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Update to Hoarseness CPG Nears Publication

AAO-HNSF Clinical Practice Guideline (Update): Hoarseness (Dysphonia)

  • 4:45  – 5:45 pm
  • Sunday
  • Room N230

The AAO-HNSF has updated its clinical practice guideline (CPG) for hoarseness (dysphonia), and it is expected to be published in early 2018. A Sunday Miniseminar will preview the update, which clarifies recommendations for the use of laryngoscopy, antibiotics, steroids, anti-reflux medications, and imaging for use by all clinicians, regardless of specialty, treating patients presenting with hoarseness.

Other updates in the guideline include incorporating new evidence profiles with the role of patient preferences, confidence in the evidence, difference of opinion, and quality improvement opportunities. It also references three new guidelines, 16 new systematic reviews, and four new randomized controlled trials.

“A lot of work has gone into making sure that the perspective of all stakeholders has been taken into account,” said Robert J. Stachler, MD, the chair of the panel that developed Clinical Practice Guideline: Dysphonia (Hoarseness) (Update). “We addressed things that were contentious after publication of the first guideline.

“Primarily, we address the timing of laryngoscopy for persistent dysphonia. As in the original guideline, physicians may perform diagnostic laryngoscopy at any time, especially in patients where there is a higher level of concern. For all patients with dysphonia, we clarified that earlier evaluation of the larynx is beneficial.”

The current guideline was published in 2009 and was controversial because it allowed waiting up to three months prior to laryngeal evaluation in patients without significant concerns, said Dr. Stachler, a clinical associate professor at Wayne State University, Detroit, MI. The update shortens the amount of time allowed before performing a laryngoscopy in all patients.

The update also uses the colloquial term “hoarseness” versus the clinical diagnosis of dysphonia because hoarseness is a symptom understood by patients, he said. The guideline defines dysphonia as altered voice quality, pitch, loudness, or vocal effort that impairs communication as assessed by a clinician and/or affects quality of life.

Another important change in the guideline update is an action statement on assessing patient outcomes, particularly for gastroesophageal reflux disease (GERD).

“We tightened up the language on GERD. We made it clear that you should not willy-nilly prescribe proton pump inhibitors,” Dr. Stachler said. “That is different. The older guideline said you could prescribe anti-reflux medications in someone with dysphonia. Now, it says you have to look at the larynx before giving someone anti-reflux medications.”

Another action statement focuses on the escalation of care if there is a concern about a neck mass, if a patient has a history of tobacco use, or if the patient is a professional voice user, he said.

Other topics in the guideline update include:

  • Clinicians should not routinely prescribe antibiotics to treat dysphonia prior to examining the larynx.
  • Clinicians should not obtain CTs or MRIs in patients with a primary voice complaint prior to examining the larynx.
  • Corticosteroids should not routinely be prescribed prior to visualizing the larynx.
  • The use of botulinum toxin for the treatment of spasmodic dysphonia and other types of laryngeal dystonia is clarified.
  • Greater emphasis on preventive measures is noted.
  • Clinicians should document resolution, improved or worsened symptoms of dysphonia, or change in quality of life after treatment or observation, and consider referring to a specialist if there is no improvement.
  • Finally, an algorithm was developed and added at the end of the guideline that clarifies how all of the guideline action statements are related.

“We took great effort to make sure this guideline addressed the needs of all the stakeholders, including consumers,” Dr. Stachler said. “This document clarifies the critical importance of laryngoscopy to establish a diagnosis to direct any further management of patients with dysphonia to optimize patient outcomes.”

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