Thursday, September 10, 2009

Hoarseness

Otolaryngol Head Neck Surg. 2009;141:S1-S31.

Clinical Context

Hoarseness is a common presenting symptom in many different practice settings, affecting approximately one third of individuals at some point during their lifetime, but many people in the United States are unaware of the possible causes and appropriate treatment of hoarseness. Although most patients with hoarseness have benign, self-limiting conditions, persistent hoarseness may be a warning signal of underlying cancer.

A multidisciplinary panel convened by the AAO-HNSF developed a practical clinical guideline for management of hoarseness, targeting consumers as well as all clinicians who are likely to diagnose and treat patients with hoarseness. Dysphonia, or hoarseness, is characterized by altered vocal quality, pitch, volume, or vocal effort that hinders communication or decreases voice-related quality of life.


Study Highlights

The history and physical examination of the patient with hoarseness should identify factors that may affect management.
These risk factors may include recent surgery on the neck or in the recurrent laryngeal nerve territory, recent endotracheal intubation, neck radiation therapy, history of tobacco abuse, and occupation as a singer or vocal performer.
Although most causes of hoarseness are benign or self-limiting conditions, laryngeal tumor or other serious underlying condition should be ruled out, as well as adverse effects of medication.
The examining physician or consultant should perform laryngoscopy in the office to visualize the larynx if hoarseness persists for more than 3 months or if the underlying cause is not easily diagnosed or is thought to be serious.
Laryngoscopy is considered the primary diagnostic modality for hoarseness and should be done before any other imaging procedures.
Imaging studies, such as computed tomography or magnetic resonance imaging scans, should not be done before the larynx is visualized with laryngoscopy in patients whose primary complaint is hoarseness.
Unless there are signs or symptoms of significant gastroesophageal reflux disease, hoarseness should not be treated with antireflux medications. These may be prescribed when laryngoscopy suggests chronic laryngitis.
The clinician should not routinely prescribe antibiotics or oral corticosteroids to treat hoarseness.
Voice therapy is recommended for patients of all ages diagnosed with hoarseness that decreases voice-related quality of life.
Laryngoscopy should be performed before voice therapy is started, and the speech-language pathologist should be informed of the findings.
The usual regimen for voice therapy is 1 to 2 sessions per week for 4 to 8 weeks.
Most causes of hoarseness do not require surgery, but it may be indicated for suspected cancer, other tumors or growths, abnormal vocal cord movement, or abnormal vocal cord muscle tone.
For hoarseness caused by adductor spasmodic dysphonia, the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections.

Clinical Implications

Although most causes of hoarseness are benign or self-limiting conditions, laryngeal tumor or other serious underlying condition should be ruled out, as well as adverse effects from medication. Laryngoscopy is considered the primary diagnostic modality for hoarseness and should be done before any other imaging procedures.
Unless there are signs or symptoms of significant gastroesophageal reflux disease, or chronic laryngitis, hoarseness should not be treated with antireflux medications. Antibiotics or oral corticosteroids are not routinely recommended. Voice therapy is recommended for patients of all ages diagnosed with hoarseness that decreases voice-related quality of life.

http://cme.medscape.com/viewarticle/708571?sssdmh=dm1.526917&src=nldne&uac=71630FV

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