J. Scott McMurray

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.

Cidofovir efficacy in recurrent respiratory papillomatosis: a randomized, double-blind, placebo-controlled study.

Objectives: We performed a prospective, double-blind, placebo-controlled, longitudinal adjuvant therapy trial to determine the efficacy of cidofovir in the treatment of severe recurrent respiratory papillomatosis (RRP). Although results of case series suggest that cidofovir may decrease the frequency and rapidity of papilloma regrowth, no blinded placebo-controlled studies have demonstrated efficacy. Methods: Adults and children (n = 19) with aggressive RRP received either active drug (cidofovir) or placebo. When surgical intervention was needed, drug or placebo was injected into affected areas after surgical removal of disease. The following measures were made at baseline and at 2-month intervals for the course of 12 months: Derkay papilloma severity grading scale, Voice Handicap Index, Health-Related Quality of Life, and total number of procedures performed over 12 months. Results: At 2- and 12-month follow-ups, there was a significant (p < .05) improvement in the Derkay Severity Score within the cidofovir and placebo groups, but no difference between groups, and no difference between groups in the number of procedures performed. Significant improvement was found in Voice Handicap Index scores in the cidofovir group at the 12-month follow-up. No differences were seen in Health-Related Quality of Life. Conclusions: A randomized, blinded, placebo-controlled trial is necessary in the study of RRP, because the natural history of the disease can include remissions and reactivations. We found a significant improvement in the Derkay Severity Score 12 months after the baseline assessment in patients treated with cidofovir. This effect, however, was also seen in the placebo group. Accordingly, we were unable to provide proof of efficacy of cidofovir in the treatment of RRP.

Role of laryngoscopy, dual pH probe monitoring, and laryngeal mucosal biopsy in the diagnosis of pharyngoesophageal reflux

There is no standard for determining significant pharyngoesophageal reflux. This prospective blind comparison study compared dual pH probe studies, direct laryngoscopy, and mucosal biopsy in children without symptoms of gastroesophageal reflux who underwent airway evaluation. Significant reflux to the lower esophageal probe did not correlate with statistical significance with reflux to the upper probe. In this group of asymptomatic patients, a positive lower pH probe finding did not correlate with upper or lower esophageal mucosal inflammation. Eosinophilia in the esophageal mucosa is diagnostic of gastroesophageal reflux disease, and was seen in 5 of the laryngeal biopsies. A weak correlation was seen between positive findings at laryngoscopy and positive posterior cricoid biopsy in this group. There may be no consistent way to predict significant pharyngoesophageal reflux in asymptomatic patients. Single-probe pH testing will not predict significant pharyngoesophageal reflux with mucosal changes. Laryngoscopy and upper pH probe findings only weakly correlate with significant histologic findings. Laryngeal and posterior cricoid biopsy may be the only sensitive test for mucosal injury. Clinical trials of empiric antireflux therapy should be used to determine whether the laryngeal changes seen in these patients are reversible.

Current use of intralesional cidofovir for recurrent respiratory papillomatosis.

The authors sought to define the indications, administration, and adverse events associated with intralesional cidofovir use for recurrent respiratory papillomatosis (RRP).

Disorders of phonation in children

Vocal disturbances in children are surprisingly common. Typical pathologic conditions differ, however, from those that are seen commonly in adults. Disturbances in the vibratory characteristic of the vocal folds cause dysphonia. The most common causes for dysphonia are infectious, anatomic, congenital, inflammatory, neoplastic, neurologic, or iatrogenic in nature. A child who presents with hoarseness demands a rapid and thorough assessment. Fine points during the history may provide the clinician with clues as to the correct etiologic category. Proper treatment requires an accurate diagnosis. Although some conditions are similar in the adult larynx, treatment of the pediatric larynx often differs. An understanding of the changing and growing pediatric larynx is necessary for treatment and satisfactory results.

Implementation of a program for surgical education in laryngology.

To describe the implementation of a program for surgical education in laryngology.

Endoscopic changes in the upper airway after mandibular distraction osteogenesis.

Introduction:Children with micrognathia secondary to craniofacial disorders can experience significant airway and feeding difficulties. Mandibular distraction osteogenesis (MDO) is one treatment of severe micrognathia. We examined endoscopic images for upper airway (UA) soft tissue changes after MDO. We hypothesized that MDO produces consistent changes in UA soft tissue, which correlate with symptom resolution. Materials and Methods:This retrospective chart review included 16 patients undergoing MDO from 2002 to 2007. Demographic data, symptom information, and preoperative and early and late postoperative endoscopic images were collected. Blinded randomized images of UA soft tissues were quantitatively analyzed using ImageJ. To compare nonstandardized images, ratios of UA dimensions were made. Preoperative and early and late postoperative ratios were statistically analyzed with Students t-test. Results:Sixteen patients with a mean age of 237 days were included. Mean distance distracted was 12 mm. There were significant changes in relative dimensions of the supraglottic space in the early postoperative period, which were not maintained in the late postoperative period. Nevertheless, all experienced complete relief of airway obstruction. Discussion:Our study showed a significant increase in supraglottic space dimensions after MDO that was not maintained over time. This is likely because of the limitation of images and measurement methods. Despite this, significant clinical improvement was seen in all patients, with resolution of airway obstruction. This suggests supraglottic changes as well as tongue base alterations are related to clinical improvement. Further investigation of alterations in UA after MDO is needed to continue characterizing these changes.

Describing pediatric dysphonia with nonlinear dynamic parameters

OBJECTIVE Nonlinear dynamic analysis has emerged as a reliable and objective tool for assessing voice disorders. However, it has only been tested on adult populations. In the present study, nonlinear dynamic analysis was applied to normal and dysphonic pediatric populations with the goal of collecting normative data. Jitter analysis was also applied in order to compare nonlinear dynamic and perturbation measures. This studys findings will be useful in creating standards for the use of nonlinear dynamic analysis as a tool to describe dysphonia in the pediatric population. METHODS The study included 38 pediatric subjects (23 children with dysphonia and 15 without). Recordings of sustained vowels were obtained from each subject and underwent nonlinear dynamic analysis and percent jitter analysis. The resulting correlation dimension (D2) and percent jitter values were compared across the two groups using t-tests set at a significance level of p=0.05. RESULTS It was shown that D2 values covary with the presence of pathology in children. D2 values were significantly higher in dysphonic children than in normal children (p=0.002). Standard deviations indicated a higher level of variation in normal childrens D2 values than in dysphonic childrens D2 values. Jitter analysis showed markedly higher percent jitter in dysphonic children than in normal children (p=0.025) and large standard deviations for both groups. CONCLUSION This study indicates that nonlinear dynamic analysis could be a viable tool for the detection and assessment of dysphonia in children. Further investigations and more normative data are needed to create standards for using nonlinear dynamic parameters for the clinical evaluation of pediatric dysphonia.

Care of pediatric tracheostomy in the immediate postoperative period and timing of first tube change

OBJECTIVE To analyze the safety of a standardized pediatric tracheostomy care protocol in the immediate postoperative period and its impact on tracheostomy related complications. STUDY DESIGN Retrospective case series. SUBJECTS Pediatric patients undergoing tracheotomy from February 2010-February 2014. METHODS In 2012, a standardized protocol was established regarding postoperative pediatric tracheostomy care. This protocol included securing newly placed tracheostomy tubes using a foam strap with hook and loop fastener rather than twill ties, placing a fresh drain sponge around the tracheostomy tube daily, and performing the first tracheostomy tube change on postoperative day 3 or 4. Outcome measures included rate of skin breakdown and presence of a mature stoma allowing for a safe first tracheostomy tube change. Two types of tracheotomy were performed based on patient age: standard pediatric tracheotomy and adult-style tracheotomy with a Bjork flap. Patients were analyzed separately based on age and the type of tracheotomy performed. RESULTS Thirty-seven patients in the pre-protocol group and 35 in the post-protocol group were analyzed. The rate of skin breakdown was significantly lower in the post-protocol group (standard: p=0.0048; Bjork flap: p=0.0003). In the post-protocol group, all tube changes were safely accomplished on postoperative day three or four, and the stomas were deemed to be adequately matured to do so in all cases. CONCLUSION A standardized postoperative pediatric tracheostomy care protocol resulted in decreased rates of skin breakdown and demonstrated that pediatric tracheostomy tubes can be safely changed as early as 3 days postoperatively.

Unique presentation of a bronchial foreign body in an asymptomatic child

A child who aspirates a foreign body may present in many ways. We present the case of an 8-year-old boy whose initial presentation consisted only of his preoccupation with his lost toy and his gesturing toward his oral cavity. There was no witnessed coughing or choking episode, and there were no initial physical examination findings of note, and no abnormalities on appropriate radiographic studies. The patient was transferred to our institution for further evaluation and management. Our careful examination revealed a slight wheeze at the left upper lobe. Endoscopy was immediately performed, and bronchoscopy revealed a yellow, tubular, plastic foreign body in the left main bronchus through which the patient was breathing freely. This was removed without incident by means of optical graspers. The physical characteristics of this foreign body, including its small size, relatively inert material, and large lumen, allowed this patient to present relatively asymptomatically. This case demonstrates the need for a high index of suspicion in the evaluation and management of foreign bodies in the aerodigestive tract.