 percent of children with a voice disorder, suggesting anopportunity for early intervention.19 In addition, olderadults are also at particular risk,3 with a point prevalence of29 percent20 and a lifetime incidence up to 47 percent.20,21

Hoarseness has significant public health implications.Patients suffer social isolation, depression, and reduced dis-ease-specific and general QOL.1,8,22,23 For example, pa-tients with hoarseness caused by neurologic disorders (Par-kinson disease, spasmodic dysphonia, vocal tremor, orvocal fold paralysis) reported severe levels of voice handi-cap and reduced general health-related QOL, comparable toimpairments observed in patients with congestive heart fail-ure, angina, and chronic obstructive pulmonary disease.7,8

Hoarseness may also impair work-related function.Approximately 28 million US workers have occupationsthat require use of voice.9 In the general population, 7.2percent of individuals surveyed missed work for one ormore days within the preceding year because of a problem

Table 1Interventions considered in hoarseness guidelinedevelopment

Diagnosis Targeted historyPhysical examinationLaryngoscopyStroboscopyComputed tomography (CT)Magnetic resonance imaging (MRI)

Treatment Watchful waiting/observationEducation/informationVoice therapyAnti-reflux medicationsAntibioticsSteroidsSurgeryBotulinum toxin (BOTOX)

Prevention Voice trainingVocal hygieneEducationEnvironmental measureswith their voice.1 Among teachers this rate increases to 20

boto.sagepub.comDownloaded from percent,6,14 resulting in a $2.5 billion loss among US adultsbecause of missed work annually.9

Medical, surgical, and behavioral treatment options existfor managing hoarseness. Among the general population,however, only 5.9 percent of those with hoarseness soughttreatment.1 Similarly, only 14.3 percent of teachers hadconsulted a physician or speech-language pathologist forhoarseness, even though voice function is essential to theirprofession.2 In some circumstances, complete resolution ofhoarseness may not be achieved and the clinicians respon-sibilities will include minimizing hoarseness and optimizingpatient function as well as assisting the patient in develop-ing understanding and realistic expectations.

Lack of awareness about hoarseness and its causes arepotential barriers to appropriate care. Among older adults,individuals commonly attribute their hoarseness to advanc-ing age. Such assumptions may prevent or delay those withhoarseness from obtaining treatment. Improved educationamong all health professionals24 and efficient medical careare essential for reducing the health burden of hoarseness.25

Inadequate insurance coverage has been cited as a cause offailure to seek treatment for both functional voice problems,as seen in singers,25 and life-threatening ones, as seen incancer patients.26

The primary outcomes considered in this guideline areimprovement in vocal function and change in voice-relatedQOL. Secondary outcomes include complications and ad-verse events. Economic consequences, adherence to ther-apy, global QOL, return to work, improved communicationfunction, and return health care visits were also considered.The high prevalence, significant individual and societal im-plications, diversity of interventions, and lack of consensusmake this an important condition for an up-to-date, evi-dence-based practice guideline.

GENERAL METHODS AND LITERATURESEARCH

The guideline was developed using an explicit and trans-parent a priori protocol for creating actionable statementsbased on supporting evidence and the associated balanceof benefit and harm.27,28 The multidisciplinary guidelinedevelopment panel was chosen to represent the fields ofneurology, speech-language pathology, professional voiceteaching, family medicine, pulmonology, geriatric medi-cine, nursing, internal medicine, otolaryngologyhead andneck surgery, pediatric medicine, and consumers. Severalgroup members had significant prior experience in develop-ing clinical practice guidelines.

Several initial literature searches were performedthrough November 17, 2008 by AAO-HNSF staff usingMEDLINE, The National Guidelines Clearinghouse (NGC)(www.guideline.gov), The Cochrane Library, GuidelinesInternational Network (GIN), The Cumulative Index to

Nursing and Allied Health Literature (CINAHL), and


http://www.guideline.govhttp://oto.sagepub.com/

S4 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009EMBASE. The initial broad MEDLINE search using hoarse-ness[mh] or dysphonia[tw] or voice disorders[mh] inany field showed 6032 potential articles:

1) Clinical practice guidelines were identified by a GIN,NGC, and MEDLINE search using guideline as apublication type or title word. The search identified eightguidelines with a topic of hoarseness or dysphonia. Aftereliminating articles that did not have hoarseness or dys-phonia as the primary focus, no guidelines met qualitycriteria of being produced under the auspices of a med-ical association or organization and having an explicitmethod for ranking evidence and linking evidence torecommendations.

2) Systematic reviews were identified in MEDLINE using avalidated filter strategy.29 That strategy initially yielded92 potential articles. The final data set included 14 sys-tematic reviews or meta-analyses (including two Co-chrane systematic reviews) on hoarseness or dysphoniathat were distributed to the panel members.

3) Randomized controlled trials were identified through theCochrane Library (Cochrane Controlled Trials Register)and totaled 256 trials with hoarseness or dysphoniain any field.

4) Original research studies were identified by limiting theMEDLINE, CINAHL, and EMBASE search to articleson humans published in English. The resulting data setof 769 articles yielded 262 related to therapy, 256 todiagnosis, 205 to etiology, and 46 to prognosis.

Results of all literature searches were distributed toguideline panel members at the first meeting, includingelectronic listings with abstracts (if available) of thesearches for randomized trials, systematic reviews, andother studies. This material was supplemented, as needed,with targeted searches to address specific needs identified inwriting the guideline through February 8, 2009.

In a series of conference calls, the working group definedthe scope and objectives of the proposed guideline. Duringthe nine months devoted to guideline development ending in2009, the group met twice, with interval electronic reviewand feedback on each guideline draft to ensure accuracy ofcontent and consistency with standardized criteria for re-porting clinical practice guidelines.30

AAO-HNSF staff used GEM-COGS,31 the GuidelineImplementability Appraisal and Extractor, to appraise ad-herence of the draft guideline to methodological standards,to improve clarity of recommendations, and to predict po-tential obstacles to implementation. Guideline panel mem-bers received summary appraisals in April 2009 and mod-ified an advanced draft of the guideline.

The final draft practice guideline underwent extensive,multidisciplinary, external peer review. Comments werecompiled and reviewed by the group chairpersons, and amodified version of the guideline was distributed and ap-proved by the development panel. The recommendations

contained in the practice guideline are based on the best

boto.sagepub.comDownloaded from available published data through February 2009. Wheredata were lacking, a combination of clinical experience andexpert consensus was used. A scheduled review process willoccur at five years from publication, or sooner if new com-pelling evidence warrants earlier consideration.

Classification of Evidence-Based StatementsGuidelines are intended to reduce inappropriate variationsin clinical care, to produce optimal health outcomes forpatients, and to minimize harm. The evidence-based ap-proach to guideline development requires that the evidencesupporting a policy be identified, appraised, and summa-rized and that an explicit link between evidence and state-ments be defined. Evidence-based statements reflect boththe quality of evidence and the balance of benefit and harmthat is anticipated when the statement is followed. Thedefinitions for evidence-based statements32 are listed inTables 2 and 3.

Guidelines are never intended to supersede professionaljudgment; rather, they may be viewed as a relative con-straint on individual clinician discretion in a particular clin-ical circumstance. Less frequent variation in practice isexpected for a strong recommendation than might beexpected with a recommendation. Options offer themost opportunity for practice variability.33 Cliniciansshould always act and decide in a way that they believe willbest serve their patients interests and needs, regardless ofguideline recommendations. They must also operate withintheir scope of practice and according to their training.Guidelines represent the best judgment of a team of expe-rienced clinicians and methodologists addressing the scien-tific evidence for a particular topic.32

Making recommendations about health practices in-volves value judgments on the desirability of various out-comes associated with management options. Values appliedby the guideline panel sought to minimize harm and dimin-ish unnecessary and inappropriate therapy. A major goal ofthe committee was to be transparent and explicit about howvalues were applied and to document the process.

Financial Disclosure and Conflicts of InterestThe cost of developing this guideline, including travel ex-penses of all panel members, was covered in full by theAAO-HNS Foundation. Potential conflicts of interest for allpanel members in the past five years were compiled anddistributed before the first conference call. After review anddiscussion of these disclosures,34 the panel concluded thatindividuals with potential conflicts could remain on thepanel if they: 1) reminded the panel of potential conflictsbefore any related discussion, 2) recused themselves from arelated discussion if asked by the panel, and 3) agreed not todiscuss any aspect of the guideline with industry beforepublication. Lastly, panelists were reminded that conflicts ofinterest extend beyond financial relationships and may in-clude personal experiences, how a participant earns a living,and the participants previously established stake in an

issue.35



S5Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)HOARSENESS (DYSPHONIA) GUIDELINEACTION STATEMENTS

Each action statement is organized in a similar fashion:statement in boldface type, followed by an italicized state-ment on the strength of the recommendation. Several para-graphs then discuss the evidence base supporting the state-ment, concluding with an evidence profile of aggregateevidence quality, benefit-harm assessment, and statement ofcosts. Lastly, there is an explicit statement of the valuejudgments, the role of patient preferences, and a repeatstatement of the strength of the recommendation. An over-view of evidence-based statements in the guideline and theirinterrelationship is shown in Table 4.

The role of patient preference in making decisions de-serves further clarification. For some statements the evi-dence base demonstrates clear benefit, which would mini-mize the role of patient preference. If the evidence is weakor benefits are unclear, however, not all informed patientsmight opt to follow the suggestion. In these cases, thepractice of shared decision making, where the managementdecision is made by a collaborative effort between the

Table 2Guideline definitions for evidence-based statements

Statement Definition

Strong recommendation A strong recommendation mof the recommended apprexceed the harms (or thatexceed the benefits, in thenegative recommendationquality of the supporting eexcellent (Grade A or B*).identified circumstances, srecommendations may belesser evidence when highis impossible to obtain anbenefits strongly outweigh

Recommendation A recommendation means texceed the harms (or thatthe benefits, in the case orecommendation), but theevidence is not as strongIn some clearly identifiedrecommendations may belesser evidence when highis impossible to obtain anbenefits outweigh the har

Option An option means either thaevidence that exists is susor that well-done studiesC*) show little clear advanapproach vs another.

*See Table 3 for definition of evidence grades.clinician and the informed patient, becomes more useful.

boto.sagepub.comDownloaded from Factors related to patient preference include (but are notlimited to) absolute benefits (number needed to treat), ad-verse effects (number needed to harm), cost of drugs ortests, frequency and duration of treatment, and desire to takeor avoid antibiotics. Comorbidity can also impact patientpreferences by several mechanisms, including the potentialfor drug-drug interactions when planning therapy.

STATEMENT 1. DIAGNOSIS: Clinicians should diag-nose hoarseness (dysphonia) in a patient with alteredvoice quality, pitch, loudness, or vocal effort that im-pairs communication or reduces voice-related QOL.Recommendation based on observational studies with apreponderance of benefit over harm.

Supporting TextThe purpose of this statement is to promote awareness ofhoarseness (dysphonia) by all clinicians as a condition thatmay require intervention or additional investigation. Theproposed diagnosis (dysphonia) is based on strictly clinicalcriteria, and does not require testing or additional investi-gations. Hoarseness is a symptom reported by the patient or

Implication

the benefitsclearlyarms clearlyof a strongthat thece is

me clearly

e based onity evidenceanticipatedharms.

Clinicians should follow a strongrecommendation unless a clear andcompelling rationale for analternative approach is present.

nefitsarms exceedgativety ofe B or C*).

stances,e based onity evidenceanticipated

Clinicians should also generally followa recommendation, but shouldremain alert to new information andsensitive to patient preferences.

uality ofGrade D*)

e A, B, orto one

Clinicians should be flexible in theirdecision making regardingappropriate practice, although theymay set bounds on alternatives;patient preference should have asubstantial influencing role.eansoachthe hcase

) andvidenIn sotrongmad-qual

d thethe

he bethe h

f a nequali

(Gradcircummad-qual

d thems.t the qpect (

(Gradtageproxy, identified by the clinician, or both.



S6 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009Some patients with objectively minor changes may beunable to work and have a significant decrement in QOL.Others with significant disease such as malignancy mayhave minimal functional impairment of their voice. Of pa-tients with laryngeal cancer, 52 percent thought theirhoarseness was harmless and delayed seeing a physician.36

Accordingly, patients with minimal objective voice changeand significant complaints as well as patients with limited

Table 3Evidence quality for grades of evidence

Grade Evidence quality

A Well-designed randomized controlled trialsor diagnostic studies performed on apopulation similar to the guidelinestarget population

B Randomized controlled trials or diagnosticstudies with minor limitations;overwhelmingly consistent evidencefrom observational studies

C Observational studies (case-control andcohort design)

D Expert opinion, case reports, reasoningfrom first principles (bench research oranimal studies)

X Exceptional situations where validatingstudies cannot be performed and thereis a clear preponderance of benefit overharm

Table 4Outline of guideline action statements

Hoarseness (dysphonia) (statement number)

I. Diagnosisa. Diagnosis (Statement 1)b. Modifying factors (Statement 2)c. Laryngoscopy and hoarseness (Statement 3A)d. Indications for laryngoscopy

(Statement 3B)e. Imaging prior to laryngoscopy (Statement 4)

II. Medical therapya. Anti-reflux therapy for hoarseness in the absence

or chronic laryngitis (Statement 5A)b. Anti-reflux therapy with chronic laryngitis (Statemc. Corticosteroid therapy (Statement 6)d. Antimicrobial therapy (Statement 7)

III. Voice therapya. Laryngoscopy prior to beginning (Statement 8A)b. Advocating for

(Statement 8B)IV. Invasive therapies

a. Advocating surgery in selected patients (Statemenb. Botulinum toxin for adductor spasmodic dysphon

(Statement 10)V. Prevention (Statement 11) boto.sagepub.comDownloaded from complaints but with objective alterations of voice qualitywarrant evaluation.

Patients with hoarseness may experience discomfort withspeaking, increased phonatory effort, and weak voice, aswell as altered quality such as wobbly or shaky voice,breathiness, and raspiness.20,37,38 While a breathy voicemay signify vocal fold paralysis or another cause of incom-plete vocal fold closure, a strained voice with altered pitchor pitch breaks is common in spasmodic dysphonia.39

Changes in voice quality may be limited to the singing voiceand not affect the speaking voice. Among infants and youngchildren, an abnormal cry may signify underlying pathologyincluding vocal fold paralysis, laryngeal papilloma, or othersystemic conditions.

Listening to the voice (perceptual evaluation) in a criticaland objective manner may provide important diagnosticinformation. Characterizing the patients complaint andvoice quality is important for assessing hoarseness severityand for differentiating among specific causes of hoarseness,such as muscle tension dysphonia and spasmodic dyspho-nia.40,41

Hoarseness may impair communication. Difficulty beingheard and understood while using the telephone has beenreported in the geriatric population.20,38 Trouble beingheard in groups and problems being understood are alsocommon complaints among hoarse patients.37 Conse-quently, patients describe less confidence, decreased social-ization, and impaired work-related function.1,37

Hoarseness may lead to decreased voice-related QOLand a decrement in physical, social, and emotional aspects

Statement strength

RecommendationRecommendationOptionRecommendation

Recommendation against

RD Recommendation against

) OptionRecommendation againstStrong recommendation against

RecommendationStrong recommendation

RecommendationRecommendation

Optionof GE

ent 5B

t 9)iay guest on March 7, 2015


S7Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)

boto.sagepub.comDownloaded from of global QOL similar to those associated with other chronicdiseases, such as congestive heart failure and chronic ob-structive pulmonary disease.7,8

Clinicians should consider input from proxies when di-agnosing hoarseness (dysphonia). Of patients with vocalfold cancer, 40 percent waited three months before seekingmedical attention for their hoarseness. Furthermore, 16.7percent only sought treatment after encouragement fromother people.36 These data highlight the fact that hoarsenessmay not be recognized by the patient.

Children and patients with cognitive impairment or se-vere emotional burden may be unaware or unable to recog-nize and report on their own hoarseness.42 QOL studies inolder adults have required proxy input in approximately 25percent of the geriatric population.43 While self-report mea-sures for hoarseness are available, patients may be unable tocomplete them.44-46 In these cases, proxy judgments bysignificant others about QOL are a good alternative.42 Mod-erate agreement has been shown between adult patients andtheir communication partners on the Voice Handicap Index.Parent proxy self-report measures have also been validatedfor use in the pediatric population.38,47

When evaluating a patient with hoarseness, the clini-cian should obtain a detailed medical history (Table 5)and review current medications (Table 6) as this infor-mation may identify the cause of the hoarseness (dyspho-nia) or an alternative underlying condition that may war-rant attention.

Evidence profile for Statement 1: Diagnosis

Aggregate evidence quality: Grade C, observational stud-

Table 5continued

Allergic rhinitisChronic rhinitisHypertension (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, chronic obstructive pulmonary disease

(because of use of inhaled steroids)Aneurysm of thoracic aorta (rare cause)Laryngeal cancerLung cancer (or metastasis to the lung)Thyroid cancerHypothyroidism and other endocrinopathiesVocal fold nodulesVocal fold paralysisVocal abuseChemical laryngitisChronic tobacco useSjgren syndromeAlcohol (moderate to heavy use or abuse)Table 5Pertinent medical history for assessing a patientwith hoarseness48-50

Voice-specific questionsDid your problem start suddenly or gradually?Is your voice ever normal?Do you have pain when talking?Does your voice deteriorate or fatigue with use?Does it take more effort to use your voice?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?

SymptomsGlobus pharyngeus (persisting sensation of lump

in throat)DysphagiaSore throatChronic throat clearingCoughOdynophagia (pain with swallowing)Nasal drainagePost-nasal drainageNon-anginal chest painAcid refluxRegurgitationHeartburnWaterbrash (sudden appearance of salty liquid in

the mouth)Halitosis (bad breath)FeverHemoptysisWeight lossNight sweatsOtalgia (ear pain)Difficulty breathing

Medical history relevant to hoarsenessOccupation and/or avocation requiring extensive

voice use (ie, teacher, singer)Absenteeism from occupation due to hoarsenessPrior episode(s) of hoarsenessRelationship of instrumentation (intubation, etc) to

onset of hoarsenessRelationship of prior surgery to neck or chest to

onset of hoarsenessCognitive impairment (requirement for proxy

historian)Anxiety

Acute conditionsInfection of the throat and/or larynx: viral,

bacterial, fungalForeign body in larynx, trachea, or esophagusNeck or laryngeal trauma

Chronic conditionsStrokeDiabetesParkinsons diseaseDiseases from the Parkinsons Plus family

(progressive supranuclear palsy, etc)Myasthenia gravisMultiple sclerosisAmyotrophic lateral sclerosis (ALS)Testosterone deficiencyies for symptoms with one systematic review of QOL in



S8 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009voice disorders and two systematic reviews on medica-tion side effects

Benefit: Identify patients who may benefit from treatmentor from further investigation to identify underlying con-ditions that may be serious, promote prompt recognitionand treatment, and discourage the perception of hoarse-ness as a trivial condition that does not warrant attention

Harm: Potential anxiety related to diagnosis Cost: Time expended in diagnosis, documentation, and

discussion Benefits-harm assessment: Preponderance of benefits

over harm Value judgments: None Role of patient preference: Limited Intentional vagueness: None Exclusions: None Policy Level: Recommendation

STATEMENT 2. MODIFYING FACTORS: Cliniciansshould assess the patient with hoarseness by historyand/or physical examination for factors that modifymanagement such as one or more of the following: re-cent surgical procedures involving the neck or affectingthe recurrent laryngeal nerve, recent endotracheal intu-bation, radiation treatment to the neck, a history oftobacco abuse, and occupation as a singer or vocal per-former. Recommendation based on observational studieswith a preponderance of benefit over harm.

Supporting TextThe term modifying factors as used in this recommenda-tion refers to details elicited by history taking or physicalexamination that provide a clue to the presence of an im-

Table 6Medications that may cause hoarseness

MedicationMechanism of impact

on voice

Coumadin, thrombolytics,phosphodiesterase-5inhibitors

Vocal fold hematoma51-53

Biphosphonates Chemical laryngitis54

Angiotensin-convertingenzyme inhibitors

Cough55

Antihistamines, diuretics,anticholinergics

Drying effect onmucosa56,57

Danocrine, testosterone Sex hormone production/utilization alteration58,59

Antipsychotics, atypicalantipsychotics

Laryngeal dystonia60,61

Inhaled steroids Dose-dependent mucosalirritation,62 fungallaryngitisportant underlying etiology of hoarseness (dysphonia) that

boto.sagepub.comDownloaded from may lead to a change in management. The history andphysical examination of the patient with hoarseness mayprovide insight into the nature of the patients conditionprior to the initiation of a more in-depth evaluation.

Surgery on the cervical spine via an anterior approachhas been associated with a high incidence of voice prob-lems. Recurrent laryngeal nerve paralysis has been reportedto range from 1.27 percent to 2.7 percent.63-65 Assessmentwith laryngoscopy suggests an even higher incidence.66 Theincidence of hoarseness immediately following anterior cer-vical spine surgery may be as high as 50 percent.67 Hoarse-ness resulting from anterior cervical spine surgery may ormay not resolve over time.68,69

Thyroid surgery has been associated with voice disor-ders. Patients with thyroid disease requiring surgery mayhave hoarseness and identifiable abnormalities on indirectlaryngoscopy prior to surgery.70 Thyroidectomy may causehoarseness as a result of recurrent laryngeal nerve paralysisin up to 2.1 percent of patients.71 Surgery in the anteriorneck can also lead to injury to the superior laryngeal nervewith resulting voice alteration, although this is uncom-mon.72

Carotid endarterectomy is frequently associated withpostoperative voice problems73 and may result in recurrentlaryngeal nerve damage in up to 6 percent of patients.74,75

Surgery to achieve an urgent airway or on the larynx directlymay alter its structure, resulting in abnormal voice.76,77

Surgical procedures not involving the neck may alsoresult in hoarseness (dysphonia). Hoarseness following car-diac surgery is a common problem, occurring in 17 percentto 31 percent of patients.78,79 Hoarseness may result fromchanges in position or manipulation of the endotracheal tubeor from lengthy procedures.78 Recurrent laryngeal nerveinjury occurs in about 1.4 percent of patients during cardiacsurgery.78 The left recurrent laryngeal nerve is damagedmore commonly than the right as it extends into the chestand loops under the arch of the aorta. Damage may resultfrom direct physical injury to the nerve or hypothermicinjury due to cold cardioplegia.80

Surgery for esophageal cancer frequently results in dam-age to the recurrent laryngeal nerve with subsequent hoarse-ness. In one study, 51 of 141 patients undergoing esopha-gectomy for cancer had laryngeal nerve paralysis, with 30 ofthese patients having persistent paralysis one year followingsurgery.81 The implantation of vagal nerve stimulators forintractable seizures has been associated with hoarseness inas many as 28 percent of patients.82

Prolonged endotracheal intubation has been associatedwith hoarseness. Direct laryngoscopy of patients intubatedfor more than four days (mean nine days) demonstrates that94 percent of patients have laryngeal injury.83 The injurypatterns seen in the patients with prolonged intubation in-clude laryngeal edema and posterior and medial vocal foldulceration. As many as 44 percent of patients with pro-longed intubation may develop vocal fold granulomas

within four weeks of being extubated. In this study, 18



S9Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)percent of patients had prolonged true vocal fold immobilityfor at least four weeks after extubation.84 Another studyfollowing a large group of patients for several years foundchronic phonatory dysfunction in many patients after long-term intubation.85

Short-term intubation for general anesthesia may resultin hoarseness and vocal fold pathology in over 50 percent ofcases.86 While most symptoms resolved after five days,prolonged symptoms may result from vocal fold granuloma.If hoarseness persists, the remoteness of the index eventmay confound the evaluating clinician. Use of a laryngealmask airway may reduce postsurgical complaints of dis-comfort, but does not objectively reduce hoarseness.87

Long-term intubation of neonates may result in voiceproblems related to arytenoid and posterior commissureulceration and cartilage erosion.88 Children with a history ofprolonged intubation may have long-term complications ofhoarseness and arytenoid dysfunction.

Voice disorders are common in older adults and signif-icantly affect the QOL in these patients.21 Vocal fold atro-phy with resulting hoarseness (dysphonia) is a commondisorder of older adults and is frequently undiagnosed byprimary care providers.89,90 Hoarseness resulting from neu-rologic disorders such as cerebral vascular accident andParkinson disease is also more common in elderly pa-tients.91-94 Multiple sclerosis can lead to hoarseness in pa-tients of any age.95

Chronic hoarseness (dysphonia) is quite common inyoung children and has an adverse impact on QOL.96 Prev-alence ranges from 15 percent to 24 percent of the popula-tion.17,97 In one study, 77 percent of hoarse children hadvocal fold nodules.17 These may persist into adolescence ifnot properly treated.98 Craniofacial anomalies such as oro-facial clefts are associated with abnormal voice,99 but theseare frequently resonance disorders requiring very differenttherapies than for hoarse children with normal anatomicaldevelopment.

Hoarseness or dysphonia in infants may be recognizedonly by an abnormal cry, and suspicion of such symptomsshould prompt consultation with an otolaryngologist.100

When infants do present with hoarseness, underlying etiol-ogies such as birth trauma, an intracranial process such asArnold-Chiari malformation or posterior fossa mass, or me-diastinal pathology should be considered.101

Hoarseness in tobacco smokers is associated with anincreased frequency of polypoid vocal fold lesions and headand neck cancer.102 Accordingly, this requires an expedientassessment for malignancy as the potential cause of hoarse-ness. In addition, in patients treated with external beamradiation for glottic cancer, radiation treatment is associatedwith hoarseness in about 8 percent of cases.103,104

Patients who use inhaled corticosteroids for the treatmentof asthma or chronic obstructive pulmonary disease maypresent to a clinician with hoarseness that is a side effect oftherapy either from direct irritation or from a fungal infec-

tion of the larynx.105

boto.sagepub.comDownloaded from Singers or vocal performers should be identified by theclinician when eliciting a history from the hoarse patient.These patients have significant impairment with symptomsthat may be subclinical in other patients. They may be moresubject to voice over-use or have a different etiology fortheir symptoms, and hoarseness may have a more significantimpact on their QOL or ability to earn income. For example,while hoarseness is relatively rare following thyroid sur-gery, there are objective, measurable changes in the voice ofmost patients that could affect pitch and the ability tosing.106 Singers are also prone to develop microvascularectasias that affect voice and require specific therapy.107

To a slightly lesser degree, individuals in a number ofother occupations or avocations, such as teachers andclergy, depend on voice use. As an example, over 50 percentof teachers have hoarseness, and vocal overuse is a com-mon, but not exclusive, etiologic factor.108 Cliniciansshould inquire about an individuals voice use in order todetermine the degree to which altered voice quality mayimpact the individual professionally.

Evidence profile for Statement 2: Modifying Factors

Aggregate evidence quality: Grade C, observationalstudies

Benefit: To identify factors early in the course of man-agement that could influence the timing of diagnosticprocedures, choice of interventions, or provision of fol-low-up care

Harm: None Cost: None Benefits-harm assessment: Preponderance of benefit over

harm Value judgments: Importance of history taking and iden-

tifying modifying factors as an essential component ofproviding quality care

Role of patient preferences: Limited or none Intentional vagueness: None Exclusions: None Policy level: Recommendation

STATEMENT 3A. LARYNGOSCOPY AND HOARSE-NESS: Clinicians may perform laryngoscopy, or mayrefer the patient to a clinician who can visualize thelarynx, at any time in a patient with hoarseness. Optionbased on observational studies, expert opinion, and a bal-ance of benefit and harm.

STATEMENT 3B. INDICATIONS FOR LARYNGOS-COPY: Clinicians should visualize the patients larynx,or refer the patient to a clinician who can visualize thelarynx, when hoarseness fails to resolve by a maximumof three months after onset, or irrespective of duration ifa serious underlying cause is suspected. Recommendationbased on observational studies, expert opinion, and a pre-

ponderance of benefit over harm.



S10 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009Supporting TextThe purpose of these statements is to highlight the importantrole of visualizing the larynx and vocal folds in managing apatient with hoarseness, especially if the hoarseness fails toimprove within three months of onset (Statement 3B). Pa-tients with persistent hoarseness may have a serious under-lying disorder (Table 7) that would not be diagnosed unlessthe larynx was visualized. This does not, however, implythat all patients must wait three months before laryngoscopyis performed, because, as outlined below, early assessmentof some patients with hoarseness may improve manage-ment. Therefore, clinicians may perform laryngoscopy, orrefer to a clinician for laryngoscopy, at any time (Statement3A) if deemed appropriate based on the patients specificclinical presentation and modifying factors.

Laryngoscopy and HoarsenessVisualization of the larynx is part of a comprehensive eval-uation for voice disorders. While not all clinicians have thetraining and equipment necessary to visualize the larynx,those who do may examine the larynx of a patient present-ing with hoarseness at any time if considered appropriate.Although most hoarseness is caused by benign or self-limited conditions, early identification of some disordersmay increase the likelihood of optimal outcomes.

There are a number of conditions where laryngoscopy atthe time of initial assessment allows for timely diagnosisand management. Laryngoscopy can be used at the bedsidefor patients with hoarseness after surgery or intubation toidentify vocal fold immobility, intubation trauma, or othersources of postsurgical hoarseness. Laryngoscopy plays acritical role in evaluating laryngeal patency after laryngealtrauma where visualization of the airway allows for assess-ment of the need for surgical intervention and for followingpatients in whom immediate surgery is not required.109,110

Laryngoscopy is used routinely for diagnosing laryngeal

Table 7Conditions leading to suspicion of a seriousunderlying cause

Hoarseness with a history of tobacco or alcohol useHoarseness with concomitant discovery of a neck

massHoarseness after traumaHoarseness associated with hemoptysis, dysphagia,

odynophagia, otalgia, or airway compromiseHoarseness with accompanying neurologic

symptomsHoarseness with unexplained weight lossHoarseness that is worseningHoarseness in an immunocompromised hostHoarseness and possible aspiration of a foreign bodyHoarseness in a neonateUnresolving hoarseness after surgery (intubation or

neck surgery)cancer. The usefulness of laryngoscopy for establishing the

boto.sagepub.comDownloaded from diagnosis and the benefit of early detection have led theBritish medical system to employ fast-track screening clin-ics for laryngeal cancer that mandate laryngoscopy within14 days of suspicion of laryngeal cancer.111,112 Fungal lar-yngitis from inhalers and other causes is best diagnosedwith laryngoscopy and must be distinguished from malig-nancy.113

Unilateral vocal fold paralysis causes breathy hoarsenessand is often caused by thoracic, cervical, or brain tumorsthat either compress or invade the vagus nerve or itsbranches that innervate the larynx. Stroke may also presentwith hoarseness due to vocal fold paralysis. Vocal foldparalysis is routinely identified, characterized, and followedby laryngoscopy.79,114

In patients with cranial nerve deficits or neuromuscularchanges, laryngoscopy is useful to identify neurologiccauses of vocal dysfunction.115 Benign vocal fold lesionssuch as vocal fold cysts, nodules, and polyps are readilydetected on laryngoscopy. Visualization of the larynx mayalso provide supporting evidence in the diagnosis of laryn-gopharyngeal reflux.116

Hoarseness caused by neurologic or motor neuron dis-ease such as Parkinson disease, amyotrophic lateral sclero-sis, and spasmodic dysphonia may have laryngoscopic find-ings that the clinician can identify to initiate management ofthe underlying disease.117 Office laryngoscopy is also acritical tool in the evaluation of the aging voice.

Neonates with hoarseness should undergo laryngoscopyto identify vocal fold paralysis,118 laryngeal webs,119 orother congenital anomalies that might affect their ability toswallow or breathe.120

Hoarseness in children is rarely a sign of a serious un-derlying condition and is more likely the result of a benignlesion of the larynx such as a vocal fold polyp, nodules, orcyst.121 However, determining if laryngeal papilloma is theetiology of hoarseness in a child is particularly importantgiven the high potential for life-threatening airway obstruc-tion and the potential for malignant transformation.122 Ahoarse child with other symptoms such as stridor, airwayobstruction, or dysphagia may have a serious underlyingproblem such as a Chiari malformation,123 hydrocephalus,skull base tumors, or a compressing neck or mediastinalmass. Persistent hoarseness in children may be a symptomof vocal fold paralysis with underlying etiologies that in-clude neck masses, congenital heart disease, or previouscardiothoracic, esophageal, or neck surgery.124

Indications for LaryngoscopyLaryngoscopy is indicated for the assessment of hoarsenessif symptoms fail to improve or resolve within three months,or at any time the clinician suspects a serious underlyingdisorder. In this context serious describes an etiology thatwould shorten the lifespan of the patient or otherwise reduceprofessional viability or voice-related QOL. If the clinicianis concerned that hoarseness may be caused by a serious

underlying condition, the optimal way to address this con-



S11Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)cern is by visualization of the vocal folds with laryngos-copy.

The major cause of community-acquired hoarseness isviral. Symptoms from viral laryngitis typically last 1 to 3weeks.125,126 Symptoms of hoarseness persisting beyondthis time warrant further evaluation to insure that no malig-nancy or morbid conditions are missed and to allow furthertreatment to be initiated based on specific benign patholo-gies if indicated. One population-based cohort study127 andone large case-control study128 have shown that delays indiagnosis of laryngeal cancer lead to higher stages of dis-ease at diagnosis and worse prognosis. In the cohort study,delay longer than three months led to poorer survival.

The expediency of laryngoscopy also depends on patientconsiderations. Singers, performers, and patients whoselivelihood depends upon their voice will not be able to waitseveral weeks for their hoarseness to resolve as they may beunable to work in the interim. In fact, a number of profes-sionals with high vocal demands may benefit from imme-diate evaluation.

Even in the absence of serious concern or patient con-siderations indicating immediate laryngoscopy, persistenthoarseness should be evaluated to rule out significant pa-thology such as cancer or vocal fold paralysis. In the ab-sence of immediate concern, there is little guidance from theliterature on the proper length of time a hoarse patient canor should be observed before visualization of the larynx ismandated. The working group weighed the risk of delayeddiagnosis against the potential over-utilization of resourcesand selected a fairly long window of three months prior tomandating laryngoscopy. This safety net approach, based onexpert opinion, was designed to address the main concern ofthe working group that many patients with persistenthoarseness are currently experiencing delayed diagnosis orare not undergoing laryngoscopy at all.

Techniques for Visualizing the LarynxDifferent techniques are available for laryngoscopy andconfer varying levels of risk. The working group does nothave recommendations as to the preferred method. Choiceof method is at the discretion of the evaluating clinician.

Office laryngoscopy can be performed transorally with amirror or rigid endoscope, transnasally with a flexible fi-beroptic or distal-chip laryngoscope, and with either halo-gen light or stroboscopic light application.129 The surfaceand mobility of the vocal folds are well assessed with thesetools.

Stroboscopy is used to visualize the vocal folds as theyvibrate, allowing for an assessment of both anatomy andfunction during the act of phonation.130 When hoarsenesssymptoms are out of proportion to the laryngoscopic exam-ination, stroboscopy should be considered. The addition ofstroboscopic light allows for an assessment of the pliabilityof the vocal folds, making additional pathologies such asvocal fold scar easy to identify. Stroboscopy has resulted inaltered diagnosis in 47 percent of cases,131 and stroboscopic

parameters aid in the differentiation of specific vocal fold

boto.sagepub.comDownloaded from pathology, such as polyps and cysts.132 Surgical endoscopywith magnification (microlaryngoscopy) is utilized moreoften when more detailed examination, manipulation, orbiopsy of the structures is required.133

In the adult, visualization by indirect mirror examinationmay be limited by patient tolerance and photo documenta-tion is not possible. Discomfort in transnasal laryngoscopyis usually mitigated by the application of topical deconges-tant and/or anesthetic such as lidocaine. A study of 1208patients evaluated by fiberoptic laryngoscopy for assess-ment of vocal fold paralysis after thyroidectomy showed nosignificant adverse events.134 No other reports of significantrisks of fiberoptic laryngoscopy were found in a detailedMEDLINE search using key words: laryngoscopy, compli-cations, risk, and adverse events. Transoral examinations ofthe larynx may be preceded by topical lidocaine to the throatand carries similarly minimal risk.

Operative laryngoscopy carries more substantial risk butgenerally allows for ease of tissue manipulation and biopsy.Risks associated with direct laryngoscopy with general an-esthesia, include airway distress; dental trauma; oral cavity,oropharyngeal, and hypopharyngeal trauma; tongue dyses-thesia; taste changes; and cardiovascular risk.135-137 Thecost of direct laryngoscopy is substantially greater than thatof office-based laryngoscopy due to the additional costs ofstaff, equipment, and additional care required.138-140

Special consideration is given to children for whomlaryngoscopy requires either advanced skill or a specializedsetting. With the advent of small-diameter flexible laryngo-scopes, awake, flexible laryngoscopy can be employed inthe clinic in children as young as newborns but is subject tothe skill of the clinician and comfort with children. Theadvantage is that this examination allows for evaluation ofboth anatomy and function of the larynx in the hoarse child.Direct laryngoscopy under anesthesia with or without amicroscope may be used to verify flexible fiberoptic find-ings, manage laryngeal papillomas or other vocal fold le-sions, and further define laryngeal pathology such as con-genital anomalies of the larynx. Intraoperative palpation ofthe cricoarytenoid joint may also help differentiate betweenvocal fold paralysis and fixation.

Evidence profile for Statement 3A: Laryngoscopy andHoarseness

Aggregate evidence quality: Grade C, based on observa-tional studies

Benefit: Visualization of the larynx to improve diagnosticaccuracy and allow comprehensive evaluation

Harm: Risk of laryngoscopy, patient discomfort Cost: Procedural expense Benefits-harm assessment: Balance of benefit and harm Value judgments: Laryngoscopy is an important tool for

evaluating voice complaints and may be performed at anytime in the patient with hoarseness Intentional vagueness: None



S12 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009 Role of patient preferences: Substantial; the level of pa-tient concern should be considered in deciding when toperform laryngoscopy

Exclusions: None Policy level: Option

Evidence profile for Statement 3B: Indications for La-ryngoscopy

Aggregate evidence quality: Grade C, observational stud-ies on the natural history of benign laryngeal disorders;grade C for observational studies plus expert opinion ondefining what constitutes a serious underlying condition

Benefit: Avoid missed or delayed diagnosis of seriousconditions in patients without additional signs or symp-toms to suggest underlying disease; permit prompt assess-ment of the larynx when serious concern exists

Harm: Potential for up to a three-month delay in diagno-sis; procedure-related morbidity

Cost: Procedural expense Benefits-harm assessment: Preponderance of benefit over

harm Value judgments: A need to balance timely diagnostic

intervention with the potential for over-utilization andexcessive cost. The guideline panel debated on the max-imum duration of hoarseness prior to mandated evalua-tion and opted to select a safety net approach with agenerous time allowance (three months), but options toproceed promptly based on clinical circumstances

Intentional vagueness: The term serious underlying con-cern is subject to the discretion of the clinician. Someconditions are clearly serious, but in other patients, theseriousness of the condition is dependent on the patient.Intentional vagueness was incorporated to allow for clin-ical judgment in the expediency of evaluation

Role of patient preferences: Limited Exclusions: None Policy level: Recommendation

STATEMENT 4. IMAGING: Clinicians should not ob-tain computed tomography (CT) or magnetic resonanceimaging (MRI) of the patient with a primary complaintof hoarseness prior to visualizing the larynx. Recommen-dation against imaging based on observational studies ofharm, absence of evidence concerning benefit, and a pre-ponderance of harm over benefit.

Supporting TextThe purpose of this statement is not to discourage the use ofimaging in the comprehensive work-up of hoarseness, butrather to emphasize that it should be used to assess forspecific pathology after the larynx has been visualized.

Laryngoscopy is the primary diagnostic modality forevaluating patients with hoarseness. Imaging studies, in-cluding CT and MRI, have also been used, but are unnec-essary in most patients because most hoarseness is self-

limited or caused by pathology that can be identified by

boto.sagepub.comDownloaded from laryngoscopy. The value of imaging procedures before la-ryngoscopy is undocumented; no articles were found in thesystematic literature review for this guideline regarding thediagnostic yield of imaging studies prior to laryngeal exam-ination. Conversely, the risk of imaging studies is welldocumented.

The risk of radiation-induced malignancy from CT scansis small but real. More than 62 million CT scans per year areobtained in the United States for all indications, including 4million performed on children (nationwide evaluation ofx-ray trends). In a study of 400,000 radiation workers in thenuclear industry who were exposed to an average dose of 20mSVs (a typical organ dose from a single CT scan for anadult), a significant association was reported between theradiation dose and mortality from cancer in this cohort.These risks were quantitatively similar to those reported foratomic bomb survivors.141 Children have higher rates ofmalignancy and a longer lifespan in which radiation-in-duced malignancies can develop.142,143 It is estimated thatabout 0.4 percent of all cancers in the United States may beattributable to the radiation from CT studies.144,145 The riskmay be higher (1.5% to 2%) if we adjust this estimate basedon our current use of CT scans.

There are also risks associated with IV contrast dye usedto increase diagnostic yield of CT scans.146 Allergies tocontrast dye are common (5% to 8% of the population).Severe, life-threatening reactions, including anaphylaxis,occur in 0.1 percent of people receiving iodinated contrastmaterial, with a death rate of up to one in 29,500 peo-ple.147,148

While MRI has no radiation effects, it is not without risk.A review of the safety risks of MRI149 details five mainclasses of injury: 1) projectile effects (anything metal thatgets attracted by the magnetic field); 2) twisting of indwell-ing metallic objects (cerebral artery clips, cochlear implants,or shrapnel); 3) burning (electrical conductive material incontact with the skin with an applied magnetic field, ie,EKG electrodes or medication patches); 4) artifacts (radio-frequency effects from the device itself simulating pathol-ogy); and 5) device malfunction (pacemakers will fire in-appropriately or work at an elevated frequency, thusdistorting cardiac conduction).150

The small confines of the MRI scanner may lead toclaustrophobia and anxiety.151 Some patients, children inparticular, require sedation (with its associated risks). Thegadolinium contrast used for MRI rarely induces anaphy-lactic reactions,152,153 but there is recent evidence of renaltoxicity with gadolinium in patients with pre-existing renaldisease.154 Transient hearing loss has been reported, but thisis usually avoided with hearing protection.155 The costs ofMRI, however, are significantly more than CT scanning.Despite these risks and their considerable cost, cross-sec-tional imaging studies are being used with increasing fre-quency.156-158

After laryngoscopy, evidence does support the use of

imaging to further evaluate 1) vocal fold paralysis or 2) a



S13Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)mass or lesion of the vocal fold or larynx that suggestsmalignancy or airway obstruction.159 If vocal fold palsy isnoted and recent surgery can explain the cause of the pa-ralysis, imaging studies are generally not useful. If thehealth care provider suspects a lesion along the recurrentlaryngeal nerve, imaging studies are indicated.

Unexplained vocal fold paralysis found on laryngoscopywarrants imaging the skull base to the thoracic inlet/arch ofthe aorta. Including these anatomic areas allows for evalu-ation of the entire path of the recurrent laryngeal nerve as itloops around the arch of the aorta on the left side. On theright, it will show any lesions in the lung apex along thecourse of the right recurrent laryngeal nerve as it loopsaround the subclavian artery. One study showed that acomplete radiographic work-up improved rates of diagno-sis,160 but there is no consensus on whether CT or MRI isbetter for evaluating the recurrent laryngeal nerve.161,162

Lesions at the skull base and brain are best evaluated usingan MRI of the brain and brain stem with gadolinium en-hancement. If a patient presents with additional lower cra-nial nerve palsy, the skull base, particularly the jugularforamen (CN IX, X, XI), should be evaluated.159

Primary lesions of the larynx, pharynx, subglottis, thy-roid, and any pertinent lymph node groups can also beevaluated by imaging the entire area. Intravenous contrastmay help to distinguish vascular lesions from normal pa-thology on CT. Due to the substantial dose of ionizingradiation delivered to the radiosensitive thyroid gland,163

CT examination in children is cautioned when MRI is avail-able.

There is still significant controversy whether MRI or CTis the preferred study to evaluate invasion of laryngealcartilage. Before the advent of the helical CT, MRI was thepreferred method.164 The extent of bone marrow infiltrationby malignant tumors (ie, nasopharyngeal carcinoma) can beassessed with MRI of the skull base.165 MRI is preferred inchildren and can easily be extended to include the medias-tinum to help evaluate congenital and neoplastic lesions.For those patients who have absolute contraindications toMRI such as pacemaker, cochlear implants, heart valveprosthesis, or aneurysmal clip, CT is a viable alternative.

Imaging studies are valuable tools in diagnosing certaincauses of hoarseness in children. A plain chest radiographwill aid in the diagnosis of a mediastinal mass or foreignbody. A CT scan can elucidate more detail if the initialradiography fails to show a lesion. A soft tissue radiographof the neck can aid in the diagnosis of an infectious orallergic process.166 CT imaging has been the test of choicefor congenital cysts, laryngeal webs, solid neoplasms, andexternal trauma, as it provides adequate resolution withouthaving to sedate the patient as may be necessary for MRI.The risk of radiation must be weighed against these benefits.MRI is the better option for imaging the brain stem.166

FDG-PET imaging is used increasingly to assess patientswith head and neck cancer. PET scans may help identify

mediastinal or pulmonary neoplasms that cause vocal fold

boto.sagepub.comDownloaded from paralysis.167 PET scanning is very costly, however, and maygive false-positive results in patients with vocal fold paral-ysis. FDG activity in the normal vocal fold can be misin-terpreted as a tumor.168

Evidence profile for Statement 4: Imaging

Aggregate evidence quality: Grade C, observational stud-ies regarding the adverse events of CT and MRI; noevidence identified concerning benefits in patients withhoarseness before laryngoscopy

Benefit: Avoid unnecessary testing; minimize cost andadverse events; maximize the diagnostic yield of CT andMRI when indicated

Harm: Potential for delayed diagnosis Cost: None Benefits-harm assessment: Preponderance of benefit over

harm Value judgments: Avoidance of unnecessary testing Role of patient preferences: Limited Intentional vagueness: None Exclusions: None Policy level: Recommendation against

STATEMENT 5A. ANTI-REFLUX MEDICATIONAND HOARSENESS. Clinicians should not prescribeanti-reflux medications for patients with hoarsenesswithout signs or symptoms of gastroesophageal refluxdisease (GERD). Recommendation against prescribingbased on randomized trials with limitations and observa-tional studies with a preponderance of harm over benefit.

STATEMENT 5B. ANTI-REFLUX MEDICATIONAND CHRONIC LARYNGITIS. Clinicians may pre-scribe anti-reflux medication for patients with hoarse-ness and signs of chronic laryngitis. Option based onobservational studies with limitations and a relative bal-ance of benefit and harm.

Supporting TextThe primary intent of this statement is to limit widespreaduse of anti-reflux medications as empiric therapy for hoarse-ness without symptoms of GERD or laryngeal findingsconsistent with laryngitis, given the known adverse effectsof the drugs and limited evidence of benefit. The purpose isnot to limit use of anti-reflux medications in managinglaryngeal inflammation, when inflammation is seen on la-ryngoscopy (eg, laryngitis denoted by erythema, edema,redundant tissue, and/or surface irregularities of the inter-arytenoid mucosa, arytenoid mucosa, posterior laryngealmucosa, and/or vocal folds). To emphasize these dual con-siderations, the working group has split the statement intopart A, a recommendation against empiric therapy forhoarseness, and part B, an option to use anti-reflux therapy

in managing properly diagnosed laryngitis.



S14 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009Anti-Reflux Medications and the EmpiricTreatment of HoarsenessThe benefit of anti-reflux treatment for hoarseness in pa-tients without symptoms of esophageal reflux (heartburnand regurgitation) or evidence for esophagitis is unclear. ACochrane systematic review of 302 eligible studies thatassess the effectiveness of anti-reflux therapy for patientswith hoarseness did not identify any high-quality trialsmeeting the inclusion criteria.169 For example, a nonran-domized study on treating patients with documented refluxof stomach contents into the throat (laryngopharyngeal re-flux) with twice-daily proton pump inhibitors (PPIs) couldnot be included in the review because hoarseness was onlyone component of the reflux symptom index and not anoutcome separate from heartburn.170 One randomized, pla-cebo-controlled trial was also not included because it didnot separate hoarseness as an outcome from other laryngealsymptoms.171 However, the response rate for the laryngealsymptoms was 50 percent in the PPI group compared to 10percent in the placebo group.

A randomized trial published after the Cochrane reviewof anti-reflux treatment for hoarseness included 145 subjectswith chronic laryngeal symptoms (throat clearing, cough,globus, sore throat, or hoarseness and no cardinal GERDsymptoms) and laryngoscopic evidence for laryngitis(erythema, edema, and/or surface irregularities of the inter-arytenoid mucosa, arytenoid mucosa, posterior laryngealmucosa, and/or vocal folds).172 Subjects received eitheresomeprazole 40 mg twice daily or placebo for 16 weeks.There was no evidence for benefit in symptom score orlaryngopharyngeal reflux health-related QOL score betweenthe groups at the end of the study. However, this studyincluded patients with one of many possible laryngealsymptoms and excluded patients with heartburn three ormore days per week.172

The benefits of anti-reflux medication for control ofGERD symptoms are well documented. High-quality con-trolled studies demonstrate that PPIs and H2RA (hista-mine-2 receptor antagonist) improve important clinical out-comes in esophageal GERD over placebo, with PPIsdemonstrating superior response.173,174 Response rates foresophageal symptoms and esophagitis healing are high (ap-proximately 80% for PPIs).173,174

In patients with hoarseness and a diagnosis of GERD,anti-reflux treatment is more likely to reduce hoarseness.Anti-reflux treatment given to patients with GERD (basedon positive pH probe, esophagitis on endoscopy, or pres-ence of heartburn or regurgitation) showed improvedchronic laryngitis symptoms, including hoarseness, overthose without GERD.175

There is some evidence supporting the pharmacologicaltreatment of GERD without documented esophagitis, butthe number needed to treat tends to be higher.173 Thesestudies have esophageal symptoms and/or mucosal healing

as outcomes, not hoarseness.

boto.sagepub.comDownloaded from While generally safe for therapy shorter than two months,prolonged therapy with PPIs and H2RAs for greater thanthree months has been associated with significant risk.H2RAs are associated with impaired cognition in olderadults.176,177 PPI use may increase the risk of bacterial gastro-enteritis, specifically campylobacter and salmonella178 andpossibly clostridium difficile.179 Epidemiological studiesalso associate PPIs with community-acquired pneumo-nia.180,181 Although patients with primary voice disordersmay differ from those in the above mentioned studies, thetreating clinician needs to consider these adverse events.Furthermore, PPIs may impair the ability of clopidogrel toinhibit platelet aggregation activity,182 to varying degreesdepending upon the particular PPI.

Higher doses such as the twice-daily PPI therapy maycarry a higher risk than once-daily therapy, and older adultsmay be more likely than younger adults to be harmed.183

Although pneumonia is more common in young childrenusing PPIs, the prevalence of profound regurgitation andswallowing disorders is high in that population, so it isdifficult to draw conclusions about the effect of the drugitself.184

Use of PPI may interfere with calcium absorption andbone homeostasis. PPI use is associated with an increasedrisk for hip fractures in older adults.185 PPIs decrease vita-min B12 (cobalamin) absorption in a dose-dependent man-ner,186 and serum vitamin B12 levels may underestimate theresulting serum cobalamin deficiency.187 PPI use also de-creases iron absorption and may cause iron deficiency ane-mia.188 Additionally, acid-suppressing drugs (both H2RAsand PPIs) were associated with an increased risk of pancre-atitis in a case-controlled study, not explained by theslightly higher risk of pancreatitis seen in patients withGERD symptoms alone.189

For patients with hoarseness and GERD, a trial ofanti-reflux therapy may be prescribed. If hoarseness doesnot respond or if symptoms worsen, then pharmacologi-cal therapy should be discontinued and a search foralternative causes of hoarseness should be initiated withlaryngoscopy.

Anti-Reflux Medications and Treatment ofChronic LaryngitisLaryngoscopy is helpful in determining whether anti-refluxtreatment should be considered in managing a patient withhoarseness. Increased pharyngeal acid reflux events aremore common in patients with vocal process granulomascompared to controls.190 Also, erythema in the vocal folds,arytenoid mucosa, and posterior commissure has improvedwith omeprazole treatment in patients with sore throat,throat clearing, hoarseness, and/or cough.191 While no dif-ferences in hoarseness improvement was seen between threemonths of esomeprazole vs placebo, one small randomizedcontrolled trial found that findings of erythema, diffuse

laryngeal edema, and posterior commissure hypertrophy



S15Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)showed greater improvement in the treatment arm comparedto placebo.192

More improvement in signs of laryngitis of the true vocalfolds (such as erythema, edema, redundant tissue, and/orsurface irregularities), posterior cricoid mucosa, and aryte-noid complex were noted in patients whose laryngeal symp-toms, including hoarseness, responded to four months ofPPI treatment compared to nonresponders.193 Additionally,the above abnormalities of the interarytenoid mucosa andtrue vocal folds were predictive of improvement in laryn-geal symptoms, including hoarseness.193

Reflux of stomach contents into the laryngopharynx is animportant consideration in the management of patients withlaryngeal disorders. Reflux of gastric contents into the hy-popharynx has been linked with subglottic stenosis.194

Case-control studies have shown that GERD may be a riskfactor for laryngeal cancer,195 and that anti-reflux therapymay reduce the risk of laryngeal cancer recurrence.196 Bet-ter healing and reduced polyp recurrence after vocal foldsurgery in patients taking PPIs compared to no PPIs havealso been described.197

PPI treatment may improve laryngeal lesions and ob-jective measures of voice quality. Observational studieshave demonstrated that vocal process granulomas, whichmay cause hoarseness, have resolved or regressed aftertreatment with anti-reflux medication with or withoutvoice therapy.198 Case series also have shown improvedacoustic voice measures of voice quality after one to twomonths of PPI therapy compared to baseline.199

Nonetheless, there are limitations of the endoscopic la-ryngeal examination in diagnosing patients who may re-spond to PPIs. The presence of abnormal findings, such asthe interarytenoid bar, has been noted in normal individu-als.177 In addition, in a study of healthy volunteers notroutinely using anti-reflux medication and with GERDsymptoms no more than three times per month, erythema ofthe medial arytenoid, posterior commissure hypertrophy,and pseudosulcus were noted.200 Furthermore, the presenceof specific findings depended upon the method of laryngos-copy (rigid vs flexible) and the inter-rater reliability rangedfrom moderate to poor depending on the specific finding.200

In a study of patients with hoarseness from a variety ofdiagnoses, problems with intra- and inter-rater reliability forfindings of edema and erythema of the vocal folds andarytenoids have also been noted.201

Further research exploring the sensitivity, specificity,and reliability of laryngoscopic examination findings is nec-essary to determine which signs are associated with treat-ment response with respect to hoarseness and which tech-niques are best to identify them.

Evidence profile for Statement 5A: Anti-reflux Medica-tions and Hoarseness

Aggregate evidence quality: Grade B, randomized trials withlimitations showing lack of benefits for anti-reflux therapy in

patients with laryngeal symptoms, including hoarseness; ob-

boto.sagepub.comDownloaded from servational studies with inconsistent or inconclusive results;inconclusive evidence regarding the prevalence of hoarse-ness as the only manifestation of reflux disease

Benefit: Avoid adverse events from unproven therapy;reduce cost; limit unnecessary treatment

Harm: Potential withholding of therapy from patientswho may benefit

Cost: None Benefits-harm assessment: Preponderance of benefit over

harm Value judgments: Acknowledgment by the working

group of the controversy surrounding laryngopharyngealreflux, and the need for further research before definitiveconclusions can be drawn; desire to avoid known adverseevents from anti-reflux therapy

Intentional vagueness: None Patient preference: Limited Exclusions: Patients immediately before or after laryn-

geal surgery and patients with other diagnosed pathologyof the larynx

Policy level: Recommendation against

Evidence profile for Statement 5B: Anti-reflux Medica-tion and Chronic Laryngitis

Aggregate evidence quality: Grade C, observationalstudies with limitations showing benefit with laryngealsymptoms, including hoarseness, and observationalstudies with limitations showing improvement in signsof laryngeal inflammation

Benefit: Improved outcomes, promote resolution of lar-yngitis

Harm: Adverse events related to anti-reflux medications Cost: Direct cost of medications Benefits-harm assessment: Relative balance of benefit

and harm Value judgments: Although the topic is controversial, the

working group acknowledges the potential role of anti-reflux therapy in patients with signs of chronic laryngitisand recognizes that these patients may differ from thosewith an empiric diagnosis of hoarseness (dysphonia)without laryngeal examination

Patient preference: Substantial role for shared decisionmaking

Intentional vagueness: None Exclusions: None Policy level: Option

STATEMENT 6. CORTICOSTEROID THERAPY:Clinicians should not routinely prescribe oral cortico-steroids to treat hoarseness. Recommendation againstprescribing based on randomized trials showing adverseevents and absence of clinical trials demonstrating ben-efits with a preponderance of harm over benefit for ste-

roid use.



S16 OtolaryngologyHead and Neck Surgery, Vol 141, No 3S2, September 2009Supporting TextOral steroids are commonly prescribed for hoarseness andacute laryngitis, despite an overwhelming lack of support-ing data of efficacy. A systematic search of MEDLINE,CINAHL, EMBASE, and the Cochrane Library revealed nostudies supporting the use of corticosteroids as empirictherapy for hoarseness except in special circumstances asdiscussed below.

Although hoarseness is often attributed to acute inflam-mation of the larynx, the temptation to prescribe systemic orinhaled steroids for acute or chronic hoarseness or laryngitisshould be avoided because of the potential for significantand serious side effects. Side effects from corticosteroids canoccur with short- or long-term use, although the frequencyincreases with longer durations of therapy (Table 8).202 Addi-tionally, there are many reports implicating long-term inhaledsteroid use as a cause of hoarseness.208-219

Despite these side effects, there are some indications forsteroid use in specific disease entities and patients. A spe-cific and accurate diagnosis should be achieved, however,before beginning this therapy. The literature does supportsteroid use for recurrent croup with associated laryngitis inpediatric patients220 and allergic laryngitis.212,221 Patientswith chronic laryngitis and dysphonia may have environ-mental allergy.221 In limited cases, systemic steroids havebeen reported to provide quick relief from allergic laryngitisfor performers.212,221 While these are not high-quality trials,they suggest a possible role for steroids in these selectedpatient populations. Additionally, in patients acutely depen-dent on their voice, the balance of benefit and harm may beshifted. The length of treatment for allergy-associated dys-phonia with steroids has not been well defined in the liter-ature.

Pediatric patients with croup and other associated symp-toms such as hoarseness had better outcomes when treated

Table 8Documented side effects of short- and long-termsteroid therapy202-207

LipodystrophyHypertensionCardiovascular diseaseCerebrovascular diseaseOsteoporosisImpaired wound healingMyopathyCataractsPeptic ulcersInfectionMood disorderOphthalmologic disordersSkin disordersMenstrual disordersAvascular necrosisPancreatitisDiabetogenesiswith systemic steroids.220 Steroids should also be consid-

boto.sagepub.comDownloaded from ered in patients with airway compromise to decrease edemaand inflammation. An appropriate evaluation and determi-nation of the cause of the airway compromise is requiredprior to starting the steroid therapy. Steroids are also helpfulin some autoimmune disorders involving the larynx such assystemic lupus erythematosus, sarcoidosis, and Wegenergranulomatosis.222,223

Evidence profile for Statement 6: Corticosteroid Therapy

Aggregate evidence quality: Grade B, randomized trialsshowing increased incidence of adverse events associatedwith orally administered steroids; absence of clinical tri-als demonstrating any benefit of steroid treatment onoutcomes

Benefit: Avoid potential adverse events associated withunproven therapy

Harm: None Cost: None Benefits-harm assessment: Preponderance of harm over

benefit for steroid use Value judgments: Avoid adverse events of ineffective or

unproven therapy Role of patient preferences: Some; there is a role for

shared decision making in weighing the harms of steroidsagainst the potential yet unproven benefit in specific cir-cumstances (ie, professional or avocation voice use andacute laryngitis)

Intentional vagueness: Use of the word routine to ac-knowledge there may be specific situations, based onlaryngoscopy results or other associated conditions, thatmay justify steroid use on an individualized basis

Exclusions: None Policy level: Recommendation against

STATEMENT 7. ANTIMICROBIAL THERAPY: Cli-nicians should not routinely prescribe antibiotics to treathoarseness. Strong recommendation against prescribingbased on systematic reviews and randomized trials showingineffectiveness of antibiotic therapy and a preponderance ofharm over benefit.

Supporting TextHoarseness in most patients is caused by acute laryngitis ora viral upper respiratory infection, neither of which arebacterial infections. Since antimicrobials are only effectivefor bacterial infections, their routine, empiric use in treatingpatients with hoarseness is unwarranted.

Upper respiratory infections often produce symptoms ofsore throat and hoarseness, which may alter voice qualityand function. Acute upper respiratory infections caused byparainfluenza, rhinovirus, influenza, and adenovirus havebeen linked to laryngitis.224,225 Furthermore, acute laryngi-tis is self-limited, with patients having improvement in 7 to10 days undergoing placebo treatment.226 A Cochrane re-

view examining the role of antibiotics in acute laryngitis in



S17Schwartz et al Clinical practice guideline: Hoarseness (Dysphonia)adults found only two studies meeting the inclusion criteriaand no benefit of either penicillin or erythromycin.227 Sim-ilar findings of no benefit for antibiotics in acute upperrespiratory tract infections in adults and children were notedin another Cochrane review.228

The potential harm from antibiotics must also be consid-ered. Common adverse effects include rash, abdominalpain, diarrhea, and vomiting and are more common in pa-tients receiving antibiotics compared to placebo.228,229 In-teractions may also occur between specific antibiotics andother medications.230

In addition to negative consequences from antibioticuse on an individual level, important societal implica-tions exist. Over-prescribing antibiotics may contributeto bacterial resistance to antibiotics. Compared to theyears 2001 to 2003, more methicillin-resistant Staphylo-coccus aureus has been isolated in acute and chronicmaxillary sinusitis in the period 2004 to 2006.231 Fur-thermore, antibiotic treatment costs for infectious dis-eases, such as community-acquired pneumonia, were 33percent higher in communities with high antibiotic resis-tance rates.232 Thus, overuse of antibiotics for hoarsenesshas negative potential results for both the individual andthe general population.

While uncommon, antibiotics may be appropriate in se-lect rare causes of hoarseness. Laryngeal tuberculosis inrenal transplant patients and in patients with human immu-nodeficiency virus (HIV) have been reported.233,234 Anatypical mycobacterial laryngeal infection has also beenreported in a patient on inhaled steroids.235 Although im-munosuppression may predispose to a bacterial laryngitis,laryngeal tuberculosis has also been documented in patientswithout HIV and laryngeal actinomycosis has occurred inan immunocompetent patient.236-238 A laryngeal mass orulcer is often present in these infectious etiologies, requiringa high index of suspicion for malignancy. For immunocom-promised patients with hoarseness, laryngoscopy is war-ranted and biopsy for diagnosis should be performed, ifindicated.

Antibiotics may also be warranted in patients withhoarseness secondary to other bacterial infections. Recently,community outbreaks of pertussis attributed to waning im-munity in adolescents and adults have been reported.239

Among adults with pertussis, multiple symptoms have beenreported including hoarseness in 18 percent.240 Among chil-dren, bacterial tracheitis, often from Staphylococcus aureus,may be associated with crusting and may cause severe upperairway infection and present with multiple symptoms suchas cough, stridor, increased work of breathing, and hoarse-ness.241

Evidence profile for Statement 7: Antimicrobial Therapy

Aggregate evidence quality: Grade A, systematic reviewsshowing no benefit for antibiotics for acute laryngitis orupper respiratory tract infection; grade A evidence show-

ing potential harms of antibiotic therapy

boto.sagepub.comDownloaded from Benefit: Avoidance of ineffective therapy with docu-mented adverse events

Harm: Potential for failing to treat bacterial, fungal, ormycobacterial causes of hoarseness

Cost: None Benefit-harm assessment: Preponderance of harm over

benefit if antibiotics are prescribed Values: Importance of limiting antimicrobial therapy to

treating bacterial infections Role of patient preferences: None Int

clinical practice guideline: hoarseness (dysphonia)

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