Edie R. Hapner

Clinical practice guideline: Hoarseness (Dysphonia)

Objective: This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness. Purpose: The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology–head and neck surgery, pediatrics, and consumers. Results The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patients larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures. Disclaimer: This clinical practice guideline is not intended as 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 is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Prevalence of Perceived Dysphonia in a Geriatric Population

OBJECTIVES: To characterize geriatric dysphonia, including its prevalence, quality‐of‐life impairment, and association with overall health status.

A study of voice therapy dropout.

Treatment dropout is a consistent problem among behavior change therapies. A recent study by the authors demonstrated that 38% of patients did not attend a voice evaluation after referral by the otolaryngologist. Further, 47% of patients who attended a voice evaluation did not return for therapy. No previous study has set out to document completion/dropout rates for voice therapy, but high rates of attrition are reported as problematic within voice therapy research studies. The purpose of this study was to quantify the problem of voice therapy dropout over the course of voice therapy and to analyze factors that may predict dropout using a retrospective chart review. Data were collected at two voice centers and included demographics (gender, age, and race/ethnicity), quality-of-life impact (Voice Handicap Index [VHI]), severity of dysphonia (Consensus Auditory Perceptual Evaluation of Voice [CAPE-V] overall severity score), diagnosis, and completion/dropout status. Results indicated a 65% voice therapy dropout rate in this study. There was no significant difference in dropout rates for gender, age, race, VHI, CAPE-V, or diagnosis. No factor studied was strongly associated with dropout. The 65% dropout rate in this study was consistent with literature published in other behavior change fields. The variables analyzed in this study were not predictive of dropout. Future research should examine methods to effect a reduction in dropout, from otolaryngologist referral through completion of therapy.

Preliminary data on two voice therapy interventions in the treatment of presbyphonia

Presbyphonia is common among elderly individuals, yet few studies have evaluated behavioral treatment approaches for presbyphonia. The primary aim of this study was to assess the short‐term efficacy of two types of voice therapy—vocal function exercises (VFE) and phonation resistance training exercise (PhoRTE) therapy—in the treatment of presbyphonia. The secondary aim was to determine if differences in adherence and treatment satisfaction existed between the two therapy approaches.

Spontaneous resolution of hemorrhagic polyps of the true vocal fold.

Hemorrhagic polyps are the most common benign lesions surgically removed from the vocal folds. Although this modality does offer satisfactory results in most of the cases, there is a subset of polyps that seems to resolve with conservative therapy. This study was performed to examine this subset of polyps. Thirty-four consecutive subjects diagnosed with hemorrhagic polyps of the true vocal fold were retrospectively reviewed to determine the incidence of spontaneous resolution of the lesions with nonsurgical therapy. Sixteen subjects began conservative therapy, consisting of voice therapy and proper vocal hygiene, often while awaiting an optimal personal time for surgical intervention. Of these subjects, nine (56.3%) experienced a resolution of their lesion and symptoms without undergoing surgical therapy. Surgical removal of hemorrhagic polyps is often considered the standard of treatment for these benign lesions. However, these observations support a regimen of voice therapy and observation in select cases.

Differences in Temporal Variables Between Voice Therapy Completers and Dropouts

OBJECTIVES The aim of this study was to examine temporal variables thought to be associated with voice therapy completion. STUDY DESIGN Retrospective chart review of 197 cases (120 dropouts and 77 completers) seen at two voice centers. METHODS Cases included males and females aged 15-90 years presenting with a chief complaint of dysphonia who were referred by an otolaryngologist to a speech-language pathologist for voice therapy. Cases were analyzed from the date of physician referral through the final therapy session. The dependent variable was completion of voice therapy. Independent variables included selected temporal variables related to the timing, frequency, and duration of voice therapy. A binary logistic regression was performed to evaluate the relationship between the dependent variable and the temporal variables. Differences between groups were assessed with independent t tests and post hoc analysis. RESULTS There were significant differences between groups for the number of sessions attended and the wait time between otolaryngology referral and speech-language pathology evaluation, which were also the strongest predictors of therapy completion. CONCLUSIONS There was a strong relationship found between selected temporal variables and therapy completion. Future research directions will examine methods to use these findings to effect a reduction in voice therapy dropout.

An exploratory study of voice change associated with healthy speakers after transcutaneous electrical stimulation to laryngeal muscles.

OBJECTIVES The purpose of this study was to determine if measurable changes in fundamental frequency (F(0)) and relative sound level (RSL) occurred in healthy speakers after transcutaneous electrical stimulation (TES) as applied via VitalStim (Chattanooga Group, Chattanooga, TN). STUDY DESIGN A prospective, repeated-measures design. METHODS Ten healthy female and 10 healthy male speakers, 20-53 years of age, participated in the study. All participants were nonsmokers and reported negative history for voice disorders. Participants received 1 hour of TES while engaged in eating, drinking, and conversation to simulate a typical dysphagia therapy protocol. Voice recordings were obtained before and immediately after TES. The voice samples consisted of a sustained vowel task and reading of the Rainbow Passage. Measurements of F(0) and RSL were obtained using TF32 (Milenkovic, 2005, University of Wisconsin). The participants also reported any sensations 5 minutes and 24 hours after TES. RESULTS Measurable changes in F(0) and RSL were found for both tasks but were variable in direction and magnitude. These changes were not statistically significant. Subjective comments ranged from reports of a vocal warm-up feeling to delayed onset muscle soreness. CONCLUSIONS These findings demonstrate that application of TES produces measurable changes in F(0) and RSL. However, the direction and magnitude of these changes are highly variable. Further research is needed to determine factors that may affect the extent to which TES contributes to significant changes in voice.

Coprevalence of tremor with spasmodic dysphonia: a case-control study.

The aim of this study was to define the coprevalence of tremor with spasmodic dysphonia (SD).

Results of a Large-Scale Head and Neck Cancer Screening of an At-Risk Population

OBJECTIVE/HYPOTHESIS To determine whether a community-based head and neck cancer screening could be an effective method to detect positive findings of head and neck cancer in at-risk populations. STUDY DESIGN Survey-based study with a nonexperimental intervention component. METHODS Five hundred sixty-eight adults were screened for oral and laryngeal cancers by otolaryngologists and oral and maxillofacial surgeons during three National Association of Stock Car Auto Racing race weekend events. A prescreening survey collected demographic information, relevant medical history, and information regarding risk factors for head and neck cancers, including current or past tobacco use, alcohol consumption, and chemical exposures. Signs and symptoms of head and neck cancer were documented during the screening. RESULTS Forty-three percent of participants with a history of smoking had abnormal findings. A Pearson chi-square indicated that the proportion of males who evidenced positive findings was significantly (P<0.05) higher than the proportion of females who evidenced positive findings. For every pack of cigarettes smoked per day, an individual was 1.95 times more likely to evidence abnormal findings even after controlling for alcohol use, family history of cancer, personal history of head and neck cancers, sex, age, and occupation. CONCLUSIONS This study is the first to document the results of a large-scale head and neck cancer screening of a population of people known to be at risk of head and neck cancers. The study demonstrates the feasibility of developing and implementing large-scale community-based head and neck cancer screenings, as are often seen in the early diagnosis and education of signs, symptoms, and risks for other cancers.

Voice Outcomes from Subligamentous Cordectomy for Early Glottic Cancer

Objectives: We evaluated the voice and vocal fold pliability outcomes of European Laryngological Society (ELS) deep type I (subepithelial) and type II (subligamentous) cordectomies for early glottic cancer. Methods: We reviewed the medical records of patients with glottic carcinoma at a tertiary care medical center between 2005 and 2011. Their procedures were stratified into ELS type I and ELS type II cordectomies. The data recorded included age, gender, tumor stage, recurrence, patient-assessed voice-related quality of life, perceptual voice evaluation, and stroboscopy. Results: Four patients were identified as having subepithelial cordectomy, and 13 as having subligamentous cordectomy. The average preoperative and postoperative voice-related quality of life scores were 65 and 74 for the ELS I cohort and 64 and 95 for the ELS II group. The preoperative and postoperative perceptual voice evaluation scores were 56 and 35 for the ELS I cohort and 45 and 21 for the ELS II cohort. The ELS I cohort had a moderately to severely reduced mucosal wave, with 75% of patients demonstrating glottic insufficiency, whereas the ELS II cohort had a mildly to moderately reduced mucosal wave, with 8% of patients demonstrating glottic insufficiency. The survival outcomes were the same. Conclusions: Patients who underwent subligamentous excision of early glottic cancer had significantly improved postoperative voice and stroboscopy scores. This finding suggests that if tumor resection reaches the vocal ligament, and minimal superficial lamina propria can be preserved, subligamentous cordectomy should be performed.