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