Joseph C. Stemple

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.

Efficacy of vocal function exercises as a method of improving voice production

Objective voice analysis including acoustic, aerodynamic, and laryngeal videostroboscopic measures demonstrated normal voice in 35 adult women. The subjects were then randomly divided into experimental, placebo, and control groups. The experimental group engaged in vocal function exercises. The placebo group engaged in a placebo exercise program. Objective measures taken after 4 weeks of execise demonstrated significant changes in phonation volume, flow rate, maximum phonation time, and frequency range for the experimental group. No significant changes were noted in the measurements of the control and placebo groups.

Dysphagia in the Elderly: Preliminary Evidence of Prevalence, Risk Factors, and Socioemotional Effects

Objectives: Epidemiological studies of dysphagia in the elderly are rare. A non-treatment-seeking, elderly cohort was surveyed to provide preliminary evidence regarding the prevalence, risks, and socioemotional effects of swallowing disorders. Methods: Using a prospective, cross-sectional survey design, we interviewed 117 seniors living independently in Utah and Kentucky (39 men and 78 women; mean age, 76.1 years; SD, 8.5 years; range, 65 to 94 years) regarding 4 primary areas related to swallowing disorders: Lifetime and current prevalence, symptoms and signs, risk and protective factors, and socioemotional consequences. Results: The lifetime prevalence of a swallowing disorder was 38%, and 33% of the participants reported a current problem. Most seniors with dysphagia described a sudden onset with chronic problems that had persisted for at least 4 weeks. Stepwise logistic regression identified 3 primary symptoms uniquely associated with a history of swallowing disorders: Taking a longer time to eat (odds ratio [OR], 9.5; 95% confidence interval [CI], 2.3 to 40.2); coughing, throat clearing, or choking before, during, or after eating (OR, 3.4; 95% CI, 1.1 to 10.2); and a sensation of food stuck in the throat (OR, 5.2; 95% CI, 1.8 to 10.0). Stroke (p = .02), esophageal reflux (p = .003), chronic obstructive pulmonary disease (p = .05), and chronic pain (p = .03) were medical conditions associated with a history of dysphagia. Furthermore, dysphagia produced numerous adverse socioemotional effects. Conclusions: This study provides preliminary evidence to suggest that chronic swallowing disorders are common among the elderly, and highlights the need for larger epidemiological studies of these disorders.

Objective measures of voice production in normal subjects following prolonged voice use

Laryngeal fatigue affects the physical sensations, effort, and perceptual quality of voice production. The underlying physiology of fatigue is not well understood. Acoustic, aerodynamic, and videostroboscopic data were measured in 10 normal speakers before and after prolonged voice use. Significant changes were found in the fundamental frequency of connected speech. Anterior glottal chinks were induced in a majority of subjects. Implications are discussed.

Epidemiology of Voice Disorders in the Elderly: Preliminary Findings

Objectives: Epidemiologic studies of the prevalence and risk factors of voice disorders in the elderly, nontreatment seeking population are nonexistent. The purpose of this preliminary investigation was to 1) estimate the prevalence of voice disorders, 2) identify variables associated with increased risk of voice disorders, and 3) measure the socioemotional impact of voice disorders on the elderly who live independently.

Shifts in relative prevalence of laryngeal pathology in a treatment-seeking population.

The prevalence of laryngeal pathology in a treatment-seeking population of southwestern Ohio underwent a 15-year reexamination. Relationships between pathology and demographic variables of age, gender, and occupation were investigated. Data were collected from 1,158 new patients seen by participating otolaryngologists between 1996 and 1998. The most frequent pathologies were reflux laryngitis, functional (including diagnoses of laryngeal myasthenia and hoarseness), vocal fold paralysis, nodules, and laryngitis. Pathologies were found to occur more often in females, with some pathologies more common to one gender. Pathologies occurred more often in the older age categories. The most common occupations found in the sample were retired persons, executives/managers, and homemakers. Comparisons were made to an earlier investigation of laryngeal pathology in the same otolaryngology practices. Differences from the previous study were noted in the prevalence of pathology and the distribution of demographic variables. Relationships between pathology and demographic variables reported by the two studies were examined for consistency.

Aerodynamic changes as a result of vocal function exercises in elderly men.

Objectives/Hypothesis: Voice therapy can improve the vocal quality of elderly patients with voice problems, but the changes in vocal aerodynamics associated with physiologic voice therapy are not well documented. The purpose of the present study was to determine the changes in vocal aerodynamics as a result of the management program known as Vocal Function Exercises (VFEs).

Videophone-Delivered Voice Therapy: A Comparative Analysis of Outcomes to Traditional Delivery for Adults with Parkinson’s Disease

Individuals with idiopathic Parkinsons disease (IPD) usually develop a speech disorder characterized by reduced loudness, hoarse and breathy voice, monotony of pitch, short rushes of speech, and imprecise consonants. The inability to effectively communicate impairs their ability to function in society and quality of life. A successful program developed to improve speech in these individuals is the Lee Silverman Voice Treatment (LSVT). A critical component of this treatment is intense daily therapy for 4 weeks, a regimen that is difficult for many elderly patients to complete. Treatment delivered through videophones placed in the homes of individuals with IPD offers an alternative and could improve accessibility of treatment if the results were the same. This study compared the outcomes of LSVT delivered via videophones to the outcomes of traditional treatment delivered face-to-face.

Coping and Adjustment in Alaryngeal Speakers

In this investigation the coping, adjustment, self-esteem, general well-being, perceived communication abilities, and preferred communication modes of 41 patients with laryngectomies were evaluated. Specifically, we wanted to determine how well patients with laryngectomies adjust to and cope with their cancer, whether differences in coping and adjustment vary as a function either of the type of alaryngeal voice used or the amount of time since the laryngectomy, and whether relationships exist between the speech of patients with laryngectomies and their adjustment. Standardized interview protocols and tests were employed during face-to-face interviews. Results revealed that 73% of the sample showed good adjustment and used predominantly problem-focused and seeking-social-support strategies to cope with their cancer. The 27% who were classified as poor copers also performed poorly on self-esteem and general well-being measures and used more self-blame and avoidance strategies. There were no significant diff...

Quick Screen for Voice and Supplementary Documents for Identifying Pediatric Voice Disorders

Three documents are provided to help the speech-language pathologist (SLP) identify children with voice disorders and educate family members. The first is a quickly administered screening test that covers multiple aspects of voice, respiration, and resonance. It was tested on 3000 children in kindergarten and first and fifth grades, and on 47 preschoolers. The second document is a checklist of functional indicators of voice disorders that could be given to parents, teachers, or other caregivers to increase their attention to potential causes of voice problems and to provide the SLP with information pertinent to identification. The final document is a brochure with basic information about voice disorders and the need for medical examination. It may be used to help the SLP educate parents, particularly about the need for laryngeal examination for children who have been identified as having a voice problem.