HoarsenessEvidence-based Key points for Approach

Sasan Dabiri, Assistant Professor

Department of otorhinolaryngology – Head & Neck Surgery

Amir A’lam hospital

Tehran University of Medial Sciences

Hoarseness : Evidence-based Key points for Approach

• Definition:

– Altered voice quality, pitch, loudness, or vocal effort that

o impairs communication

or

o reduces voice-related QOL

self-perceived decrement in physical, social, and emotional aspects

Introduction

Hoarseness : Evidence-based Key points for Approach

• Grading of Evidence• A: Well-designed RCTs or diagnostic studies performed on a population

similar to the guideline’s target population

• B: RCTs or diagnostic studies with minor limitations; or

overwhelmingly consistent evidence from observational studies

• C: Observational studies (case-control and cohort design)

• D: Expert opinion, case reports, reasoning from first principles

(bench research or animal studies)

Introduction

Hoarseness : Evidence-based Key points for Approach

• Important underlying etiology of hoarseness

Thyroid surgery

Carotid endarterectomy

Cervical spine surgery (anterior approach)

Cardiac surgery

Surgery for esophageal cancer

Prolonged endotracheal intubation (four days injury)

History Taking

Hoarseness : Evidence-based Key points for Approach

• Important underlying etiology of hoarseness

• Medications that may cause hoarseness

History Taking

Medication Mechanism of impact on voice

Biphosphonates Chemical laryngitis

ACE inhibitors Cough

Antihistamines and Anticholinergics Drying effect on mucosa

Diuretics Drying effect on mucosa

Antipsychotics Laryngeal dystonia

Inhaled steroids Dose-dependent mucosal irritationFungal laryngitis

Hoarseness : Evidence-based Key points for Approach

• Laryngoscopy should be done when:• Fails to resolve by a max. of 3 months after onset

• Serious underlying cause is suspected

Physical Examination

with a history of tobacco or alcohol use with unexplained weight loss with hemoptysis, dysphagia, odynophagia, otalgia, or airway compromise with accompanying neurologic symptoms with concomitant neck mass in an immunocompromised host in a neonate after trauma unresolving after surgery that is worsening possible aspiration of a foreign body

Hoarseness : Evidence-based Key points for Approach

• Office laryngoscopy• transorally

– with a mirror

– rigid endoscope

• transnasally– with a flexible fiberoptic

– distal-chip laryngoscope

• Operative laryngoscopy• Risks: cost; general anesthesia; airway distress;

dental trauma; oral cavity and pharyngeal trauma;

tongue dysesthesia; taste changes; cardiovascular risk

Physical Examination

with either halogen light or

stroboscopic light application

Hoarseness : Evidence-based Key points for Approach

Should be used after laryngoscopy

and Not in all patients with hoarseness

• Risks of Computed Tomography Scan:• radiation-induced malignancy

• IV contrast reaction

• Risks Of Magnetic Resonance Imaging:• Magnetic effects (projectile, device, burning, artifact)

• Claustrophobia

• Gadolinium reaction

• Cost

Radiologic Imaging

Hoarseness : Evidence-based Key points for Approach

• Anti refluxnot prescribe for patients with hoarseness without

signs or symptoms of GERD

o No consistent evidence for effectiveness

o In patients with GERD significantly reduces hoarseness

o Risks of Proton Pomp Inhibitors:o Infection (GI, Lung)

o Calcium absorption

o Neoplasm (?)

Empiric Therapy

High NNTIf not esophagitis

• Anti reflux

• Anti bacterial

Routine use is strongly unwarranted

o No benefits in Cochrane reviews

o Risk of adverse effects

o Bacterial resistance

o Costs

Hoarseness : Evidence-based Key points for Approach

Empiric Therapy

Hoarseness : Evidence-based Key points for Approach

• Anti reflux

• Anti bacterial

• Anti inflammatoryprescription of systemic or inhaled steroids for

acute or chronic hoarseness or laryngitis

should be avoided

o Side effects

o Some indications for specific disease entities

Empiric Therapy

should visualize the larynx

before prescribing voice therapy

o Excluding some non-responding diagnoses

o Usefulness for planning voice therapy

Hoarseness : Evidence-based Key points for Approach

Voice Therapy

Diagnosis should be

made

• One of choices for managing hoarseness

(for all ages)

• Approaches:• Hygienic : focus on eliminating behaviors considered to be

harmful to the vocal mechanism

• Symptomatic : direct modification of aberrant features of pitch, loudness, and quality

• Physiologic : retrain and rebalance the subsystems of respiration, phonation, and resonance

Hoarseness : Evidence-based Key points for Approach

Voice Therapy

Hoarseness : Evidence-based Key points for Approach

should advocate for surgery as a therapeutic option in:

• Suspected malignancy

• Benign soft tissue lesions

• Glottic insufficiency

• Laryngeal dystonia

Surgical Therapy

Surgical method used is less important than experience and skill of surgeon in obtaining satisfactory outcomes

Hoarseness : Evidence-based Key points for Approach

should advocate for surgery as a therapeutic option in:

• Suspected malignancy

• Benign soft tissue lesions

• Glottic insufficiency

• Laryngeal dystonia

Surgical Therapy

observational studies show comparable objective and subjective improvement in voice betweeninjection laryngoplasty and laryngeal framework surgery

Hoarseness : Evidence-based Key points for Approach

should advocate for surgery as a therapeutic option in:

• Suspected malignancy

• Benign soft tissue lesions

• Glottic insufficiency

• Laryngeal dystonia (Spasmodic dysphonia)

Surgical Therapy

Botulinum toxin as the first-line treatment

Hoarseness : Evidence-based Key points for Approach

should advocate for surgery as a therapeutic option in:

• Suspected malignancy

• Benign soft tissue lesions

• Glottic insufficiency

• Laryngeal dystonia (Spasmodic dysphonia)

Botulinum toxin: - not currently FDA approved for SD

- moderate overall improvement

- have a good safety record

- used for other neurological voice disorders

Surgical Therapy

Hoarseness : Evidence-based Key points for Approach

• Hydration

• avoidance of irritants

• voice training

• amplification

• avoidance of tobacco smoke (primary or secondhand)

Preventive Therapy

Hoarseness : Evidence-based Key points for Approach

• History taking

• Laryngoscopy (max after 3 months)

• Not imaging before laryngoscopy

• Not routine Steroid, Antibiotic, Anti reflux

• Voice therapy & Preventive recommendations

• Surgery

Summary

Hoarseness : Evidence-based Key points for Approach

Thanks for Your Attention