Dysphonia Hoarseness Guideline

OtolaryngologyndashHead and Neck Surgery (2009) 141 S1-S31

GUIDELINE

Clinical practice guideline Hoarseness (Dysphonia)

Seth R Schwartz MD MPH Seth M Cohen MD MPHSeth H Dailey MD Richard M Rosenfeld MD MPHEllen S Deutsch MD M Boyd Gillespie MDEvelyn Granieri MD MPH MEd Edie R Hapner PhD C Eve Kimball MDHelene J Krouse PhD RN ANP-BC J Scott McMurray MDSafdar Medina MD Karen OrsquoBrien MD Daniel R Ouellette MDBarbara J Messinger-Rapport MD PhD Robert J Stachler MDSteven Strode MD MEd MPH Dana M Thompson MDJoseph C Stemple PhD J Paul Willging MD Terrie CowleyScott McCoy DMA Peter G Bernad MD MPH and Milesh M Patel MSSeattle WA Durham NC Madison WI Brooklyn NY Wilmington DE CharlestonSC New York NY Atlanta GA Reading PA Detroit MI Uxbridge MAFort Monroe VA Cleveland OH Little Rock AR Rochester MN Lexington KY

Cincinnati OH Milwaukee WI Princeton NJ Washington DC and Alexandria VA

Sponsorships or competing interests that may be relevant to con-tent are disclosed at the end of this article

ABSTRACT

OBJECTIVE This guideline provides evidence-based recom-mendations on managing hoarseness (dysphonia) defined as adisorder characterized by altered vocal quality pitch loudness orvocal effort that impairs communication or reduces voice-relatedquality of life (QOL) Hoarseness affects nearly one-third of thepopulation at some point in their lives This guideline applies to allage groups evaluated in a setting where hoarseness would beidentified or managed It is intended for all clinicians who arelikely to diagnose and manage patients with hoarsenessPURPOSE The primary purpose of this guideline is to improvediagnostic accuracy for hoarseness (dysphonia) reduce inappropriateantibiotic use reduce inappropriate steroid use reduce inappropriateuse of anti-reflux medications reduce inappropriate use of radio-graphic imaging and promote appropriate use of laryngoscopy voicetherapy and surgery In creating this guideline the American Acad-emy of OtolaryngologymdashHead and Neck Surgery Foundation se-lected a panel representing the fields of neurology speech-languagepathology professional voice teaching family medicine pulmonol-ogy geriatric medicine nursing internal medicine otolaryngologyndashhead and neck surgery pediatrics and consumersRESULTS The panel made strong recommendations that 1) theclinician should not routinely prescribe antibiotics to treat hoarse-ness and 2) the clinician should advocate voice therapy for patientsdiagnosed with hoarseness that reduces voice-related QOL The

Received June 26 2009 accepted June 26 2009

0194-5998$3600 copy 2009 American Academy of OtolaryngologyndashHead and Necdoi101016jotohns200906744

panel made recommendations that 1) the clinician should diagnosehoarseness (dysphonia) in a patient with altered voice qualitypitch loudness or vocal effort that impairs communication orreduces voice-related QOL 2) the clinician should assess thepatient with hoarseness by history andor physical examination forfactors that modify management such as one or more of thefollowing recent surgical procedures involving the neck or affect-ing the recurrent laryngeal nerve recent endotracheal intubationradiation treatment to the neck a history of tobacco abuse andoccupation as a singer or vocal performer 3) the clinician shouldvisualize the patientrsquos larynx or refer the patient to a clinician whocan visualize the larynx when hoarseness fails to resolve by amaximum of three months after onset or irrespective of durationif a serious underlying cause is suspected 4) the clinician shouldnot obtain computed tomography or magnetic resonance imagingof the patient with a primary complaint of hoarseness prior tovisualizing the larynx 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs orsymptoms of gastroesophageal reflux disease 6) the clinicianshould not routinely prescribe oral corticosteroids to treat hoarse-ness 7) the clinician should visualize the larynx before prescribingvoice therapy and documentcommunicate the results to thespeech-language pathologist and 8) the clinician should prescribeor refer the patient to a clinician who can prescribe botulinumtoxin injections for the treatment of hoarseness caused by adductorspasmodic dysphonia The panel offered as options that 1) theclinician may perform laryngoscopy at any time in a patient withhoarseness or may refer the patient to a clinician who can visu-alize the larynx 2) the clinician may prescribe anti-reflux medi-

k Surgery Foundation All rights reserved

S2 OtolaryngologyndashHead and Neck Surgery Vol 141 No 3S2 September 2009

cation for patients with hoarseness and signs of chronic laryngitisand 3) the clinician may educatecounsel patients with hoarsenessabout controlpreventive measuresDISCLAIMER This clinical practice guideline is not intendedas 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 isnot intended to replace clinical judgment or establish a protocol forall individuals with this condition and may not provide the onlyappropriate approach to diagnosing and managing this problem

copy 2009 American Academy of OtolaryngologyndashHead and NeckSurgery Foundation All rights reserved

Nearly one-third of the population has impaired voiceproduction at some point in their lives12 Hoarse-

ness is more prevalent in certain groups such as teachersand older adults but all age groups and both genders can beaffected1-6 In addition to the impact on health and quality oflife (QOL)78 hoarseness leads to frequent health care visitsand several billion dollars in lost productivity annually fromwork absenteeism9 Hoarseness is often caused by benign orself-limited conditions but may also be the presentingsymptom of a more serious or progressive condition requir-ing prompt diagnosis and management

The terms hoarseness and dysphonia are often used in-terchangeably although hoarseness is a symptom of alteredvoice quality and dysphonia is a diagnosis Dysphonia maybe broadly defined as an alteration in the production ofvoice that impairs social and professional communicationIn contrast hoarseness is a coarse or rough quality to thevoice Although the two terms are not synonymous theguideline working group decided to use the term hoarsenessfor this guideline because it is more recognized and under-stood by patients most clinicians and the lay press

The target patient for this guideline is anyone presentingwith hoarseness (dysphonia)

Hoarseness (dysphonia) is defined as a disorder charac-terized by altered vocal quality pitch loudness or vocaleffort that impairs communication or reduces voice-re-lated QOL

Impaired communication is defined as a decreased orlimited ability to interact vocally with others

Reduced voice-related QOL is defined as a self-perceiveddecrement in physical emotional social or economicstatus as a result of voice-related dysfunction

This working definition developed by the guidelinepanel assumes that hoarseness affects people differentlySome individuals may have altered voice quality vocaleffort pitch or loudness others may experience problemswith communication and diminished voice-related QOL

The guideline is intended for all clinicians who are likelyto diagnose and manage patients with hoarseness and ap-plies to any setting in which hoarseness would be identifiedmonitored treated or managed The guideline does notapply to patients with hoarseness with the following condi-

tions history of laryngectomy (total or partial) craniofacial

anomalies velopharyngeal insufficiency and dysarthria(impaired articulation) However the guideline will discussthe relevance of these conditions in managing patients withhoarseness

There are a number of patients with modifying factorsfor whom many of the recommendations of the guidelinemay not apply There is some discussion of these factors andhow they might modify management A partial list includesprior laryngeal surgery recent surgical procedures involv-ing the neck or affecting the recurrent laryngeal nerverecent endotracheal intubation radiation treatment to theneck and patients who are singers or performers

GUIDELINE PURPOSE

The primary purpose of this guideline is to improve thequality of care for patients with hoarseness based on currentbest evidence Expert consensus to fill evidence gaps whenused is explicitly stated and is supported with a detailedevidence profile for transparency Specific objectives of theguideline are to reduce inappropriate variations in careproduce optimal health outcomes and minimize harm

The guideline is intended to focus on a limited number ofquality improvement opportunities deemed most importantby the working group and is not intended to be a compre-hensive general guide for managing patients with hoarse-ness In this context the purpose is to define actions thatcould be taken by clinicians regardless of discipline todeliver quality care Conversely the statements in thisguideline are not intended to limit or restrict care providedby clinicians based on assessment of individual patients

While there is evidence to guide management of certaincauses of hoarseness there are currently no evidence-basedclinical practice guidelines There are variations in the useof the laser voice therapy steroids and postoperative voicerest and in the treatment of reflux-related laryngitis10-13

Differences in training preference and resource availabilityinfluence management decisions A guideline is necessarygiven this practice variation and the significant public healthburden of hoarseness

This guideline addresses the identification diagnosistreatment and prevention of hoarseness (dysphonia) (Table1) In addition it highlights needs and management optionsin special populations or in patients who have modifyingfactors Furthermore this guideline is intended to enhancethe accurate diagnosis of hoarseness (dysphonia) promoteappropriate intervention in patients with hoarseness high-light the need for evaluation and intervention in specialpopulations promote appropriate therapeutic options withoutcomes assessment and improve counseling and educa-tion for prevention and management of hoarseness Thisguideline may also be suitable for deriving a performance

measure on hoarseness

S3Schwartz et al Clinical practice guideline Hoarseness (Dysphonia)

BURDEN OF HOARSENESS

Hoarseness has a lifetime prevalence of 299 percent (per-centage of people affected at some point in their life) and apoint prevalence of 66 percent (percent of people affectedat a given point in time) in adults aged 65 years or under1

Other cross-sectional studies have found a similar highlifetime prevalence of voice complaints of 288 percent inthe general population2 Higher prevalence rates of hoarse-ness have been shown in telemarketers (31)4 aerobicsinstructors (44)5 and teachers (58)26 Women are morefrequently affected than men with a 6040 FM ratio1314

Hoarseness may affect all age groups Among childrenprevalence rates vary from 39 percent to 234 percent15-17

with the most affected age range of 8 to 14 years18 Voiceproblems persist four years or longer after identification in38 percent of children with a voice disorder suggesting anopportunity for early intervention19 In addition olderadults are also at particular risk3 with a point prevalence of29 percent20 and a lifetime incidence up to 47 percent2021

Hoarseness has significant public health implicationsPatients suffer social isolation depression and reduced dis-ease-specific and general QOL182223 For example pa-tients with hoarseness caused by neurologic disorders (Par-kinson disease spasmodic dysphonia vocal tremor orvocal fold paralysis) reported severe levels of voice handi-cap and reduced general health-related QOL comparable toimpairments observed in patients with congestive heart fail-ure angina and chronic obstructive pulmonary disease78

Hoarseness may also impair work-related functionApproximately 28 million US workers have occupationsthat require use of voice9 In the general population 72percent of individuals surveyed missed work for one ormore days within the preceding year because of a problem

1

Table 1

Interventions considered in hoarseness guideline

development

Diagnosis Targeted historyPhysical examinationLaryngoscopyStroboscopyComputed tomography (CT)Magnetic resonance imaging (MRI)

Treatment Watchful waitingobservationEducationinformationVoice therapyAnti-reflux medicationsAntibioticsSteroidsSurgeryBotulinum toxin (BOTOX)

Prevention Voice trainingVocal hygieneEducationEnvironmental measures

with their voice Among teachers this rate increases to 20

percent614 resulting in a $25 billion loss among US adultsbecause of missed work annually9

Medical surgical and behavioral treatment options existfor managing hoarseness Among the general populationhowever only 59 percent of those with hoarseness soughttreatment1 Similarly only 143 percent of teachers hadconsulted a physician or speech-language pathologist forhoarseness even though voice function is essential to theirprofession2 In some circumstances complete resolution ofhoarseness may not be achieved and the clinicianrsquos respon-sibilities will include minimizing hoarseness and optimizingpatient function as well as assisting the patient in develop-ing understanding and realistic expectations

Lack of awareness about hoarseness and its causes arepotential barriers to appropriate care Among older adultsindividuals commonly attribute their hoarseness to advanc-ing age Such assumptions may prevent or delay those withhoarseness from obtaining treatment Improved educationamong all health professionals24 and efficient medical careare essential for reducing the health burden of hoarseness25

Inadequate insurance coverage has been cited as a cause offailure to seek treatment for both functional voice problemsas seen in singers25 and life-threatening ones as seen incancer patients26

The primary outcomes considered in this guideline areimprovement in vocal function and change in voice-relatedQOL Secondary outcomes include complications and ad-verse events Economic consequences adherence to ther-apy global QOL return to work improved communicationfunction and return health care visits were also consideredThe high prevalence significant individual and societal im-plications diversity of interventions and lack of consensusmake this an important condition for an up-to-date evi-dence-based practice guideline

GENERAL METHODS AND LITERATURE

SEARCH

The guideline was developed using an explicit and trans-parent a priori protocol for creating actionable statementsbased on supporting evidence and the associated balanceof benefit and harm2728 The multidisciplinary guidelinedevelopment panel was chosen to represent the fields ofneurology speech-language pathology professional voiceteaching family medicine pulmonology geriatric medi-cine nursing internal medicine otolaryngologyndashhead andneck surgery pediatric medicine and consumers Severalgroup members had significant prior experience in develop-ing clinical practice guidelines

Several initial literature searches were performedthrough November 17 2008 by AAO-HNSF staff usingMEDLINE The National Guidelines Clearinghouse (NGC)(wwwguidelinegov) The Cochrane Library GuidelinesInternational Network (GIN) The Cumulative Index to

Nursing and Allied Health Literature (CINAHL) and


EMBASE The initial broad MEDLINE search using ldquohoarse-ness[mh]rdquo or ldquodysphonia[tw]rdquo or ldquovoice disorders[mh]rdquo inany field showed 6032 potential articles

1) Clinical practice guidelines were identified by a GINNGC and MEDLINE search using ldquoguidelinerdquo as apublication type or title word The search identified eightguidelines with a topic of hoarseness or dysphonia Aftereliminating articles that did not have hoarseness or dys-phonia as the primary focus no guidelines met qualitycriteria of being produced under the auspices of a med-ical association or organization and having an explicitmethod for ranking evidence and linking evidence torecommendations

2) Systematic reviews were identified in MEDLINE using avalidated filter strategy29 That strategy initially yielded92 potential articles The final data set included 14 sys-tematic reviews or meta-analyses (including two Co-chrane systematic reviews) on hoarseness or dysphoniathat were distributed to the panel members

3) Randomized controlled trials were identified through theCochrane Library (Cochrane Controlled Trials Register)and totaled 256 trials with ldquohoarsenessrdquo or ldquodysphoniardquoin any field

4) Original research studies were identified by limiting theMEDLINE CINAHL and EMBASE search to articleson humans published in English The resulting data setof 769 articles yielded 262 related to therapy 256 todiagnosis 205 to etiology and 46 to prognosis

Results of all literature searches were distributed toguideline panel members at the first meeting includingelectronic listings with abstracts (if available) of thesearches for randomized trials systematic reviews andother studies This material was supplemented as neededwith targeted searches to address specific needs identified inwriting the guideline through February 8 2009

In a series of conference calls the working group definedthe scope and objectives of the proposed guideline Duringthe nine months devoted to guideline development ending in2009 the group met twice with interval electronic reviewand feedback on each guideline draft to ensure accuracy ofcontent and consistency with standardized criteria for re-porting clinical practice guidelines30

AAO-HNSF staff used GEM-COGS31 the GuidelineImplementability Appraisal and Extractor to appraise ad-herence of the draft guideline to methodological standardsto improve clarity of recommendations and to predict po-tential obstacles to implementation Guideline panel mem-bers received summary appraisals in April 2009 and mod-ified an advanced draft of the guideline

The final draft practice guideline underwent extensivemultidisciplinary external peer review Comments werecompiled and reviewed by the group chairpersons and amodified version of the guideline was distributed and ap-proved by the development panel The recommendations

contained in the practice guideline are based on the best

available published data through February 2009 Wheredata were lacking a combination of clinical experience andexpert consensus was used A scheduled review process willoccur at five years from publication or sooner if new com-pelling evidence warrants earlier consideration

Classification of Evidence-Based StatementsGuidelines are intended to reduce inappropriate variationsin clinical care to produce optimal health outcomes forpatients and to minimize harm The evidence-based ap-proach to guideline development requires that the evidencesupporting a policy be identified appraised and summa-rized and that an explicit link between evidence and state-ments be defined Evidence-based statements reflect boththe quality of evidence and the balance of benefit and harmthat is anticipated when the statement is followed Thedefinitions for evidence-based statements32 are listed inTables 2 and 3

Guidelines are never intended to supersede professionaljudgment rather they may be viewed as a relative con-straint on individual clinician discretion in a particular clin-ical circumstance Less frequent variation in practice isexpected for a ldquostrong recommendationrdquo than might beexpected with a ldquorecommendationrdquo ldquoOptionsrdquo offer themost opportunity for practice variability33 Cliniciansshould always act and decide in a way that they believe willbest serve their patientsrsquo interests and needs regardless ofguideline recommendations They must also operate withintheir scope of practice and according to their trainingGuidelines represent the best judgment of a team of expe-rienced clinicians and methodologists addressing the scien-tific evidence for a particular topic32

Making recommendations about health practices in-volves value judgments on the desirability of various out-comes associated with management options Values appliedby the guideline panel sought to minimize harm and dimin-ish unnecessary and inappropriate therapy A major goal ofthe committee was to be transparent and explicit about howvalues were applied and to document the process

Financial Disclosure and Conflicts of InterestThe cost of developing this guideline including travel ex-penses of all panel members was covered in full by theAAO-HNS Foundation Potential conflicts of interest for allpanel members in the past five years were compiled anddistributed before the first conference call After review anddiscussion of these disclosures34 the panel concluded thatindividuals with potential conflicts could remain on thepanel if they 1) reminded the panel of potential conflictsbefore any related discussion 2) recused themselves from arelated discussion if asked by the panel and 3) agreed not todiscuss any aspect of the guideline with industry beforepublication Lastly panelists were reminded that conflicts ofinterest extend beyond financial relationships and may in-clude personal experiences how a participant earns a livingand the participantrsquos previously established ldquostakerdquo in an

35

issue


HOARSENESS (DYSPHONIA) GUIDELINE

ACTION STATEMENTS

Each action statement is organized in a similar fashionstatement in boldface type followed by an italicized state-ment on the strength of the recommendation Several para-graphs then discuss the evidence base supporting the state-ment concluding with an ldquoevidence profilerdquo of aggregateevidence quality benefit-harm assessment and statement ofcosts Lastly there is an explicit statement of the valuejudgments the role of patient preferences and a repeatstatement of the strength of the recommendation An over-view of evidence-based statements in the guideline and theirinterrelationship is shown in Table 4

The role of patient preference in making decisions de-serves further clarification For some statements the evi-dence base demonstrates clear benefit which would mini-mize the role of patient preference If the evidence is weakor benefits are unclear however not all informed patientsmight opt to follow the suggestion In these cases thepractice of shared decision making where the managementdecision is made by a collaborative effort between the

Table 2

Guideline definitions for evidence-based statements

Statement Definition

Strong recommendation A strong recommendation mof the recommended apprexceed the harms (or thatexceed the benefits in thenegative recommendationquality of the supporting eexcellent (Grade A or B)identified circumstances srecommendations may belesser evidence when highis impossible to obtain anbenefits strongly outweigh

Recommendation A recommendation means texceed the harms (or thatthe benefits in the case orecommendation) but theevidence is not as strongIn some clearly identifiedrecommendations may belesser evidence when highis impossible to obtain anbenefits outweigh the har

Option An option means either thaevidence that exists is susor that well-done studiesC) show little clear advanapproach vs another

See Table 3 for definition of evidence grades

clinician and the informed patient becomes more useful

Factors related to patient preference include (but are notlimited to) absolute benefits (number needed to treat) ad-verse effects (number needed to harm) cost of drugs ortests frequency and duration of treatment and desire to takeor avoid antibiotics Comorbidity can also impact patientpreferences by several mechanisms including the potentialfor drug-drug interactions when planning therapy

STATEMENT 1 DIAGNOSIS Clinicians should diag-nose hoarseness (dysphonia) in a patient with alteredvoice quality pitch loudness or vocal effort that im-pairs communication or reduces voice-related QOLRecommendation based on observational studies with apreponderance of benefit over harm

Supporting TextThe purpose of this statement is to promote awareness ofhoarseness (dysphonia) by all clinicians as a condition thatmay require intervention or additional investigation Theproposed diagnosis (dysphonia) is based on strictly clinicalcriteria and does not require testing or additional investi-gations Hoarseness is a symptom reported by the patient or

Implication

the benefitsclearlyarms clearlyof a strongthat thece is

me clearly

e based onity evidenceanticipatedharms

Clinicians should follow a strongrecommendation unless a clear andcompelling rationale for analternative approach is present

nefitsarms exceedgativety ofe B or C)

stancese based onity evidenceanticipated

Clinicians should also generally followa recommendation but shouldremain alert to new information andsensitive to patient preferences

uality ofGrade D)

e A B orto one

Clinicians should be flexible in theirdecision making regardingappropriate practice although theymay set bounds on alternativespatient preference should have asubstantial influencing role

eansoachthe hcase

) andvidenIn sotrongmad-qual

d thethe

he bethe h

f a nequali

(Gradcircummad-qual

d themst the qpect (

(Gradtage

proxy identified by the clinician or both


Some patients with objectively minor changes may beunable to work and have a significant decrement in QOLOthers with significant disease such as malignancy mayhave minimal functional impairment of their voice Of pa-tients with laryngeal cancer 52 percent thought theirhoarseness was harmless and delayed seeing a physician36

Accordingly patients with minimal objective voice changeand significant complaints as well as patients with limited

Table 3

Evidence quality for grades of evidence

Grade Evidence quality

A Well-designed randomized controlled trialsor diagnostic studies performed on apopulation similar to the guidelinersquostarget population

B Randomized controlled trials or diagnosticstudies with minor limitationsoverwhelmingly consistent evidencefrom observational studies

C Observational studies (case-control andcohort design)

D Expert opinion case reports reasoningfrom first principles (bench research oranimal studies)

X Exceptional situations where validatingstudies cannot be performed and thereis a clear preponderance of benefit overharm

Table 4

Outline of guideline action statements

Hoarseness (dysphonia) (statement number)

I Diagnosisa Diagnosis (Statement 1)b Modifying factors (Statement 2)c Laryngoscopy and hoarseness (Statement 3A)d Indications for laryngoscopy

(Statement 3B)e Imaging prior to laryngoscopy (Statement 4)

II Medical therapya Anti-reflux therapy for hoarseness in the absence

or chronic laryngitis (Statement 5A)b Anti-reflux therapy with chronic laryngitis (Statemc Corticosteroid therapy (Statement 6)d Antimicrobial therapy (Statement 7)

III Voice therapya Laryngoscopy prior to beginning (Statement 8A)b Advocating for

(Statement 8B)IV Invasive therapies

a Advocating surgery in selected patients (Statemenb Botulinum toxin for adductor spasmodic dysphon

(Statement 10)V Prevention (Statement 11)

complaints but with objective alterations of voice qualitywarrant evaluation

Patients with hoarseness may experience discomfort withspeaking increased phonatory effort and weak voice aswell as altered quality such as wobbly or shaky voicebreathiness and raspiness203738 While a breathy voicemay signify vocal fold paralysis or another cause of incom-plete vocal fold closure a strained voice with altered pitchor pitch breaks is common in spasmodic dysphonia39

Changes in voice quality may be limited to the singing voiceand not affect the speaking voice Among infants and youngchildren an abnormal cry may signify underlying pathologyincluding vocal fold paralysis laryngeal papilloma or othersystemic conditions

Listening to the voice (perceptual evaluation) in a criticaland objective manner may provide important diagnosticinformation Characterizing the patientrsquos complaint andvoice quality is important for assessing hoarseness severityand for differentiating among specific causes of hoarsenesssuch as muscle tension dysphonia and spasmodic dyspho-nia4041

Hoarseness may impair communication Difficulty beingheard and understood while using the telephone has beenreported in the geriatric population2038 Trouble beingheard in groups and problems being understood are alsocommon complaints among hoarse patients37 Conse-quently patients describe less confidence decreased social-ization and impaired work-related function137

Hoarseness may lead to decreased voice-related QOLand a decrement in physical social and emotional aspects

Statement strength

RecommendationRecommendationOptionRecommendation

Recommendation against

RD Recommendation against

) OptionRecommendation againstStrong recommendation against

RecommendationStrong recommendation

RecommendationRecommendation

Option

of GE

ent 5B

t 9)ia


of global QOL similar to those associated with other chronicdiseases such as congestive heart failure and chronic ob-structive pulmonary disease78

Clinicians should consider input from proxies when di-agnosing hoarseness (dysphonia) Of patients with vocalfold cancer 40 percent waited three months before seekingmedical attention for their hoarseness Furthermore 167percent only sought treatment after encouragement fromother people36 These data highlight the fact that hoarsenessmay not be recognized by the patient

Children and patients with cognitive impairment or se-vere emotional burden may be unaware or unable to recog-nize and report on their own hoarseness42 QOL studies inolder adults have required proxy input in approximately 25percent of the geriatric population43 While self-report mea-sures for hoarseness are available patients may be unable tocomplete them44-46 In these cases proxy judgments bysignificant others about QOL are a good alternative42 Mod-erate agreement has been shown between adult patients andtheir communication partners on the Voice Handicap IndexParent proxy self-report measures have also been validatedfor use in the pediatric population3847

When evaluating a patient with hoarseness the clini-cian should obtain a detailed medical history (Table 5)and review current medications (Table 6) as this infor-mation may identify the cause of the hoarseness (dyspho-nia) or an alternative underlying condition that may war-rant attention

Evidence profile for Statement 1 Diagnosis

Aggregate evidence quality Grade C observational stud-

Table 5

continued

Allergic rhinitisChronic rhinitisHypertension (because of certain medications used

for this condition)Schizophrenia (because of anti-psychotics used for

mental health problems)Osteoporosis (because of certain medications used

for this condition)Asthma chronic obstructive pulmonary disease

(because of use of inhaled steroids)Aneurysm of thoracic aorta (rare cause)Laryngeal cancerLung cancer (or metastasis to the lung)Thyroid cancerHypothyroidism and other endocrinopathiesVocal fold nodulesVocal fold paralysisVocal abuseChemical laryngitisChronic tobacco useSjoumlgren syndromeAlcohol (moderate to heavy use or abuse)

Table 5

Pertinent medical history for assessing a patient

with hoarseness48-50

Voice-specific questionsDid your problem start suddenly or graduallyIs your voice ever normalDo you have pain when talkingDoes your voice deteriorate or fatigue with useDoes it take more effort to use your voiceWhat is different about the sound of your voiceDo you have a difficult time getting loud or

projectingHave you noticed changes in your pitch or rangeDo you run out of air when talkingDoes your voice crack or break

SymptomsGlobus pharyngeus (persisting sensation of lump

in throat)DysphagiaSore throatChronic throat clearingCoughOdynophagia (pain with swallowing)Nasal drainagePost-nasal drainageNon-anginal chest painAcid refluxRegurgitationHeartburnWaterbrash (sudden appearance of salty liquid in

the mouth)Halitosis (ldquobad breathrdquo)FeverHemoptysisWeight lossNight sweatsOtalgia (ear pain)Difficulty breathing

Medical history relevant to hoarsenessOccupation andor avocation requiring extensive

voice use (ie teacher singer)Absenteeism from occupation due to hoarsenessPrior episode(s) of hoarsenessRelationship of instrumentation (intubation etc) to

onset of hoarsenessRelationship of prior surgery to neck or chest to

onset of hoarsenessCognitive impairment (requirement for proxy

historian)Anxiety

Acute conditionsInfection of the throat andor larynx viral

bacterial fungalForeign body in larynx trachea or esophagusNeck or laryngeal trauma

Chronic conditionsStrokeDiabetesParkinsonrsquos diseaseDiseases from the Parkinsonrsquos Plus family

(progressive supranuclear palsy etc)Myasthenia gravisMultiple sclerosisAmyotrophic lateral sclerosis (ALS)Testosterone deficiency

ies for symptoms with one systematic review of QOL in


voice disorders and two systematic reviews on medica-tion side effects

Benefit Identify patients who may benefit from treatmentor from further investigation to identify underlying con-ditions that may be serious promote prompt recognitionand treatment and discourage the perception of hoarse-ness as a trivial condition that does not warrant attention

Harm Potential anxiety related to diagnosis Cost Time expended in diagnosis documentation and

discussion Benefits-harm assessment Preponderance of benefits

over harm Value judgments None Role of patient preference Limited Intentional vagueness None Exclusions None Policy Level Recommendation

STATEMENT 2 MODIFYING FACTORS Cliniciansshould assess the patient with hoarseness by historyandor physical examination for factors that modifymanagement such as one or more of the following re-cent surgical procedures involving the neck or affectingthe recurrent laryngeal nerve recent endotracheal intu-bation radiation treatment to the neck a history oftobacco abuse and occupation as a singer or vocal per-former Recommendation based on observational studieswith a preponderance of benefit over harm

Supporting TextThe term ldquomodifying factorsrdquo as used in this recommenda-tion refers to details elicited by history taking or physicalexamination that provide a clue to the presence of an im-

Table 6

Medications that may cause hoarseness

MedicationMechanism of impact

on voice

Coumadin thrombolyticsphosphodiesterase-5inhibitors

Vocal fold hematoma51-53

Biphosphonates Chemical laryngitis54

Angiotensin-convertingenzyme inhibitors

Cough55

Antihistamines diureticsanticholinergics

Drying effect onmucosa5657

Danocrine testosterone Sex hormone productionutilization alteration5859

Antipsychotics atypicalantipsychotics

Laryngeal dystonia6061

Inhaled steroids Dose-dependent mucosalirritation62 fungallaryngitis

portant underlying etiology of hoarseness (dysphonia) that

may lead to a change in management The history andphysical examination of the patient with hoarseness mayprovide insight into the nature of the patientrsquos conditionprior to the initiation of a more in-depth evaluation

Surgery on the cervical spine via an anterior approachhas been associated with a high incidence of voice prob-lems Recurrent laryngeal nerve paralysis has been reportedto range from 127 percent to 27 percent63-65 Assessmentwith laryngoscopy suggests an even higher incidence66 Theincidence of hoarseness immediately following anterior cer-vical spine surgery may be as high as 50 percent67 Hoarse-ness resulting from anterior cervical spine surgery may ormay not resolve over time6869

Thyroid surgery has been associated with voice disor-ders Patients with thyroid disease requiring surgery mayhave hoarseness and identifiable abnormalities on indirectlaryngoscopy prior to surgery70 Thyroidectomy may causehoarseness as a result of recurrent laryngeal nerve paralysisin up to 21 percent of patients71 Surgery in the anteriorneck can also lead to injury to the superior laryngeal nervewith resulting voice alteration although this is uncom-mon72

Carotid endarterectomy is frequently associated withpostoperative voice problems73 and may result in recurrentlaryngeal nerve damage in up to 6 percent of patients7475

Surgery to achieve an urgent airway or on the larynx directlymay alter its structure resulting in abnormal voice7677

Surgical procedures not involving the neck may alsoresult in hoarseness (dysphonia) Hoarseness following car-diac surgery is a common problem occurring in 17 percentto 31 percent of patients7879 Hoarseness may result fromchanges in position or manipulation of the endotracheal tubeor from lengthy procedures78 Recurrent laryngeal nerveinjury occurs in about 14 percent of patients during cardiacsurgery78 The left recurrent laryngeal nerve is damagedmore commonly than the right as it extends into the chestand loops under the arch of the aorta Damage may resultfrom direct physical injury to the nerve or hypothermicinjury due to cold cardioplegia80

Surgery for esophageal cancer frequently results in dam-age to the recurrent laryngeal nerve with subsequent hoarse-ness In one study 51 of 141 patients undergoing esopha-gectomy for cancer had laryngeal nerve paralysis with 30 ofthese patients having persistent paralysis one year followingsurgery81 The implantation of vagal nerve stimulators forintractable seizures has been associated with hoarseness inas many as 28 percent of patients82

Prolonged endotracheal intubation has been associatedwith hoarseness Direct laryngoscopy of patients intubatedfor more than four days (mean nine days) demonstrates that94 percent of patients have laryngeal injury83 The injurypatterns seen in the patients with prolonged intubation in-clude laryngeal edema and posterior and medial vocal foldulceration As many as 44 percent of patients with pro-longed intubation may develop vocal fold granulomas

within four weeks of being extubated In this study 18


percent of patients had prolonged true vocal fold immobilityfor at least four weeks after extubation84 Another studyfollowing a large group of patients for several years foundchronic phonatory dysfunction in many patients after long-term intubation85

Short-term intubation for general anesthesia may resultin hoarseness and vocal fold pathology in over 50 percent ofcases86 While most symptoms resolved after five daysprolonged symptoms may result from vocal fold granulomaIf hoarseness persists the remoteness of the index eventmay confound the evaluating clinician Use of a laryngealmask airway may reduce postsurgical complaints of dis-comfort but does not objectively reduce hoarseness87

Long-term intubation of neonates may result in voiceproblems related to arytenoid and posterior commissureulceration and cartilage erosion88 Children with a history ofprolonged intubation may have long-term complications ofhoarseness and arytenoid dysfunction

Voice disorders are common in older adults and signif-icantly affect the QOL in these patients21 Vocal fold atro-phy with resulting hoarseness (dysphonia) is a commondisorder of older adults and is frequently undiagnosed byprimary care providers8990 Hoarseness resulting from neu-rologic disorders such as cerebral vascular accident andParkinson disease is also more common in elderly pa-tients91-94 Multiple sclerosis can lead to hoarseness in pa-tients of any age95

Chronic hoarseness (dysphonia) is quite common inyoung children and has an adverse impact on QOL96 Prev-alence ranges from 15 percent to 24 percent of the popula-tion1797 In one study 77 percent of hoarse children hadvocal fold nodules17 These may persist into adolescence ifnot properly treated98 Craniofacial anomalies such as oro-facial clefts are associated with abnormal voice99 but theseare frequently resonance disorders requiring very differenttherapies than for hoarse children with normal anatomicaldevelopment

Hoarseness or dysphonia in infants may be recognizedonly by an abnormal cry and suspicion of such symptomsshould prompt consultation with an otolaryngologist100

When infants do present with hoarseness underlying etiol-ogies such as birth trauma an intracranial process such asArnold-Chiari malformation or posterior fossa mass or me-diastinal pathology should be considered101

Hoarseness in tobacco smokers is associated with anincreased frequency of polypoid vocal fold lesions and headand neck cancer102 Accordingly this requires an expedientassessment for malignancy as the potential cause of hoarse-ness In addition in patients treated with external beamradiation for glottic cancer radiation treatment is associatedwith hoarseness in about 8 percent of cases103104

Patients who use inhaled corticosteroids for the treatmentof asthma or chronic obstructive pulmonary disease maypresent to a clinician with hoarseness that is a side effect oftherapy either from direct irritation or from a fungal infec-

105

tion of the larynx

Singers or vocal performers should be identified by theclinician when eliciting a history from the hoarse patientThese patients have significant impairment with symptomsthat may be subclinical in other patients They may be moresubject to voice over-use or have a different etiology fortheir symptoms and hoarseness may have a more significantimpact on their QOL or ability to earn income For examplewhile hoarseness is relatively rare following thyroid sur-gery there are objective measurable changes in the voice ofmost patients that could affect pitch and the ability tosing106 Singers are also prone to develop microvascularectasias that affect voice and require specific therapy107

To a slightly lesser degree individuals in a number ofother occupations or avocations such as teachers andclergy depend on voice use As an example over 50 percentof teachers have hoarseness and vocal overuse is a com-mon but not exclusive etiologic factor108 Cliniciansshould inquire about an individualrsquos voice use in order todetermine the degree to which altered voice quality mayimpact the individual professionally

Evidence profile for Statement 2 Modifying Factors

Aggregate evidence quality Grade C observationalstudies

Benefit To identify factors early in the course of man-agement that could influence the timing of diagnosticprocedures choice of interventions or provision of fol-low-up care

Harm None Cost None Benefits-harm assessment Preponderance of benefit over

harm Value judgments Importance of history taking and iden-

tifying modifying factors as an essential component ofproviding quality care

Role of patient preferences Limited or none Intentional vagueness None Exclusions None Policy level Recommendation

STATEMENT 3A LARYNGOSCOPY AND HOARSE-NESS Clinicians may perform laryngoscopy or mayrefer the patient to a clinician who can visualize thelarynx at any time in a patient with hoarseness Optionbased on observational studies expert opinion and a bal-ance of benefit and harm

STATEMENT 3B INDICATIONS FOR LARYNGOS-COPY Clinicians should visualize the patientrsquos larynxor refer the patient to a clinician who can visualize thelarynx when hoarseness fails to resolve by a maximumof three months after onset or irrespective of duration ifa serious underlying cause is suspected Recommendationbased on observational studies expert opinion and a pre-

ponderance of benefit over harm


Supporting TextThe purpose of these statements is to highlight the importantrole of visualizing the larynx and vocal folds in managing apatient with hoarseness especially if the hoarseness fails toimprove within three months of onset (Statement 3B) Pa-tients with persistent hoarseness may have a serious under-lying disorder (Table 7) that would not be diagnosed unlessthe larynx was visualized This does not however implythat all patients must wait three months before laryngoscopyis performed because as outlined below early assessmentof some patients with hoarseness may improve manage-ment Therefore clinicians may perform laryngoscopy orrefer to a clinician for laryngoscopy at any time (Statement3A) if deemed appropriate based on the patientrsquos specificclinical presentation and modifying factors

Laryngoscopy and HoarsenessVisualization of the larynx is part of a comprehensive eval-uation for voice disorders While not all clinicians have thetraining and equipment necessary to visualize the larynxthose who do may examine the larynx of a patient present-ing with hoarseness at any time if considered appropriateAlthough most hoarseness is caused by benign or self-limited conditions early identification of some disordersmay increase the likelihood of optimal outcomes

There are a number of conditions where laryngoscopy atthe time of initial assessment allows for timely diagnosisand management Laryngoscopy can be used at the bedsidefor patients with hoarseness after surgery or intubation toidentify vocal fold immobility intubation trauma or othersources of postsurgical hoarseness Laryngoscopy plays acritical role in evaluating laryngeal patency after laryngealtrauma where visualization of the airway allows for assess-ment of the need for surgical intervention and for followingpatients in whom immediate surgery is not required109110

Laryngoscopy is used routinely for diagnosing laryngeal

Table 7

Conditions leading to suspicion of a ldquoserious

underlying causerdquo

Hoarseness with a history of tobacco or alcohol useHoarseness with concomitant discovery of a neck

massHoarseness after traumaHoarseness associated with hemoptysis dysphagia

odynophagia otalgia or airway compromiseHoarseness with accompanying neurologic

symptomsHoarseness with unexplained weight lossHoarseness that is worseningHoarseness in an immunocompromised hostHoarseness and possible aspiration of a foreign bodyHoarseness in a neonateUnresolving hoarseness after surgery (intubation or

neck surgery)

cancer The usefulness of laryngoscopy for establishing the

diagnosis and the benefit of early detection have led theBritish medical system to employ fast-track screening clin-ics for laryngeal cancer that mandate laryngoscopy within14 days of suspicion of laryngeal cancer111112 Fungal lar-yngitis from inhalers and other causes is best diagnosedwith laryngoscopy and must be distinguished from malig-nancy113

Unilateral vocal fold paralysis causes breathy hoarsenessand is often caused by thoracic cervical or brain tumorsthat either compress or invade the vagus nerve or itsbranches that innervate the larynx Stroke may also presentwith hoarseness due to vocal fold paralysis Vocal foldparalysis is routinely identified characterized and followedby laryngoscopy79114

In patients with cranial nerve deficits or neuromuscularchanges laryngoscopy is useful to identify neurologiccauses of vocal dysfunction115 Benign vocal fold lesionssuch as vocal fold cysts nodules and polyps are readilydetected on laryngoscopy Visualization of the larynx mayalso provide supporting evidence in the diagnosis of laryn-gopharyngeal reflux116

Hoarseness caused by neurologic or motor neuron dis-ease such as Parkinson disease amyotrophic lateral sclero-sis and spasmodic dysphonia may have laryngoscopic find-ings that the clinician can identify to initiate management ofthe underlying disease117 Office laryngoscopy is also acritical tool in the evaluation of the aging voice

Neonates with hoarseness should undergo laryngoscopyto identify vocal fold paralysis118 laryngeal webs119 orother congenital anomalies that might affect their ability toswallow or breathe120

Hoarseness in children is rarely a sign of a serious un-derlying condition and is more likely the result of a benignlesion of the larynx such as a vocal fold polyp nodules orcyst121 However determining if laryngeal papilloma is theetiology of hoarseness in a child is particularly importantgiven the high potential for life-threatening airway obstruc-tion and the potential for malignant transformation122 Ahoarse child with other symptoms such as stridor airwayobstruction or dysphagia may have a serious underlyingproblem such as a Chiari malformation123 hydrocephalusskull base tumors or a compressing neck or mediastinalmass Persistent hoarseness in children may be a symptomof vocal fold paralysis with underlying etiologies that in-clude neck masses congenital heart disease or previouscardiothoracic esophageal or neck surgery124

Indications for Laryngoscopy

Laryngoscopy is indicated for the assessment of hoarsenessif symptoms fail to improve or resolve within three monthsor at any time the clinician suspects a serious underlyingdisorder In this context ldquoseriousrdquo describes an etiology thatwould shorten the lifespan of the patient or otherwise reduceprofessional viability or voice-related QOL If the clinicianis concerned that hoarseness may be caused by a serious

underlying condition the optimal way to address this con-


cern is by visualization of the vocal folds with laryngos-copy

The major cause of community-acquired hoarseness isviral Symptoms from viral laryngitis typically last 1 to 3weeks125126 Symptoms of hoarseness persisting beyondthis time warrant further evaluation to insure that no malig-nancy or morbid conditions are missed and to allow furthertreatment to be initiated based on specific benign patholo-gies if indicated One population-based cohort study127 andone large case-control study128 have shown that delays indiagnosis of laryngeal cancer lead to higher stages of dis-ease at diagnosis and worse prognosis In the cohort studydelay longer than three months led to poorer survival

The expediency of laryngoscopy also depends on patientconsiderations Singers performers and patients whoselivelihood depends upon their voice will not be able to waitseveral weeks for their hoarseness to resolve as they may beunable to work in the interim In fact a number of profes-sionals with high vocal demands may benefit from imme-diate evaluation

Even in the absence of serious concern or patient con-siderations indicating immediate laryngoscopy persistenthoarseness should be evaluated to rule out significant pa-thology such as cancer or vocal fold paralysis In the ab-sence of immediate concern there is little guidance from theliterature on the proper length of time a hoarse patient canor should be observed before visualization of the larynx ismandated The working group weighed the risk of delayeddiagnosis against the potential over-utilization of resourcesand selected a fairly long window of three months prior tomandating laryngoscopy This safety net approach based onexpert opinion was designed to address the main concern ofthe working group that many patients with persistenthoarseness are currently experiencing delayed diagnosis orare not undergoing laryngoscopy at all

Techniques for Visualizing the LarynxDifferent techniques are available for laryngoscopy andconfer varying levels of risk The working group does nothave recommendations as to the preferred method Choiceof method is at the discretion of the evaluating clinician

Office laryngoscopy can be performed transorally with amirror or rigid endoscope transnasally with a flexible fi-beroptic or distal-chip laryngoscope and with either halo-gen light or stroboscopic light application129 The surfaceand mobility of the vocal folds are well assessed with thesetools

Stroboscopy is used to visualize the vocal folds as theyvibrate allowing for an assessment of both anatomy andfunction during the act of phonation130 When hoarsenesssymptoms are out of proportion to the laryngoscopic exam-ination stroboscopy should be considered The addition ofstroboscopic light allows for an assessment of the pliabilityof the vocal folds making additional pathologies such asvocal fold scar easy to identify Stroboscopy has resulted inaltered diagnosis in 47 percent of cases131 and stroboscopic

parameters aid in the differentiation of specific vocal fold

pathology such as polyps and cysts132 Surgical endoscopywith magnification (microlaryngoscopy) is utilized moreoften when more detailed examination manipulation orbiopsy of the structures is required133

In the adult visualization by indirect mirror examinationmay be limited by patient tolerance and photo documenta-tion is not possible Discomfort in transnasal laryngoscopyis usually mitigated by the application of topical deconges-tant andor anesthetic such as lidocaine A study of 1208patients evaluated by fiberoptic laryngoscopy for assess-ment of vocal fold paralysis after thyroidectomy showed nosignificant adverse events134 No other reports of significantrisks of fiberoptic laryngoscopy were found in a detailedMEDLINE search using key words laryngoscopy compli-cations risk and adverse events Transoral examinations ofthe larynx may be preceded by topical lidocaine to the throatand carries similarly minimal risk

Operative laryngoscopy carries more substantial risk butgenerally allows for ease of tissue manipulation and biopsyRisks associated with direct laryngoscopy with general an-esthesia include airway distress dental trauma oral cavityoropharyngeal and hypopharyngeal trauma tongue dyses-thesia taste changes and cardiovascular risk135-137 Thecost of direct laryngoscopy is substantially greater than thatof office-based laryngoscopy due to the additional costs ofstaff equipment and additional care required138-140

Special consideration is given to children for whomlaryngoscopy requires either advanced skill or a specializedsetting With the advent of small-diameter flexible laryngo-scopes awake flexible laryngoscopy can be employed inthe clinic in children as young as newborns but is subject tothe skill of the clinician and comfort with children Theadvantage is that this examination allows for evaluation ofboth anatomy and function of the larynx in the hoarse childDirect laryngoscopy under anesthesia with or without amicroscope may be used to verify flexible fiberoptic find-ings manage laryngeal papillomas or other vocal fold le-sions and further define laryngeal pathology such as con-genital anomalies of the larynx Intraoperative palpation ofthe cricoarytenoid joint may also help differentiate betweenvocal fold paralysis and fixation

Evidence profile for Statement 3A Laryngoscopy andHoarseness

Aggregate evidence quality Grade C based on observa-tional studies

Benefit Visualization of the larynx to improve diagnosticaccuracy and allow comprehensive evaluation

Harm Risk of laryngoscopy patient discomfort Cost Procedural expense Benefits-harm assessment Balance of benefit and harm Value judgments Laryngoscopy is an important tool for

evaluating voice complaints and may be performed at anytime in the patient with hoarseness

Intentional vagueness None


Role of patient preferences Substantial the level of pa-tient concern should be considered in deciding when toperform laryngoscopy

Exclusions None Policy level Option

Evidence profile for Statement 3B Indications for La-ryngoscopy

Aggregate evidence quality Grade C observational stud-ies on the natural history of benign laryngeal disordersgrade C for observational studies plus expert opinion ondefining what constitutes a serious underlying condition

Benefit Avoid missed or delayed diagnosis of seriousconditions in patients without additional signs or symp-toms to suggest underlying disease permit prompt assess-ment of the larynx when serious concern exists

Harm Potential for up to a three-month delay in diagno-sis procedure-related morbidity

Cost Procedural expense Benefits-harm assessment Preponderance of benefit over

harm Value judgments A need to balance timely diagnostic

intervention with the potential for over-utilization andexcessive cost The guideline panel debated on the max-imum duration of hoarseness prior to mandated evalua-tion and opted to select a ldquosafety net approachrdquo with agenerous time allowance (three months) but options toproceed promptly based on clinical circumstances

Intentional vagueness The term ldquoserious underlying con-cernrdquo is subject to the discretion of the clinician Someconditions are clearly serious but in other patients theseriousness of the condition is dependent on the patientIntentional vagueness was incorporated to allow for clin-ical judgment in the expediency of evaluation

Role of patient preferences Limited Exclusions None Policy level Recommendation

STATEMENT 4 IMAGING Clinicians should not ob-tain computed tomography (CT) or magnetic resonanceimaging (MRI) of the patient with a primary complaintof hoarseness prior to visualizing the larynx Recommen-dation against imaging based on observational studies ofharm absence of evidence concerning benefit and a pre-ponderance of harm over benefit

Supporting TextThe purpose of this statement is not to discourage the use ofimaging in the comprehensive work-up of hoarseness butrather to emphasize that it should be used to assess forspecific pathology after the larynx has been visualized

Laryngoscopy is the primary diagnostic modality forevaluating patients with hoarseness Imaging studies in-cluding CT and MRI have also been used but are unnec-essary in most patients because most hoarseness is self-

limited or caused by pathology that can be identified by

laryngoscopy The value of imaging procedures before la-ryngoscopy is undocumented no articles were found in thesystematic literature review for this guideline regarding thediagnostic yield of imaging studies prior to laryngeal exam-ination Conversely the risk of imaging studies is welldocumented

The risk of radiation-induced malignancy from CT scansis small but real More than 62 million CT scans per year areobtained in the United States for all indications including 4million performed on children (nationwide evaluation ofx-ray trends) In a study of 400000 radiation workers in thenuclear industry who were exposed to an average dose of 20mSVs (a typical organ dose from a single CT scan for anadult) a significant association was reported between theradiation dose and mortality from cancer in this cohortThese risks were quantitatively similar to those reported foratomic bomb survivors141 Children have higher rates ofmalignancy and a longer lifespan in which radiation-in-duced malignancies can develop142143 It is estimated thatabout 04 percent of all cancers in the United States may beattributable to the radiation from CT studies144145 The riskmay be higher (15 to 2) if we adjust this estimate basedon our current use of CT scans

There are also risks associated with IV contrast dye usedto increase diagnostic yield of CT scans146 Allergies tocontrast dye are common (5 to 8 of the population)Severe life-threatening reactions including anaphylaxisoccur in 01 percent of people receiving iodinated contrastmaterial with a death rate of up to one in 29500 peo-ple147148

While MRI has no radiation effects it is not without riskA review of the safety risks of MRI149 details five mainclasses of injury 1) projectile effects (anything metal thatgets attracted by the magnetic field) 2) twisting of indwell-ing metallic objects (cerebral artery clips cochlear implantsor shrapnel) 3) burning (electrical conductive material incontact with the skin with an applied magnetic field ieEKG electrodes or medication patches) 4) artifacts (radio-frequency effects from the device itself simulating pathol-ogy) and 5) device malfunction (pacemakers will fire in-appropriately or work at an elevated frequency thusdistorting cardiac conduction)150

The small confines of the MRI scanner may lead toclaustrophobia and anxiety151 Some patients children inparticular require sedation (with its associated risks) Thegadolinium contrast used for MRI rarely induces anaphy-lactic reactions152153 but there is recent evidence of renaltoxicity with gadolinium in patients with pre-existing renaldisease154 Transient hearing loss has been reported but thisis usually avoided with hearing protection155 The costs ofMRI however are significantly more than CT scanningDespite these risks and their considerable cost cross-sec-tional imaging studies are being used with increasing fre-quency156-158

After laryngoscopy evidence does support the use of

imaging to further evaluate 1) vocal fold paralysis or 2) a


mass or lesion of the vocal fold or larynx that suggestsmalignancy or airway obstruction159 If vocal fold palsy isnoted and recent surgery can explain the cause of the pa-ralysis imaging studies are generally not useful If thehealth care provider suspects a lesion along the recurrentlaryngeal nerve imaging studies are indicated

Unexplained vocal fold paralysis found on laryngoscopywarrants imaging the skull base to the thoracic inletarch ofthe aorta Including these anatomic areas allows for evalu-ation of the entire path of the recurrent laryngeal nerve as itloops around the arch of the aorta on the left side On theright it will show any lesions in the lung apex along thecourse of the right recurrent laryngeal nerve as it loopsaround the subclavian artery One study showed that acomplete radiographic work-up improved rates of diagno-sis160 but there is no consensus on whether CT or MRI isbetter for evaluating the recurrent laryngeal nerve161162

Lesions at the skull base and brain are best evaluated usingan MRI of the brain and brain stem with gadolinium en-hancement If a patient presents with additional lower cra-nial nerve palsy the skull base particularly the jugularforamen (CN IX X XI) should be evaluated159

Primary lesions of the larynx pharynx subglottis thy-roid and any pertinent lymph node groups can also beevaluated by imaging the entire area Intravenous contrastmay help to distinguish vascular lesions from normal pa-thology on CT Due to the substantial dose of ionizingradiation delivered to the radiosensitive thyroid gland163

CT examination in children is cautioned when MRI is avail-able

There is still significant controversy whether MRI or CTis the preferred study to evaluate invasion of laryngealcartilage Before the advent of the helical CT MRI was thepreferred method164 The extent of bone marrow infiltrationby malignant tumors (ie nasopharyngeal carcinoma) can beassessed with MRI of the skull base165 MRI is preferred inchildren and can easily be extended to include the medias-tinum to help evaluate congenital and neoplastic lesionsFor those patients who have absolute contraindications toMRI such as pacemaker cochlear implants heart valveprosthesis or aneurysmal clip CT is a viable alternative

Imaging studies are valuable tools in diagnosing certaincauses of hoarseness in children A plain chest radiographwill aid in the diagnosis of a mediastinal mass or foreignbody A CT scan can elucidate more detail if the initialradiography fails to show a lesion A soft tissue radiographof the neck can aid in the diagnosis of an infectious orallergic process166 CT imaging has been the test of choicefor congenital cysts laryngeal webs solid neoplasms andexternal trauma as it provides adequate resolution withouthaving to sedate the patient as may be necessary for MRIThe risk of radiation must be weighed against these benefitsMRI is the better option for imaging the brain stem166

FDG-PET imaging is used increasingly to assess patientswith head and neck cancer PET scans may help identify

mediastinal or pulmonary neoplasms that cause vocal fold

paralysis167 PET scanning is very costly however and maygive false-positive results in patients with vocal fold paral-ysis FDG activity in the normal vocal fold can be misin-terpreted as a tumor168

Evidence profile for Statement 4 Imaging

Aggregate evidence quality Grade C observational stud-ies regarding the adverse events of CT and MRI noevidence identified concerning benefits in patients withhoarseness before laryngoscopy

Benefit Avoid unnecessary testing minimize cost andadverse events maximize the diagnostic yield of CT andMRI when indicated

Harm Potential for delayed diagnosis Cost None Benefits-harm assessment Preponderance of benefit over

harm Value judgments Avoidance of unnecessary testing Role of patient preferences Limited Intentional vagueness None Exclusions None Policy level Recommendation against

STATEMENT 5A ANTI-REFLUX MEDICATIONAND HOARSENESS Clinicians should not prescribeanti-reflux medications for patients with hoarsenesswithout signs or symptoms of gastroesophageal refluxdisease (GERD) Recommendation against prescribingbased on randomized trials with limitations and observa-tional studies with a preponderance of harm over benefit

STATEMENT 5B ANTI-REFLUX MEDICATIONAND CHRONIC LARYNGITIS Clinicians may pre-scribe anti-reflux medication for patients with hoarse-ness and signs of chronic laryngitis Option based onobservational studies with limitations and a relative bal-ance of benefit and harm

Supporting Text

The primary intent of this statement is to limit widespreaduse of anti-reflux medications as empiric therapy for hoarse-ness without symptoms of GERD or laryngeal findingsconsistent with laryngitis given the known adverse effectsof the drugs and limited evidence of benefit The purpose isnot to limit use of anti-reflux medications in managinglaryngeal inflammation when inflammation is seen on la-ryngoscopy (eg laryngitis denoted by erythema edemaredundant tissue andor surface irregularities of the inter-arytenoid mucosa arytenoid mucosa posterior laryngealmucosa andor vocal folds) To emphasize these dual con-siderations the working group has split the statement intopart A a recommendation against empiric therapy forhoarseness and part B an option to use anti-reflux therapy

in managing properly diagnosed laryngitis


Anti-Reflux Medications and the Empiric

Treatment of Hoarseness

The benefit of anti-reflux treatment for hoarseness in pa-tients without symptoms of esophageal reflux (heartburnand regurgitation) or evidence for esophagitis is unclear ACochrane systematic review of 302 eligible studies thatassess the effectiveness of anti-reflux therapy for patientswith hoarseness did not identify any high-quality trialsmeeting the inclusion criteria169 For example a nonran-domized study on treating patients with documented refluxof stomach contents into the throat (laryngopharyngeal re-flux) with twice-daily proton pump inhibitors (PPIs) couldnot be included in the review because hoarseness was onlyone component of the reflux symptom index and not anoutcome separate from heartburn170 One randomized pla-cebo-controlled trial was also not included because it didnot separate hoarseness as an outcome from other laryngealsymptoms171 However the response rate for the laryngealsymptoms was 50 percent in the PPI group compared to 10percent in the placebo group

A randomized trial published after the Cochrane reviewof anti-reflux treatment for hoarseness included 145 subjectswith chronic laryngeal symptoms (throat clearing coughglobus sore throat or hoarseness and no cardinal GERDsymptoms) and laryngoscopic evidence for laryngitis(erythema edema andor surface irregularities of the inter-arytenoid mucosa arytenoid mucosa posterior laryngealmucosa andor vocal folds)172 Subjects received eitheresomeprazole 40 mg twice daily or placebo for 16 weeksThere was no evidence for benefit in symptom score orlaryngopharyngeal reflux health-related QOL score betweenthe groups at the end of the study However this studyincluded patients with one of many possible laryngealsymptoms and excluded patients with heartburn three ormore days per week172

The benefits of anti-reflux medication for control ofGERD symptoms are well documented High-quality con-trolled studies demonstrate that PPIs and H2RA (hista-mine-2 receptor antagonist) improve important clinical out-comes in esophageal GERD over placebo with PPIsdemonstrating superior response173174 Response rates foresophageal symptoms and esophagitis healing are high (ap-proximately 80 for PPIs)173174

In patients with hoarseness and a diagnosis of GERDanti-reflux treatment is more likely to reduce hoarsenessAnti-reflux treatment given to patients with GERD (basedon positive pH probe esophagitis on endoscopy or pres-ence of heartburn or regurgitation) showed improvedchronic laryngitis symptoms including hoarseness overthose without GERD175

There is some evidence supporting the pharmacologicaltreatment of GERD without documented esophagitis butthe number needed to treat tends to be higher173 Thesestudies have esophageal symptoms andor mucosal healing

as outcomes not hoarseness

While generally safe for therapy shorter than two monthsprolonged therapy with PPIs and H2RAs for greater thanthree months has been associated with significant riskH2RAs are associated with impaired cognition in olderadults176177 PPI use may increase the risk of bacterial gastro-enteritis specifically campylobacter and salmonella178 andpossibly clostridium difficile179 Epidemiological studiesalso associate PPIs with community-acquired pneumo-nia180181 Although patients with primary voice disordersmay differ from those in the above mentioned studies thetreating clinician needs to consider these adverse eventsFurthermore PPIs may impair the ability of clopidogrel toinhibit platelet aggregation activity182 to varying degreesdepending upon the particular PPI

Higher doses such as the twice-daily PPI therapy maycarry a higher risk than once-daily therapy and older adultsmay be more likely than younger adults to be harmed183

Although pneumonia is more common in young childrenusing PPIs the prevalence of profound regurgitation andswallowing disorders is high in that population so it isdifficult to draw conclusions about the effect of the drugitself184

Use of PPI may interfere with calcium absorption andbone homeostasis PPI use is associated with an increasedrisk for hip fractures in older adults185 PPIs decrease vita-min B12 (cobalamin) absorption in a dose-dependent man-ner186 and serum vitamin B12 levels may underestimate theresulting serum cobalamin deficiency187 PPI use also de-creases iron absorption and may cause iron deficiency ane-mia188 Additionally acid-suppressing drugs (both H2RAsand PPIs) were associated with an increased risk of pancre-atitis in a case-controlled study not explained by theslightly higher risk of pancreatitis seen in patients withGERD symptoms alone189

For patients with hoarseness and GERD a trial ofanti-reflux therapy may be prescribed If hoarseness doesnot respond or if symptoms worsen then pharmacologi-cal therapy should be discontinued and a search foralternative causes of hoarseness should be initiated withlaryngoscopy

Anti-Reflux Medications and Treatment of

Chronic Laryngitis

Laryngoscopy is helpful in determining whether anti-refluxtreatment should be considered in managing a patient withhoarseness Increased pharyngeal acid reflux events aremore common in patients with vocal process granulomascompared to controls190 Also erythema in the vocal foldsarytenoid mucosa and posterior commissure has improvedwith omeprazole treatment in patients with sore throatthroat clearing hoarseness andor cough191 While no dif-ferences in hoarseness improvement was seen between threemonths of esomeprazole vs placebo one small randomizedcontrolled trial found that findings of erythema diffuse

laryngeal edema and posterior commissure hypertrophy


showed greater improvement in the treatment arm comparedto placebo192

More improvement in signs of laryngitis of the true vocalfolds (such as erythema edema redundant tissue andorsurface irregularities) posterior cricoid mucosa and aryte-noid complex were noted in patients whose laryngeal symp-toms including hoarseness responded to four months ofPPI treatment compared to nonresponders193 Additionallythe above abnormalities of the interarytenoid mucosa andtrue vocal folds were predictive of improvement in laryn-geal symptoms including hoarseness193

Reflux of stomach contents into the laryngopharynx is animportant consideration in the management of patients withlaryngeal disorders Reflux of gastric contents into the hy-popharynx has been linked with subglottic stenosis194

Case-control studies have shown that GERD may be a riskfactor for laryngeal cancer195 and that anti-reflux therapymay reduce the risk of laryngeal cancer recurrence196 Bet-ter healing and reduced polyp recurrence after vocal foldsurgery in patients taking PPIs compared to no PPIs havealso been described197

PPI treatment may improve laryngeal lesions and ob-jective measures of voice quality Observational studieshave demonstrated that vocal process granulomas whichmay cause hoarseness have resolved or regressed aftertreatment with anti-reflux medication with or withoutvoice therapy198 Case series also have shown improvedacoustic voice measures of voice quality after one to twomonths of PPI therapy compared to baseline199

Nonetheless there are limitations of the endoscopic la-ryngeal examination in diagnosing patients who may re-spond to PPIs The presence of abnormal findings such asthe interarytenoid bar has been noted in normal individu-als177 In addition in a study of healthy volunteers notroutinely using anti-reflux medication and with GERDsymptoms no more than three times per month erythema ofthe medial arytenoid posterior commissure hypertrophyand pseudosulcus were noted200 Furthermore the presenceof specific findings depended upon the method of laryngos-copy (rigid vs flexible) and the inter-rater reliability rangedfrom moderate to poor depending on the specific finding200

In a study of patients with hoarseness from a variety ofdiagnoses problems with intra- and inter-rater reliability forfindings of edema and erythema of the vocal folds andarytenoids have also been noted201

Further research exploring the sensitivity specificityand reliability of laryngoscopic examination findings is nec-essary to determine which signs are associated with treat-ment response with respect to hoarseness and which tech-niques are best to identify them

Evidence profile for Statement 5A Anti-reflux Medica-tions and Hoarseness

Aggregate evidence quality Grade B randomized trials withlimitations showing lack of benefits for anti-reflux therapy in

patients with laryngeal symptoms including hoarseness ob-

servational studies with inconsistent or inconclusive resultsinconclusive evidence regarding the prevalence of hoarse-ness as the only manifestation of reflux disease

Benefit Avoid adverse events from unproven therapyreduce cost limit unnecessary treatment

Harm Potential withholding of therapy from patientswho may benefit

Cost None Benefits-harm assessment Preponderance of benefit over

harm Value judgments Acknowledgment by the working

group of the controversy surrounding laryngopharyngealreflux and the need for further research before definitiveconclusions can be drawn desire to avoid known adverseevents from anti-reflux therapy

Intentional vagueness None Patient preference Limited Exclusions Patients immediately before or after laryn-

geal surgery and patients with other diagnosed pathologyof the larynx

Policy level Recommendation against

Evidence profile for Statement 5B Anti-reflux Medica-tion and Chronic Laryngitis

Aggregate evidence quality Grade C observationalstudies with limitations showing benefit with laryngealsymptoms including hoarseness and observationalstudies with limitations showing improvement in signsof laryngeal inflammation

Benefit Improved outcomes promote resolution of lar-yngitis

Harm Adverse events related to anti-reflux medications Cost Direct cost of medications Benefits-harm assessment Relative balance of benefit

and harm Value judgments Although the topic is controversial the

working group acknowledges the potential role of anti-reflux therapy in patients with signs of chronic laryngitisand recognizes that these patients may differ from thosewith an empiric diagnosis of hoarseness (dysphonia)without laryngeal examination

Patient preference Substantial role for shared decisionmaking

Intentional vagueness None Exclusions None Policy level Option

STATEMENT 6 CORTICOSTEROID THERAPYClinicians should not routinely prescribe oral cortico-steroids to treat hoarseness Recommendation againstprescribing based on randomized trials showing adverseevents and absence of clinical trials demonstrating ben-efits with a preponderance of harm over benefit for ste-

roid use


Supporting TextOral steroids are commonly prescribed for hoarseness andacute laryngitis despite an overwhelming lack of support-ing data of efficacy A systematic search of MEDLINECINAHL EMBASE and the Cochrane Library revealed nostudies supporting the use of corticosteroids as empirictherapy for hoarseness except in special circumstances asdiscussed below

Although hoarseness is often attributed to acute inflam-mation of the larynx the temptation to prescribe systemic orinhaled steroids for acute or chronic hoarseness or laryngitisshould be avoided because of the potential for significantand serious side effects Side effects from corticosteroids canoccur with short- or long-term use although the frequencyincreases with longer durations of therapy (Table 8)202 Addi-tionally there are many reports implicating long-term inhaledsteroid use as a cause of hoarseness208-219

Despite these side effects there are some indications forsteroid use in specific disease entities and patients A spe-cific and accurate diagnosis should be achieved howeverbefore beginning this therapy The literature does supportsteroid use for recurrent croup with associated laryngitis inpediatric patients220 and allergic laryngitis212221 Patientswith chronic laryngitis and dysphonia may have environ-mental allergy221 In limited cases systemic steroids havebeen reported to provide quick relief from allergic laryngitisfor performers212221 While these are not high-quality trialsthey suggest a possible role for steroids in these selectedpatient populations Additionally in patients acutely depen-dent on their voice the balance of benefit and harm may beshifted The length of treatment for allergy-associated dys-phonia with steroids has not been well defined in the liter-ature

Pediatric patients with croup and other associated symp-toms such as hoarseness had better outcomes when treated

220

Table 8

Documented side effects of short- and long-term

steroid therapy202-207

LipodystrophyHypertensionCardiovascular diseaseCerebrovascular diseaseOsteoporosisImpaired wound healingMyopathyCataractsPeptic ulcersInfectionMood disorderOphthalmologic disordersSkin disordersMenstrual disordersAvascular necrosisPancreatitisDiabetogenesis

with systemic steroids Steroids should also be consid-

ered in patients with airway compromise to decrease edemaand inflammation An appropriate evaluation and determi-nation of the cause of the airway compromise is requiredprior to starting the steroid therapy Steroids are also helpfulin some autoimmune disorders involving the larynx such assystemic lupus erythematosus sarcoidosis and Wegenergranulomatosis222223

Evidence profile for Statement 6 Corticosteroid Therapy

Aggregate evidence quality Grade B randomized trialsshowing increased incidence of adverse events associatedwith orally administered steroids absence of clinical tri-als demonstrating any benefit of steroid treatment onoutcomes

Benefit Avoid potential adverse events associated withunproven therapy

Harm None Cost None Benefits-harm assessment Preponderance of harm over

benefit for steroid use Value judgments Avoid adverse events of ineffective or

unproven therapy Role of patient preferences Some there is a role for

shared decision making in weighing the harms of steroidsagainst the potential yet unproven benefit in specific cir-cumstances (ie professional or avocation voice use andacute laryngitis)

Intentional vagueness Use of the word ldquoroutinerdquo to ac-knowledge there may be specific situations based onlaryngoscopy results or other associated conditions thatmay justify steroid use on an individualized basis

Exclusions None Policy level Recommendation against

STATEMENT 7 ANTIMICROBIAL THERAPY Cli-nicians should not routinely prescribe antibiotics to treathoarseness Strong recommendation against prescribingbased on systematic reviews and randomized trials showingineffectiveness of antibiotic therapy and a preponderance ofharm over benefit

Supporting Text

Hoarseness in most patients is caused by acute laryngitis ora viral upper respiratory infection neither of which arebacterial infections Since antimicrobials are only effectivefor bacterial infections their routine empiric use in treatingpatients with hoarseness is unwarranted

Upper respiratory infections often produce symptoms ofsore throat and hoarseness which may alter voice qualityand function Acute upper respiratory infections caused byparainfluenza rhinovirus influenza and adenovirus havebeen linked to laryngitis224225 Furthermore acute laryngi-tis is self-limited with patients having improvement in 7 to10 days undergoing placebo treatment226 A Cochrane re-

view examining the role of antibiotics in acute laryngitis in


adults found only two studies meeting the inclusion criteriaand no benefit of either penicillin or erythromycin227 Sim-ilar findings of no benefit for antibiotics in acute upperrespiratory tract infections in adults and children were notedin another Cochrane review228

The potential harm from antibiotics must also be consid-ered Common adverse effects include rash abdominalpain diarrhea and vomiting and are more common in pa-tients receiving antibiotics compared to placebo228229 In-teractions may also occur between specific antibiotics andother medications230

In addition to negative consequences from antibioticuse on an individual level important societal implica-tions exist Over-prescribing antibiotics may contributeto bacterial resistance to antibiotics Compared to theyears 2001 to 2003 more methicillin-resistant Staphylo-coccus aureus has been isolated in acute and chronicmaxillary sinusitis in the period 2004 to 2006231 Fur-thermore antibiotic treatment costs for infectious dis-eases such as community-acquired pneumonia were 33percent higher in communities with high antibiotic resis-tance rates232 Thus overuse of antibiotics for hoarsenesshas negative potential results for both the individual andthe general population

While uncommon antibiotics may be appropriate in se-lect rare causes of hoarseness Laryngeal tuberculosis inrenal transplant patients and in patients with human immu-nodeficiency virus (HIV) have been reported233234 Anatypical mycobacterial laryngeal infection has also beenreported in a patient on inhaled steroids235 Although im-munosuppression may predispose to a bacterial laryngitislaryngeal tuberculosis has also been documented in patientswithout HIV and laryngeal actinomycosis has occurred inan immunocompetent patient236-238 A laryngeal mass orulcer is often present in these infectious etiologies requiringa high index of suspicion for malignancy For immunocom-promised patients with hoarseness laryngoscopy is war-ranted and biopsy for diagnosis should be performed ifindicated

Antibiotics may also be warranted in patients withhoarseness secondary to other bacterial infections Recentlycommunity outbreaks of pertussis attributed to waning im-munity in adolescents and adults have been reported239

Among adults with pertussis multiple symptoms have beenreported including hoarseness in 18 percent240 Among chil-dren bacterial tracheitis often from Staphylococcus aureusmay be associated with crusting and may cause severe upperairway infection and present with multiple symptoms suchas cough stridor increased work of breathing and hoarse-ness241

Evidence profile for Statement 7 Antimicrobial Therapy

Aggregate evidence quality Grade A systematic reviewsshowing no benefit for antibiotics for acute laryngitis orupper respiratory tract infection grade A evidence show-

ing potential harms of antibiotic therapy

Benefit Avoidance of ineffective therapy with docu-mented adverse events

Harm Potential for failing to treat bacterial fungal ormycobacterial causes of hoarseness

Cost None Benefit-harm assessment Preponderance of harm over

benefit if antibiotics are prescribed Values Importance of limiting antimicrobial therapy to

treating bacterial infections Role of patient preferences None Intentional vagueness The word ldquoroutinerdquo is used in the

boldface statement to discourage empiric therapy yet toacknowledge there are occasional circumstances whereantibiotic use may be appropriate

Exclusions Patients with hoarseness caused by bacterialinfection

Policy level Strong recommendation against

STATEMENT 8A LARYNGOSCOPY PRIOR TOVOICE THERAPY Clinicians should visualize thelarynx before prescribing voice therapy and docu-mentcommunicate the results to the speech-languagepathologist Recommendation based on observationalstudies showing benefit and a preponderance of benefitover harm

STATEMENT 8B ADVOCATING FOR VOICETHERAPY Clinicians should advocate voice therapyfor patients diagnosed with hoarseness (dysphonia) thatreduces voice-related QOL Strong recommendationbased on systematic reviews and randomized trials with apreponderance of benefit over harm

Laryngoscopy Prior to Voice Therapy

Voice therapy is a well-established treatment modality forsome voice disorders but therapy should not begin until adiagnosis is made Failure to visualize the larynx and es-tablish a diagnosis can lead to inappropriate therapy ordelay in diagnosis of pathology not amenable to voicetherapy127128 Additionally the information gained by la-ryngoscopy may help in designing an optimal therapy reg-imen

Evidence-based guidelines from the Royal College ofSpeech and Language Therapists mandate that a patient beevaluated by an ENT surgeon (otolaryngologist) prior tovoice therapy or simultaneously with the speech-languagepathologist (SLP)242 While the guideline does not explic-itly refer to laryngoscopy it states that the ldquoevaluation isneeded to identify disease assess structure and contribute tothe assessment of functionrdquo and laryngoscopy is the pri-mary tool for this assessment The American Speech-Lan-guage-Hearing Association (ASHA) acknowledges theseguidelines and specifies in their own practice policy that theclinical process for voice evaluation entails that ldquoall pa-

tientsclients with voice disorders are examined by a phy-


sician preferably in a discipline appropriate to the present-ing complaintrdquo243

An SLP trained in visual imaging may examine thelarynx for the purpose of evaluating vocal function andplanning an appropriate therapy program for the voice dis-order In some practices that care for voice disorders theSLP works with an otolaryngologist in the multidisciplinarytreatment of voice disorders and may perform the examina-tion which is then reviewed by the otolaryngologist50244

Examination or review by the otolaryngologist will ensurethat diagnoses not treatable with voice therapy such aslaryngeal cancer or papilloma are managed appropriatelyThis recommendation is consistent with published guide-lines of ASHA245 There are also published guidelines out-lining the knowledge skills and training necessary for theuse of videostroboscopy by the SLP246 The guideline panelagreed that performance of stroboscopic evaluation by theSLP with diagnosis by the laryngologist may be time savingin certain settings

There is significant evidence for the usefulness of laryn-goscopy specifically videostroboscopy in planning voicetherapy and in documenting the effectiveness of voice ther-apy in the remediation of vocal lesions247248 Accordinglythe results of the laryngeal examination should be docu-mented and communicated to the SLP who will conductvoice therapy prior to the initiation of medical or surgicaltreatment The report should include a detailed diagnosisdescription of the laryngeal pathology and brief history ofthe problem Visual images of the pathology may also helpin treatment planning248

Advocating for Voice TherapyClinicians should advocate voice therapy by making pa-tients aware that this is an effective intervention for hoarse-ness and providing brochures or sources of further informa-tion (see Appendix ldquoFrequently Asked Questions AboutVoice Therapyrdquo) The clinician can document advocacy in achart note by documenting a discussion of speech therapyby recording educational materials dispensed to the patientby recording that the patient was supplied with a websiteor by documenting referral to an SLP

Clinicians have several choices for managing hoarsenessincluding observation medical therapy surgical therapyvoice therapy or a combination of these approaches Voicetherapy provided by a certified SLP attends to the behav-ioral issues contributing to hoarseness Voice therapy iseffective for hoarseness across the lifespan from children toolder adults89245249-251 Children younger than two yearshowever may not be able to participate fully and effectivelyin many forms of voice therapy Education and counselingmay be of benefit to the family

Several approaches to voice therapy for treating hoarse-ness have been identified in the literature252-256 Hygienicapproaches focus on eliminating behaviors considered to beharmful to the vocal mechanism Symptomatic approachestarget the direct modification of aberrant features of pitch

loudness and quality Physiologic methods approach treat-

ment holistically as they work to retrain and rebalance thesubsystems of respiration phonation and resonance

A systematic review of the efficacy literature by Thomasand Stemple revealed various levels of support for the threeapproaches The efficacy of physiologic approaches waswell supported by randomized and other controlled trialsHygiene approaches showed mixed results in relativelywell-designed controlled trials Furthermore mostly obser-vational studies were found supporting symptomatic ap-proaches249

Hoarseness may be recurring or situational Recurringhoarseness refers to hoarseness that is intermittent as mightbe the case with functional voice disorders (characterized byabnormal voice quality not caused by anatomic changes tothe larynx) Situational hoarseness refers to hoarseness thatoccurs only during certain situations such as lecturing orsinging Voice therapy is often beneficial when combinedwith other hoarseness treatment approaches including pre-operative and postoperative therapy or in combination withcertain medical treatments (ie allergy management asthmatherapy anti-reflux therapy)9249

Specific voice therapy for treating hoarseness is effectivein Parkinson disease257 and paradoxical vocal fold dysfunc-tioncough258259 Voice therapy for treating spasmodic dys-phonia is useful as an adjunct to botulinum toxin260 Voicetherapy alone for treating spasmodic dysphonia remainscontroversial and not well supported261

The interdisciplinary treatment of hoarseness may alsoinclude contributions from singing teachers acting voicecoaches and other medical disciplines in conjunction withvoice therapy provided by an SLP245

Evidence profile for Statement 8A Visualizing the Larynx

Aggregate evidence quality Grade C observational stud-ies of the benefit of laryngoscopy for voice therapy

Benefit Avoid delay in diagnosing laryngeal conditionsnot treatable with voice therapy optimize voice therapyby allowing targeted therapy

Harm Delay in initiation of voice therapy Cost Cost of the laryngoscopy and associated clinician visit Benefits-harm assessment Preponderance of benefit over

harm Value judgments To ensure no delay in identifying pa-

thology not treatable with voice therapy SLPs cannotinitiate therapy prior to visualization of the larynx by aclinician

Intentional vagueness None Role of patient preferences Minimal Exclusions None Policy level Recommendation

Evidence profile for Statement 8B Advocating for VoiceTherapy

Aggregate evidence quality Grade A randomized con-

trolled trials and systematic reviews


Benefit Improve voice-related QOL prevent relapse po-tentially prevent need for more invasive therapy

Harm No harm reported in controlled trials Cost Direct cost of treatment Benefits-harm assessment Preponderance of benefit over

harm Value judgments Voice therapy is underutilized in man-

aging hoarseness despite efficacy advocacy is needed Role of patient preferences Adherence to therapy is es-

sential to outcomes Intentional vagueness Deciding which patients will ben-

efit from voice therapy is often determined by the voicetherapist The guideline panel elected to use a symptom-based criterion to determine to which patients the treatingclinician should advocate voice therapy

Exclusions None Policy level Strong recommendation

STATEMENT 9 SURGERY Clinicians should advo-cate for surgery as a therapeutic option in patients withhoarseness with suspected 1) laryngeal malignancy 2)benign laryngeal soft tissue lesions or 3) glottic insuffi-ciency Recommendation based on observational studiesdemonstrating a benefit of surgery in these conditions and apreponderance of benefit over harm

Supporting TextClinicians should be aware that surgery may be indicatedfor certain conditions that cause hoarseness Surgery is notthe primary treatment for the majority of hoarse patients andis targeted at specific pathologies Conditions with surgicaloptions can be categorized into four broad groups 1) sus-pected malignancy 2) benign soft tissue lesions 3) glotticinsufficiency and 4) laryngeal dystonia

Suspected malignancy Characteristics leading to suspicionof malignancy are described above (see laryngoscopy)Hoarseness may be the presenting sign in malignancy of theupper aerodigestive tract Malignancy was observed to bethe cause of hoarseness in 28 percent of patients over age 60after patients with self-limited disease were excluded91

Surgical biopsy with histopathologic evaluation is necessaryto confirm the diagnosis of malignancy in upper airwaylesions Highly suspicious lesions with increased vascula-ture ulceration or exophytic growth require prompt biopsyA trial of conservative therapy with avoidance of irritantsmay be employed prior to biopsy for superficial white le-sions on otherwise mobile vocal folds262

Benign soft tissue lesions The production of normal voicedepends in part on intact and functional vocal fold mucosaland submucosal layers Some benign lesions of the vocalfold mucosa and submucosa result in aberrant vibratorypatterns262 Specific benign lesions of the vocal folds in-clude vocal ldquosingerrsquosrdquo nodules polypoid degeneration

(Reinkersquos edema) hemorrhagic or fibrotic polyps ectatic or

dilated vessels scar or sulcus vocalis cysts (epidermalinclusion and mucous retention) and vocal process granu-lomas Another benign lesion laryngeal stenosis may notaffect the vocal folds directly but may affect the voice

A trial of conservative management is typically institutedprior to surgical intervention for most pathologies and mayobviate the need for surgery Many benign soft tissue le-sions of the vocal folds are self-limited or reversible263 Theconservative management strategy indicated depends on thelikely underlying etiology but may include voice therapy orrest smoking cessation and anti-reflux therapy In a retro-spective study of 26 patients with hoarseness secondary totrue vocal fold nodules 80 percent of patients achievednormal or near-normal voice with voice therapy alone264

Furthermore failure to address underlying etiologies maylead to frequent postsurgical recurrence of some lesionsespecially granulomas265 Surgery is reserved for benignvocal fold lesions when a satisfactory voice result cannot beachieved with conservative management and the voice maybe improved with surgical intervention263

Surgery may improve both subjective voice-related QOLand objective vocal parameters in patients with hoarsenesssecondary to benign vocal fold lesions A retrospectivereview of 42 patients with benign vocal fold lesions dem-onstrated significant improvement in voice-related QOL andacoustic parameters following surgery266 Multiple studiesof surgical treatment of ectatic vessels polypoid degenera-tion (Reinkersquos edema) nodules and polyps all showedsignificant benefit267-269

Surgery is necessary in the management of recurrentrespiratory papilloma (RRP) a benign but aggressive neo-plasm of the upper airway more commonly seen in childrenHuman papillomavirus subtypes 6 and 11 are the mostcommon cause Surgical removal with standard laryngealinstruments microdebrider or laser can prevent airway ob-struction and is effective in reducing the symptoms ofhoarseness but it is unlikely to be curative since viralparticles may be present in adjacent normal-appearing mu-cosa270-272 Additionally certain lesions may be amenableto treatment in the office under topical anesthesia usingadvanced laryngoscopic techniques267

Type of instrumentation does not seem to affect outcomewhen comparing laser to cold dissection273 The surgicalmethod used is less important than the experience and skillof the operating surgeon in obtaining satisfactory vocaloutcomes in the surgical treatment of benign vocal foldlesions266 While bleeding scarring airway compromiseand poor voice outcomes are all possible risks of surgery noserious surgery-related complications were noted in anycase series or trial266273

Glottic insufficiency A normal voice is created by two mo-bile vocal folds making contact in the midline space of thelarynx (glottis) thereby creating the vibratory sound wavesperceived as voice Glottic insufficiency due to vocal fold

weakness (eg paralysis or paresis) or vocal fold soft tissue


defects often results in a weak breathy hoarseness with poorcough and reduced airway protection during swallow De-tails of characteristics leading to suspicion of glottic insuf-ficiency are described above (see laryngoscopy section)Glottic insufficiency is especially common in older adultsin whom up to 30 percent of hoarseness was due to vocalfold changes after self-limited causes were excluded9192

Surgical management of glottic insufficiency is primarilythrough static positioning of the weak vocal fold in themidline glottis (medialization laryngoplasty) Static medial-ization of the vocal folds can be achieved either by injectionof a bulking agent into the vocal fold (injection laryngo-plasty) or external medialization with open surgery (laryn-geal framework surgery) or a combination of the twoInjection laryngoplasty can be safely performed in the officeunder local anesthesia or in the operating room under gen-eral anesthesia274 While no randomized trials were founddirectly comparing injection laryngoplasty to laryngealframework surgery observational studies show comparableobjective and subjective improvement in voice275

Resorbable temporary injectable implants are often usedto provide vocal rehabilitation while allowing time for neu-ral recovery or full denervation atrophy of the vocal mus-culature prior to permanent medialization In a randomizedcontrolled trial of patients with glottic insufficiency com-paring bovine collagen to hyaluronic acid gel 42 patientswith sufficient follow-up demonstrated significantly im-proved subjective and objective vocal parameters276 Therewere no complications noted in this study but 26 percent ofpatients required repeat injection over 24 months of obser-vation Additional retrospective series of temporary in-jectables demonstrated subjective and objective hoarse-ness reduction in 80 percent to 95 percent of treatedpatients277-280 In addition there are limited data that col-lagen or lyophilized dermis injections can provide adequatevocal rehabilitation of pediatric patients281

Injection laryngoplasty with stable semi-permanent im-plants is used when vocal recovery is unlikely274 Prospec-tive trials of both silicone and hydroxylapatite paste havedemonstrated significant improvement in validated voiceQOL measures in 94 percent to 100 percent of patientswithout significant complications after six-month follow-up282283 Since there are several suitable alternatives theuse of polytetrafluoroethylene as a permanent injectableimplant is not recommended due to its association withforeign body granulomas that can result in voice deteriora-tion and airway compromise284285

External medialization laryngoplasty by open laryngealframework surgery also known as type I thyroplasty hasdemonstrated hoarseness reduction using a variety of im-plants made of Silastic titanium Gore-tex and hydroxly-apatite286-288 When analyzed by trained blinded listenersthe voices of 15 patients who underwent external laryngo-plasty were indistinguishable from normal controls in loud-ness and pitch but had higher levels of strain and breathi-

289

ness In a retrospective study of 117 patients with glottic

insufficiency patients who received external laryngoplastydemonstrated better symptom resolution compared to pa-tients receiving voice therapy alone290

Arytenoid adduction is an additional laryngeal frame-work procedure used to rotate the vocal process of thearytenoid medially in patients with large posterior glotticgaps A meta-analysis of three studies found no clear benefitif arytenoid adduction is added to external laryngoplastycompared to external laryngoplasty alone291 External la-ryngoplasty has been performed successfully in children butmay be technically more challenging due to the variableposition of the pediatric vocal fold292293

Laryngeal dystonia Surgical treatment for laryngeal dysto-nia or adductor spasmodic dysphonia is infrequently per-formed due to the widespread acceptance of botulinumtoxin as the first-line treatment for this disorder Attempts tocontrol the disorder with recurrent laryngeal nerve sectionresulted in inconsistent often temporary improvement withrecurrence in up to 80 percent of cases294-297 A singleretrospective study of laryngeal dystonia patients treatedwith bilateral division of the adductor branch of the recur-rent laryngeal nerve followed by ansa cervicalis reinnerva-tion demonstrated resolution of symptoms in 19 of 21 pa-tients followed for at least 12 months298

Evidence profile for Statement 9 Surgery

Aggregate evidence quality Grade B in support of sur-gery to reduce hoarseness and improve voice quality inselected patients based on observational studies over-whelmingly demonstrating the benefit of surgery

Benefit Potential for improved voice outcomes in care-fully selected patients


harm Value judgments Surgical options for treating hoarseness

are not always recognized selected patients with hoarse-ness may benefit from newer less invasive technologies

Role of patient preferences Limited Intentional vagueness None Exclusions None Policy level Recommendation

STATEMENT 10 BOTULINUM TOXIN Cliniciansshould prescribe or refer the patient to a clinicianwho can prescribe botulinum toxin injections for thetreatment of hoarseness caused by spasmodic dyspho-nia Recommendation based on randomized controlledtrials with minor limitations and preponderance of ben-efit over harm

Supporting TextSpasmodic dysphonia (SD) is a focal dystonia most com-

299

monly characterized by a strained strangled voice Pa-


tients demonstrate increased tone or tremor of intralaryngealmuscle groups responsible for either opening (abductor SD)or closing (adductor SD) of the vocal folds Intramuscularinjection of botulinum toxin into the affected musclescauses transient nondestructive flaccid paralysis of thesemuscles by inhibiting the release of acetylcholine fromnerve terminals thus reducing the spasm300 SD is a disor-der of the central nervous system that cannot be cured bybotulinum toxin301 but excellent symptom control is pos-sible for 3 to 6 months with treatment302 Treatment can beperformed on awake ambulatory patients with minimaldiscomfort303

While not currently FDA approved for SD a large bodyof evidence supports the efficacy of botulinum toxin (pri-marily botulinum toxin A) for treating adductor spasmodicdysphonia Multiple double-blind randomized placebo-controlled trials of botulinum toxin for adductor spasmodicdysphonia using both self-assessment and expert listenersfound improved voice in patients treated with botulinumtoxin injections304305 Botulinum toxin treatment has alsobeen shown to improve self-perceived dysphonia mentalhealth and social functioning306 A meta-analysis con-cluded that botulinum toxin treatment of spasmodic dyspho-nia results in ldquomoderate overall improvementrdquo however itnotes concerns of methodological limitations and lack ofstandardization in assessment of botulinum toxin efficacyand recommends caution when making inferences regardingtreatment benefit260 Despite these limitations among lar-yngologists botulinum toxin is considered the ldquotreatment ofchoicerdquo for adductor SD301302307

Botulinum toxin has been used for other disorders ofexcessive or inappropriate muscular contraction300 Thereare limited reports addressing the use of botulinum toxin forspastic dysarthria nerve-section failure anterior commis-sure release adductor breathing dystonia abductor spas-modic dysphonia ventricular dysphonia (also called dys-phonia plica ventricularis) and voice tremor280281289-293

Botulinum toxin injections have a good safety recordBlitzer et al reported their 13-year experience in 901 pa-tients who underwent 6300 injections adverse effects in-cluded ldquomild breathiness and coughing on fluidsrdquo in theadductor SD patients and ldquomild stridorrdquo in abductor SDpatients308 The most common adverse effects of botulinumtoxin injection are breathiness and dysphagia includingchoking on fluids309-313 Risk of harm may be greater withinexperienced users301 Post-treatment dysphagia appearsmore common in patients with dysphagia prior to injec-tion314 Exertional wheezing exercise intolerance and stri-dor were reported more commonly in patients with abductorSD308315

Adverse events may result from diffusion of drug fromthe target muscle to adjacent muscles (this has been addedas a ldquoboxed warningrdquo by the FDA)300 Adjusting the dosedistribution and timing of injections may decrease the fre-quency of adverse events313316 Bleeding is rare and vocal

fold edema has only been documented in a single patient

receiving saline as a placebo304 Reports of sensations ofburning tickling irritation of the larynx or throat excessivethick secretions and dryness have also occurred317 Sys-temic effects are rare with only two reports of generalizedbotulism-like syndromes and one report of possible precip-itation of biliary colic300 Acquired resistance to botulinumtoxin can occur300318

Evidence profile for Statement 10 Botulinum Toxin

Aggregate evidence quality Grade B few controlled tri-als diagnostic studies with minor limitations and over-whelmingly consistent evidence from observational stud-ies

Benefit Improved voice quality and voice-related QOL Harm Risk of aspiration and airway obstruction Cost Direct costs of treatment time off work and indi-

rect costs of repeated treatments Benefit-harm assessment Preponderance of benefit over

harm Value judgments Botulinum toxin is beneficial despite

the potential need for repeated treatments considering thelack of other effective interventions for spasmodic dys-phonia

Role of patient preferences Patient must be comfortablewith FDA off-label use of botulinum toxin While strongevidence supports its use botulinum toxin injection is aninvasive therapy offering only temporarily relief of anonndashlife-threatening condition Patients may reasonablyelect not to have it performed

Intentional vagueness None Exclusions None Policy level Recommendation

STATEMENT 11 PREVENTION Clinicians may edu-catecounsel patients with hoarseness about controlpre-ventive measures Option based on observational studiesand small randomized trials of poor quality

Supporting TextThe risk of hoarseness may be diminished by preventivemeasures such as hydration avoidance of irritants voicetraining and amplification Currently available studies eval-uating these measures are limited in scope and qualityThere is some evidence that adequate hydration may de-crease the risk of hoarseness In a study of 422 teachersabsence of water intake was associated with a 60 percenthigher risk of hoarseness319 Objective findings of hoarse-ness and vocal fold thickness were found in patients withpost-dialysis dehydration320 An observational study of am-ateur singers demonstrated less vocal fatigue with hydrationand periods of voice rest321 Phonatory effort may also bedecreased by adequate hydration57 There are very limiteddata suggesting that amplification during heavy voice usemay sustain voice quality322

A 2007 Cochrane review evaluated the effectiveness of

interventions designed to prevent or reduce voice disor-


ders323 Only two studies were of adequate quality to meetinclusion criteria Direct voice training indirect voice train-ing or a combination of the two approaches were studied in55 student teachers324 and 41 kindergarten and primaryschool teachers325 The review did not find sufficient evi-dence to substantiate the use of voice training as a preven-tive measure The two randomized controlled studies in-cluded in the review had several methodological problemsrelated to sample size design and outcome measures

Despite limited evidence in the literature the panel con-curred that avoidance of tobacco smoke (primary or sec-ondhand) was beneficial to decrease the risk of hoarse-ness326 There is also observational evidence from a singlestudy of 10 symptomatic rescue workers at the World TradeCenter disaster site that irritants such as chemicals smokeparticulates and pollution can increase the likelihood ofdeveloping hoarseness327

Evidence profile for Statement 11 Prevention

Aggregate evidence quality Grade C evidence based onseveral observational studies and a few small randomizedtrials of poor quality

Benefit Possible prevention of hoarseness in high-riskpersons

Harm None Cost Cost of vocal training sessions Benefits-harm assessment Preponderance of benefit over

harm Value judgments Preventive measures may prevent

hoarseness Role of patient preferences Patients without symptoms

must weigh the benefit of preventive measures based ontheir risk of developing hoarseness or voice problems


IMPLEMENTATION CONSIDERATIONS

The complete guideline is published as a supplement toOtolaryngologyndashHead and Neck Surgery to facilitate refer-ence and distribution The guideline will be presented toAAO-HNS members as a mini-seminar at the AAO-HNSannual meeting following publication Existing brochuresand publications by the AAO-HNS will be updated to reflectthe guideline recommendations A full-text version of theguideline will also be accessible free of charge at wwwentnetorg

An anticipated barrier to diagnosis is distinguishingmodifying factors for hoarseness in a busy clinical settingThis may be assisted by a laminated teaching card or visualaid summarizing important factors that modify manage-ment

Laryngoscopy is an option at any time for patients with

hoarseness but the guideline also recommends that no pa-

tient should be allowed to wait longer than three monthsprior to having his or her larynx examined It is also clearlyrecommended that if there is a concern of an underlyingserious condition then laryngoscopy should be immediateTables in this guideline regarding causes for concern shouldhelp to guide clinicians regarding when more prompt laryn-goscopy is warranted The cost of the laryngoscopy andpossible wait times to see clinicians trained in the techniquemay hinder access to care

While the guideline acknowledges that there may be asignificant role for anti-reflux therapy to treat laryngealinflammation empiric use of anti-reflux medications forhoarseness has minimal support and a growing list of po-tential risks Avoidance of empiric use of anti-reflux therapyrepresents a significant change in practice for some clini-cians Educational pamphlets about the unfavorable risk-benefit profile of these medications in the absence of GERDsymptoms or signs of laryngeal inflammation in the face ofnewly recognized complications of long-term use of protonpump inhibitors may facilitate acceptance of this shift

Lack of knowledge about voice therapy by practitionersis a likely barrier to advocacy for its use This barrier can beovercome by educational materials about voice therapy andits indications

RESEARCH NEEDS

While there is a body of literature from which these guide-lines were drawn significant gaps in our knowledge abouthoarseness and its management remain The guideline com-mittee identified several areas where further research wouldimprove the ability of clinicians to manage hoarse patientsoptimally

Hoarseness is known to be common but the prevalenceof hoarseness in certain populations such as children is notwell known Additionally the prevalence of specific etiol-ogies of hoarseness is not known Descriptive statisticswould help to shape thinking on distribution of resourceslevels of care and cost mandates

Although a strong intuitive sense of the natural history ofmany voice disorders exists among practitioners data arelacking This dearth of information makes judgments re-lated to the value of observation vs intervention challeng-ing Some of the entities that might benefit from studyinclude viral laryngitis fungal laryngitis inhaler-related lar-yngitis voice abuse reflux and benign lesions (ie nodulespolyps cysts etc) A better understanding of the naturalhistory of these disorders could be obtained through pro-spective observational studies and will have clear implica-tions for the necessity and timing of behavioral medicaland surgical interventions

Prospective studies on the value of steroids and antibi-otics for infectious laryngitis are also lacking Given theknown potential harms from these medications prospectivestudies examining the benefits relative to placebo are war-

ranted


Reflux laryngitis is a very common diagnosis with muchcontroversy surrounding it While there are a number ofstudies looking at the use of anti-reflux therapy for chroniclaryngitis the vast majority have severe limitations Well-conducted and controlled studies of anti-reflux therapy forpatients with hoarseness and for patients with signs oflaryngeal inflammation would help to establish the value ofthese medications Further clarification of which hoarsepatients may benefit from reflux treatment would help tooptimize outcomes and minimize costs and potential sideeffects Future studies may benefit from strict inclusioncriteria and specific investigation of the outcome of hoarse-ness (dysphonia) control

Although ancillary testing such as radiographic imagingis often performed to assist in diagnosing the underlyingcause of hoarseness the role of these tests has not beenclearly defined Their usefulness as screening tools is un-clear and the cost effectiveness of their use has not beenestablished

Despite data that strongly demonstrate better survivaland local control rates in early-stage laryngeal cancers theimprovement of laryngeal cancer outcomes through earlyscreening has not been shown Study of the effect of earlyscreening and diagnosis is warranted

Voice therapy has been shown to provide short-termbenefit for hoarse patients but long-term efficacy has notbeen shown Also the relative harm of voice therapy hasnot been studied (eg lost work time anxiety) making theriskbenefit ratio difficult to evaluate

As office-based procedures are developed to managecauses of hoarseness previously treated in the operatingroom comparative studies on the safety and efficacy ofoffice-based procedures relative to those performed undergeneral anesthesia are needed (eg injection vs open thyro-plasty)

DISCLAIMER

As medical knowledge expands and technology advancesclinical indicators and guidelines are promoted as condi-tional and provisional proposals of what is recommendedunder specific conditions but they are not absolute Guide-lines are not mandates and do not and should not purport tobe a legal standard of care The responsible physician inlight of all the circumstances presented by the individualpatient must determine the appropriate treatment Adher-ence to these guidelines will not ensure successful patientoutcomes in every situation The American Academy ofOtolaryngologymdashHead and Neck Surgery (AAO-HNS) em-phasizes that these clinical guidelines should not be deemedto include all proper treatment decisions or methods of careor to exclude other treatment decisions or methods of care

reasonably directed to obtaining the same results

ACKNOWLEDGEMENT

We gratefully acknowledge the support provided by Kristine Schulz MPHfrom the AAO-HNS Foundation

AUTHOR INFORMATION

From Virginia Mason Medical Center (Dr Schwartz) Seattle WA DukeUniversity School of Medicine (Dr Cohen) Durham NC Universityof Wisconsin School of Medicine and Public Health (Drs Dailey andMcMurray) Madison WI SUNY Downstate Medical College and LongIsland College Hospital (Dr Rosenfeld) Brooklyn NY Alfred I duPontHospital for Children (Dr Deutsch) Wilmington DE Medical Universityof South Carolina (Dr Gillespie) Charleston SC Columbia UniversityCollege of Physicians and Surgeons (Dr Granieri) New York NY EmoryVoice Center (Dr Hapner) Atlanta GA All About Children PediatricPartners PC (Dr Kimball) Reading PA Wayne State University (DrKrouse) Detroit MI University of Massachusetts School of Medicine(Dr Medina) Uxbridge MA US Army Training and Doctrine Command(Dr OrsquoBrien) Fort Monroe VA Henry Ford Hospital (Dr Ouellette)Detroit MI Cleveland Clinic (Dr Messinger-Rapport) Cleveland OHHenry Ford Medical Group (Dr Stachler) Detroit MI University ofArkansas for Medical Sciences (Dr Strode) Little Rock AR Mayo Clinic(Dr Thompson) Rochester MN University of Kentucky College of HealthSciences (Dr Stemple) Lexington KY Cincinnati Childrenrsquos HospitalMedical Center (Dr Willging) Cincinnati OH The TMJ Association (MsCowley) Milwaukee WI Westminster Choir College of Rider University(Dr McCoy) Princeton NJ Metropolitan Medical Center (Dr Bernad)Washington DC and The American Academy of OtolaryngologymdashHeadand Neck Surgery (Mr Patel) Alexandria VA

Corresponding author Seth R Schwartz MD MPH Virginia MasonMedical Center 1100 Ninth Avenue MS X10-ON PO Box 900 SeattleWA 98111

E-mail address sethschwartzvmmcorg

AUTHOR CONTRIBUTIONS

Seth R Schwartz writer chair Seth M Cohen writer assistant chairSeth H Dailey writer assistant chair Richard M Rosenfeld writerconsultant Ellen S Deutsch writer M Boyd Gillespie writer EvelynGranieri writer Edie R Hapner writer C Eve Kimball writer HeleneJ Krouse writer J Scott McMurray writer Safdar Medina writerKaren OrsquoBrien writer Daniel R Ouellette writer Barbara J Mess-inger-Rapport writer Robert J Stachler writer Steven Strode writerDana M Thompson writer Joseph C Stemple writer J Paul Willg-ing writer Terrie Cowley writer Scott McCoy writer Peter G Ber-nad writer Milesh M Patel writer

DISCLOSURES

Competing interests Seth M Cohen TAP Pharmaceuticals patienteducation grant Seth H Dailey Bioform one time consultant (2008)Ellen S Deutsch Kramer Patient Education reviewer M BoydGillespie Restore Medical (Medtronic) research support study site forPillar-CPAP study Helene J Krouse Alcon Speakerrsquos Bureau Schering-Plough grant funding Daniel R Ouellette Pfizer Speakerrsquos BureauBoehringer Ingleheim Speakerrsquos Bureau Barbara J Messinger-Rap-port Forest speaker Novartis speaker Robert J StachlerGlaxoSmithKline consultant Steven Strode Central AR Veterans Health-care System employee American Academy of Family Physicians dele-

gate commission member EDoc America for-profit health information


service Joseph C Stemple KayPentax product grant Plural Publishingauthor royalties and Speakerrsquos Bureau J Paul Willging expert witnesshourly fee to review medical records and comment on quality of carendashpediatric ENT-related

Sponsorships Sponsor and funding source American Academy of Oto-laryngologymdashHead and Neck Surgery The cost of developing this guide-line including travel expenses of all panel members was covered in full bythe AAO-HNS Foundation Members of the AAO-HNS and other alliedhealthphysician organizations were involved with the study design andconduct collection analysis and interpretation of the data and writing orapproval of the manuscript

REFERENCES

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2 Roy N Merrill RM Thibeault S et al Prevalence of voice disordersin teachers and the general population J Speech Lang Hear Res200447281ndash93

3 Coyle SM Weinrich BD Stemple JC Shifts in relative prevalence oflaryngeal pathology in a treatment-seeking population J Voice 200115424ndash40

4 Jones K Sigmon J Hock L et al Prevalence and risk factors forvoice problems among telemarketers Arch Otolaryngol Head NeckSurg 2002128571ndash7

5 Long J Williford HN Olson MS et al Voice problems and riskfactors among aerobics instructors J Voice 199812197ndash207

6 Smith E Kirchner HL Taylor M et al Voice problems amongteachers differences by gender and teaching characteristics J Voice199812328ndash34

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8 Benninger MS Ahuja AS Gardner G et al Assessing outcomes fordysphonic patients J Voice 199812540ndash50

9 Ramig LO Verdolini K Treatment efficacy voice disorders JSpeech Lang Hear Res 199841S101ndash16

10 Sulica L Behrman A Management of benign vocal fold lesions asurvey of current opinion and practice Ann Otol Rhinol Laryngol2003112827ndash33

11 Allen MS Pettit JM Sherblom JC Management of vocal nodules aregional survey of otolaryngologists and speech-language patholo-gists J Speech Hear Res 199134229ndash35

12 Behrman A Sulica L Voice rest after microlaryngoscopy currentopinion and practice Laryngoscope 20031132182ndash6

13 Ahmed TF Khandwala F Abelson TI et al Chronic laryngitisassociated with gastroesophageal reflux prospective assessment ofdifferences in practice patterns between gastroenterologists and ENTphysicians Am J Gastroenterol 2006101470ndash8

14 Titze IR Lemke J Montequin D Populations in the US workforcewho rely on voice as a primary tool of trade a preliminary report JVoice 199711254ndash9

15 Duff MC Proctor A Yairi E Prevalence of voice disorders inAfrican American and European American preschoolers J Voice200418348ndash53

16 Carding PN Roulstone S Northstone K et al The prevalence ofchildhood dysphonia a cross-sectional study J Voice 200620623ndash30

17 Silverman EM Incidence of chronic hoarseness among school-agechildren J Speech Hear Disord 197540211ndash5

18 Angelillo N Di Costanzo B Angelillo M et al Epidemiologicalstudy on vocal disorders in paediatric age J Prev Med Hyg 200849

1ndash5

19 Powell M Filter MD Williams B A longitudinal study of theprevalence of voice disorders in children from a rural school divisionJ Commun Disord 198922375ndash82

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21 Golub JS Chen PH Otto KJ et al Prevalence of perceived dyspho-nia in a geriatric population J Am Geriatr Soc 2006541736ndash9

22 Mirza N Ruiz C Baum ED et al The prevalence of major psychi-atric pathologies in patients with voice disorders Ear Nose Throat J200382808ndash101214

23 Rosen CA Lee AS Osborne J et al Development and validation ofthe voice handicap index-10 Laryngoscope 20041141549ndash56

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25 Gilman M Merati AL Klein AM et al Performerrsquos attitudes towardseeking health care for voice issues understanding the barriers JVoice 200723225ndash28

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27 Rosenfeld RM Shiffman RN Clinical practice guidelines a manualfor developing evidence-based guidelines to facilitate performancemeasurement and quality improvement Otolaryngol Head Neck Surg2006135S1ndash28

28 Rosenfeld RM Shiffman RN Clinical practice guideline develop-ment manual a quality driven approach Otolaryngol Head NeckSurg 2009140S1ndash43

29 Montori VM Wilczynski NL Morgan D et al Optimal searchstrategies for retrieving systematic reviews from Medline analyticalsurvey BMJ 200533068

30 Shiffman RN Shekelle P Overhage JM et al Standardized reportingof clinical practice guidelines a proposal from the Conference onGuideline Standardization Ann Intern Med 2003139493ndash8

31 Shiffman RN Karras BT Agrawal A et al GEM a proposal for amore comprehensive guideline document model using XML J AmMed Inform Assoc 20007488ndash98

32 AAP SCQIM (American Academy of Pediatrics Steering Committeeon Quality Improvement and Management) Policy Statement Clas-sifying recommendations for clinical practice guidelines Pediatrics2004114874ndash7

33 Eddy DM A manual for assessing health practices and designingpractice policies the explicit approach Philadelphia American Col-lege of Physicians 1992

34 Choudhry NK Stelfox HT Detsky AS Relationships between au-thors of clinical practice guidelines and the pharmaceutical industryJAMA 2002287612ndash7

35 Detsky AS Sources of bias for authors of clinical practice guidelinesCMAJ 20061751033ndash5

36 Brouha XD Tromp DM de Leeuw JR et al Laryngeal cancerpatients analysis of patient delay at different tumor stages HeadNeck 200527289ndash95

37 Scott S Robinson K Wilson JA et al Patient-reported problemsassociated with dysphonia Clin Otolaryngol Allied Sci 19972237ndash 40

38 Zur KB Cotton S Kelchner L et al Pediatric Voice Handicap Index(pVHI) a new tool for evaluating pediatric dysphonia Int J PediatrOtorhinolaryngol 20077177ndash82

39 Blitzer A Brin MF Fahn S et al Clinical and laboratory character-istics of focal laryngeal dystonia study of 110 cases Laryngoscope199898636ndash40

40 Roy N Gouse M Mauszycki SC et al Task specificity in adductorspasmodic dysphonia versus muscle tension dysphonia Laryngo-scope 2005115311ndash6

41 Chhetri DK Merati AL Blumin JH et al Reliability of the percep-tual evaluation of adductor spasmodic dysphonia Ann Otol Rhinol

Laryngol 2008117159ndash65


42 Sneeuw KC Sprangers MA Aaronson NK The role of health careproviders and significant others in evaluating the quality of life ofpatients with chronic disease J Clin Epidemiol 2002551130ndash43

43 Hackett ML Duncan JR Anderson CS et al Health-related qualityof life among long-term survivors of stroke results from the Auck-land Stroke Study 1991-1992 Stroke 200031440ndash7

44 Hogikyan ND Sethuraman G Validation of an instrument to measurevoice-related quality of life (V-RQOL) J Voice 199913557ndash69

45 Jacobson BH Johnson A Grywalski C et al The Voice HandicapIndex (VHI) development and validation Am J Speech Lang Pathol1997666ndash70

46 Deary IJ Wilson JA Carding PN et al VoiSS a patient-derivedvoice symptom scale J Psychosom Res 200354483ndash9

47 Zraick RI Risner BY Smith-Olinde L et al Patient versus partnerperception of voice handicap J Voice 200721485ndash94

48 Sataloff RT Divi V Heman-Ackah YD et al Medical history invoice professionals Otolaryngol Clin North Am 200740931ndash51

49 Sataloff RT Office evaluation of dysphonia Otolaryngol Clin NorthAm 199225843ndash55

50 Rubin JS Sataloff RT Korovin GS Diagnosis and treatment of voicedisorders 3rd ed San Diego Plural Publishing Inc 2006 p 824

51 Kerr HD Kwaselow A Vocal cord hematomas complicating antico-agulant therapy Ann Emerg Med 198413552ndash3

52 Laing C Kelly J Coman S et al Vocal cord haematoma afterthrombolysis Lancet 19973501677

53 Neely JL Rosen C Vocal fold hemorrhage associated with coumadintherapy in an opera singer J Voice 200014272ndash7

54 Bhutta MF Rance M Gillett D et al Alendronate-induced chemicallaryngitis J Laryngol Otol 200511946ndash7

55 Dicpinigaitis PV Angiotensin-converting enzyme inhibitor-inducedcough ACCP evidence-based clinical practice guidelines Chest2006129169Sndash73S

56 Abaza MM Levy S Hawkshaw MJ et al Effects of medications onthe voice Otolaryngol Clin North Am 2007401081ndash90

57 Verdolini K Titze IR Fennell A Dependence of phonatory effort onhydration level J Speech Hear Res 1994371001ndash7

58 Baker J A report on alterations to the speaking and singing voices offour women following hormonal therapy with virilizing agents JVoice 199913496ndash507

59 Pattie MA Murdoch BE Theodoros D et al Voice changes inwomen treated for endometriosis and related conditions the need forcomprehensive vocal assessment J Voice 199812366ndash71

60 Christodoulou C Kalaitzi C Antipsychotic drug-induced acute la-ryngeal dystonia two case reports and a mini review J Psychophar-macol 200519307ndash11

61 Tsai CS Lee Y Chang YY et al Ziprasidone-induced tardive la-ryngeal dystonia a case report Gen Hosp Psychiatry 200830277ndash9

62 Adams NP Bestall JC Lasserson TJ Jones P Cates CJ Fluticasoneversus placebo for chronic asthma in adults and children CochraneDatabase of Systematic Reviews 2008 Issue 4 Art No CD003135DOI 10100214651858CD003135pub4

63 Kahraman S Sirin S Erdogan E et al Is dysphonia permanent ortemporary after anterior cervical approach Eur Spine J 2007162092ndash5

64 Beutler WJ Sweeney CA Connolly PJ Recurrent laryngeal nerveinjury with anterior cervical spine surgery risk with laterality ofsurgical approach Spine 2001261337ndash42

65 Baron EM Soliman AM Gaughan JP et al Dysphagia hoarsenessand unilateral true vocal fold motion impairment following anteriorcervical diskectomy and fusion Ann Otol Rhinol Laryngol 2003112921ndash6

66 Jung A Schramm J Lehnerdt K et al Recurrent laryngeal nervepalsy during anterior cervical spine surgery a prospective studyJ Neurosurg Spine 20052123ndash7

67 Winslow CP Winslow TJ Wax MK Dysphonia and dysphagiafollowing the anterior approach to the cervical spine Arch Otolar-

yngol Head Neck Surg 200112751ndash5

68 Tervonen H Niemelauml M Lauri ER et al Dysphonia and dysphagiaafter anterior cervical decompression J Neurosurg Spine 20077124ndash30

69 Yue WM Brodner W Highland TR Persistent swallowing and voiceproblems after anterior cervical discectomy and fusion with allograftand plating a 5- to 11-year follow-up study Eur Spine J 200514677ndash82

70 Yeung P Erskine C Mathews P et al Voice changes and thyroidsurgery is pre-operative indirect laryngoscopy necessary Aust N ZJ Surg 199969632ndash4

71 Moulton-Barrett R Crumley R Jalilie S et al Complications ofthyroid surgery Int Surg 19978263ndash6

72 Bellantone R Boscherini M Lombardi CP et al Is the identificationof the external branch of the superior laryngeal nerve mandatory inthyroid operation Results of a prospective randomized study Sur-gery 20011301055ndash9

73 Zannetti S Parente B De Rango P et al Role of surgical techniquesand operative findings in cranial and cervical nerve injuries duringcarotid endarterectomy Eur J Vasc Endovasc Surg 199815528ndash31

74 Maniglia AJ Han DP Cranial nerve injuries following carotid end-arterectomy an analysis of 336 procedures Head Neck 199113121ndash4

75 Espinoza FI MacGregor FB Doughty JC et al Vocal fold paral-ysis following carotid endarterectomy J Laryngol Otol 1999113439 ndash 41

76 Schindler A Favero E Nudo S et al Voice after supracricoidlaryngectomy subjective objective and self-assessment data LogopedPhoniatr Vocol 200530114ndash9

77 Holst M Hertegaringrd S Persson A Vocal dysfunction followingcricothyroidotomy a prospective study Laryngoscope 1990100749 ndash55

78 Inada T Fujise K Shingu K Hoarseness after cardiac surgeryJ Cardiovasc Surg (Torino) 199839455ndash9

79 Kamalipour H Mowla A Saadi MH et al Determination of theincidence and severity of hoarseness after cardiac surgery Med SciMonit 200612CR206ndash9

80 Hamdan AL Moukarbel RV Farhat F et al Vocal cord paralysisafter open-heart surgery Eur J Cardiothorac Surg 200221671ndash4

81 Baba M Natsugoe S Shimada M et al Does hoarseness of voicefrom recurrent nerve paralysis after esophagectomy for carcinomainfluence patient quality of life J Am Coll Surg 1999188231ndash6

82 Morris GL III Mueller WM Long-term treatment with vagus nervestimulation in patients with refractory epilepsy The Vagus NerveStimulation Study Group E01-E05 Neurology 1999531731ndash5

83 Colice GL Stukel TA Dain B Laryngeal complications of prolongedintubation Chest 198996877ndash84

84 Santos PM Afrassiabi A Weymuller EA Jr Risk factors associatedwith prolonged intubation and laryngeal injury Otolaryngol HeadNeck Surg 1994111453ndash9

85 Bastian RW Richardson BE Postintubation phonatory insufficiencyan elusive diagnosis Otolaryngol Head Neck Surg 2001124625ndash33

86 Jones MW Catling S Evans E et al Hoarseness after trachealintubation Anaesthesia 199247213ndash6

87 Zimmert M Zwirner P Kruse E et al Effects on vocal function andincidence of laryngeal disorder when using a laryngeal mask airwayin comparison with an endotracheal tube Eur J Anaesthesiol 199916511ndash5

88 Hengerer AS Strome M Jaffe BF Injuries to the neonatal larynxfrom long-term endotracheal tube intubation and suggested tube mod-ification for prevention Ann Otol Rhinol Laryngol 197584764ndash70

89 Hagen P Lyons GD Nuss DW Dysphonia in the elderly diagnosisand management of age-related voice changes South Med J 199689204ndash7

90 Kosztyła-Hojna B Rogowski M Pepinski W The evaluation ofvoice in elderly patients Acta Otorhinolaryngol Belg 200357

107ndash12


91 Kandogan T Olgun L Guumlltekin G Causes of dysphonia in pa-tients above 60 years of age Kulak Burun Bogaz Ihtis Derg200311139 ndash 43

92 Lundy DS Silva C Casiano RR et al Cause of hoarseness in elderlypatients Otolaryngol Head Neck Surg 1998118481ndash5

93 Hartman DE Neurogenic dysphonia Ann Otol Rhinol Laryngol19849357ndash64

94 Sewall GK Jiang J Ford CN Clinical evaluation of Parkinsonrsquos-related dysphonia Laryngoscope 20061161740ndash4

95 Feijoacute AV Parente MA Behlau M et al Acoustic analysis of voice inmultiple sclerosis patients J Voice 200418341ndash7

96 Connor NP Cohen SB Theis SM et al Attitudes of children withdysphonia J Voice 200822197ndash209

97 Sederholm E McAllister A Dalkvist J et al Aetiologic factorsassociated with hoarseness in ten-year-old children Folia PhoniatrLogop 199547262ndash78

98 De Bodt MS Ketelslagers K Peeters T et al Evolution of vocal foldnodules from childhood to adolescence J Voice 200721151ndash6

99 Hocevar-Boltezar I Jarc A Kozelj V Ear nose and voice problemsin children with orofacial clefts J Laryngol Otol 2006120276ndash81

100 Hirschberg J Dysphonia in infants Int J Pediatr Otorhinolaryngol199949S293ndash6

101 Shankargouda S Krishnan U Murali R et al Dysphonia a fre-quently encountered symptom in the evaluation of infants with un-obstructed supracardiac total anomalous pulmonary venous connec-tion Pediatr Cardiol 200021458ndash60

102 Matsuo K Kamimura M Hirano M Polypoid vocal folds A 10-yearreview of 191 patients Auris Nasus Larynx 198310S37ndash45

103 Tombolini V Zurlo A Cavaceppi P et al Radiotherapy for T1carcinoma of the glottis Tumori 199581414ndash8

104 Franchin G Minatel E Gobitti C et al Radiotherapy for patientswith early-stage glottic carcinoma univariate and multivariate anal-yses in a group of consecutive unselected patients Cancer 200398765ndash72

105 Bernstein IL Chervinsky P Falliers CJ Efficacy and safety of tri-amcinolone acetonide aerosol in chronic asthma Results of a multi-center short-term controlled and long-term open study Chest 19828120ndash6

106 Musholt TJ Musholt PB Garm J et al Changes of the speaking andsinging voice after thyroid or parathyroid surgery Surgery 2006140978ndash88

107 Postma GN Courey MS Ossoff RH Microvascular lesions of thetrue vocal fold Ann Otol Rhinol Laryngol 1998107472ndash6

108 Preciado-Loacutepez J Peacuterez-Fernaacutendez C Calzada-Uriondo M et alEpidemiological study of voice disorders among teaching profession-als of La Rioja Spain J Voice 200822489ndash508

109 Mace SE Blunt laryngotracheal trauma Ann Emerg Med 198615836ndash42

110 Schaefer SD The acute management of external laryngeal trauma A27-year experience Arch Otolaryngol Head Neck Surg 1992118598ndash604

111 Resouly A Hope A Thomas S A rapid access husky voice clinicuseful in diagnosing laryngeal pathology J Laryngol Otol 2001115978ndash80

112 Johnson JT Newman RK Olson JE Persistent hoarseness an ag-gressive approach for early detection of laryngeal cancer PostgradMed 198067122ndash6

113 Ishizuka T Hisada T Aoki H et al Gender and age risks forhoarseness and dysphonia with use of a dry powder fluticasonepropionate inhaler in asthma Allergy Asthma Proc 200728550ndash6

114 Hartl DA Hans S Vaissiegravere J et al Objective acoustic and aerody-namic measures of breathiness in paralytic dysphonia Eur ArchOtorhinolaryngol 2003260175ndash82

115 Mao VH Abaza M Spiegel JR et al Laryngeal myasthenia gravisreport of 40 cases J Voice 200115122ndash30

116 Belafsky PC Rees CJ Laryngopharyngeal reflux the value of oto-

laryngology examination Curr Gastroenterol Rep 200810278ndash82

117 Ludlow CL Adler CH Berke GS et al Research priorities in spas-modic dysphonia Otolaryngol Head Neck Surg 2008139495ndash505

118 de Jong AL Kuppersmith RB Sulek M et al Vocal cord paralysis ininfants and children Otolarygol Clin North Am 200033131ndash49

119 Nicollas R Triglia JM The anterior laryngeal webs Otolaryngol ClinNorth Am 200841877ndash88 viii

120 Thompson DM Abnormal sensorimotor integrative function of thelarynx in congenital laryngomalacia a new theory of etiology La-ryngoscope 20071171ndash33

121 Faust RA Childhood voice disorders ambulatory evaluation andoperative diagnosis Clin Pediatr 2003421ndash9

122 Rehberg E Kleinsasser O Malignant transformation in non-irradi-ated juvenile laryngeal papillomatosis Eur Arch Otorhinolaryngol1999256450ndash4

123 Portier F Marianowski R Morisseau-Durand MP et al Respiratoryobstruction as a sign of brainstem dysfunction in infants with Chiarimalformations Int J Pediatr Otorhinolaryngol 200157195ndash202

124 Truong MT Messner AH Kerschner JE et al Pediatric vocal foldparalysis after cardiac surgery rate of recovery and sequelae Oto-laryngol Head Neck Surg 2007137780ndash4

125 Dworkin JP Laryngitis types causes and treatments OtolaryngolClin North Am 200841419ndash36 ix

126 Reveiz L Cardona Zorrilla AF Ospina EG Antibiotics for acute laryngitisin adults Cochrane Database of Systematic Reviews 2007 Issue 2 Art NoCD004783 DOI 10100214651858CD004783pub3

127 Teppo H Alho OP Comorbidity and diagnostic delay in cancer of thelarynx tongue and pharynx Oral Oncol 2008 Dec 16 [Epub ahead ofprint]

128 Carvalho AL Pintos J Schlecht NF et al Predictive factors fordiagnosis of advanced-stage squamous cell carcinoma of the head andneck Arch Otolaryngol Head Neck Surg 2002128313ndash8

129 Dailey SH Spanou K Zeitels SM The evaluation of benign glotticlesions rigid telescopic stroboscopy versus suspension microlaryn-goscopy J Voice 200721112ndash8

130 Patel R Dailey S Bless D Comparison of high-speed digital imagingwith stroboscopy for laryngeal imaging of glottal disorders Ann OtolRhinol Laryngol 2008117413ndash24

131 Sataloff RT Spiegel JR Hawkshaw MJ Strobovideolaryngoscopyresults and clinical value Ann Otol Rhinol Laryngol 1991100725ndash7

132 Shohet JA Courey MS Scott MA et al Value of videostroboscopicparameters in differentiating true vocal fold cysts from polyps La-ryngoscope 199610619ndash26

133 Kleinsasser O Microlaryngoscopy and endolaryngeal microsurgeryPhiladelphia WB Saunders 1968 p 48ndash62

134 Lacoste L Karayan J Lehuedeacute MS et al A comparison of directindirect and fiberoptic laryngoscopy to evaluate vocal cord paralysisafter thyroid surgery Thyroid 1996617ndash21

135 Armstrong M Mark LJ Snyder DS et al Safety of direct laryngos-copy as an outpatient procedure Laryngoscope 19971071060ndash5

136 Hill RS Koltai PJ Parnes SM Airway complications from laryngos-copy and panendoscopy Ann Otol Rhinol Laryngol 198796691ndash4

137 Rosen CA Andrade Filho PA Scheffel L et al Oropharyngealcomplications of suspension laryngoscopy a prospective study La-ryngoscope 20051151681ndash4

138 Boveacute MJ Jabbour N Krishna P et al Operating room versus office-based injection laryngoplasty a comparative analysis of reimburse-ment Laryngoscope 2007117226ndash30

139 Andrade Filho PA Carrau RL Buckmire RA Safety and cost-effectiveness of intra-office flexible videolaryngoscopy with transoralvocal fold injection in dysphagic patients Am J Otolaryngol 200627319ndash22

140 Rees CJ Postma GN Koufman JA Cost savings of unsedated office-based laser surgery for laryngeal papillomas Ann Otol Rhinol Lar-yngol 200711645ndash8

141 Brenner DJ Hall EJ Computed tomographymdashan increasing source

of radiation exposure N Engl J Med 20073572277ndash84


142 Brenner D Elliston C Hall E et al Estimated risks of radiation-induced fatal cancer from pediatric CT AJR Am J Roentgenol2001176289ndash96

143 Rice HE Frush DP Farmer D et al Review of radiation risks fromcomputed tomography essentials for the pediatric surgeon J PediatrSurg 200742603ndash7

144 Berrington de Gonzalez A Darby S Risk of cancer from diagnosticX-rays estimates for the UK and 14 other countries Lancet 2004363345ndash51

145 Sources and effects of ionizing radiation United Nations ScientificCommittee on the Effects of Atomic Radiation UNSCEAR 2000report to the General Assembly New York United Nations 2000

146 Wang CL Cohan RH Ellis JH et al Frequency outcome andappropriateness of treatment of nonionic iodinated contrast mediareactions Am J Roentgenol 2008191409ndash15

147 Morteleacute KJ Oliva MR Ondategui S et al Universal use of nonioniciodinated contrast medium for CT evaluation of safety in a largeurban teaching hospital AJR Am J Roentgenol 200518431ndash4

148 Dillman JR Ellis JH Cohan RH et al Frequency and severity ofacute allergic-like reactions to gadolinium-containing iv contrastmedia in children and adults AJR Am J Roentgenol 20071891533ndash8

149 Chung SM Safety issues in magnetic resonance imaging J Neu-roophthalmol 20022235ndash9

150 Stecco A Saponaro A Carriero A Patient safety issues in magneticresonance imaging state of the art Radiol Med 2007112491ndash508

151 Quirk ME Letendre AJ Ciottone RA et al Anxiety in patientsundergoing MR imaging Radiology 1989170463ndash6

152 Prince MR Arnoldus C Frisoli JK Nephrotoxicity of high-dosegadolinium compared with iodinated contrast J Magn Reson Imaging19966162ndash6

153 Tardy B Guy C Barral G et al Anaphylactic shock induced byintravenous gadopentetate dimeglumine Lancet 199222494

154 Perazella MA Gadolinium-contrast toxicity in patients with kidneydisease nephrotoxicity and nephrogenic systemic fibrosis Curr DrugSaf 2008367ndash75

155 Brummett RE Talbot JM Charuhas P Potential hearing loss result-ing from MR imaging Radiology 1988169539ndash40

156 Smith-Bindman R Miglioretti DL Larson EB Rising use of diag-nostic medical imaging in a large integrated health system HealthAff (Millwood) 2008271491ndash502

157 Saini S Sharma R Levine LA et al Technical cost of CT exami-nations Radiology 2001218172ndash5

158 Saini S Seltzer SE Bramson RT et al Technical cost of radiologicexaminations analysis across imaging modalities Radiology 2000216269ndash72

159 Pretorius PM Milford CA Investigating the hoarse voice BMJ20083371165ndash8

160 Robinson S Pitkaumlranta A Radiology findings in adult patients withvocal fold paralysis Clin Radiol 200661863ndash7

161 MacGregor FB Roberts DN Howard DJ et al Vocal fold palsy are-evaluation of investigations J Laryngol Otol 1994108193ndash6

162 Merati AL Halum SL Smith TL Diagnostic testing for vocal foldparalysis survey of practice and evidence-based medicine reviewLaryngoscope 20061161539ndash52

163 Mazonakis M Tzedakis A Damilakis J et al Thyroid dose fromcommon head and neck CT examinations in children is there anexcess risk for thyroid cancer induction Eur Radiol 2007171352ndash7

164 Becker M Neoplastic invasion of laryngeal cartilage radiologicdiagnosis and therapeutic implications Eur J Radiol 200033216 ndash29

165 Ng SH Chang TC Ko SF et al Nasopharyngeal carcinoma MRIand CT assessment Neuroradiology 199739741ndash6

166 Ostrower ST Parikh SR Hoarseness In AAP textbook of pediatriccare McInerny TK Adam HM Campbell DE et al editors ElkGrove Village American Academy of Pediatrics 2008

167 Glastonbury CM Non-oncologic imaging of the larynx Otolaryngol

Clin North Am 200841139ndash56

168 Blodgett TM Fukui MB Snyderman CH et al Combined PET-CTin the head and neck part 1 Physiologic altered physiologic andartifactual FDG uptake Radiographics 200525897ndash912

169 Hopkins C Yousaf U Pedersen M Acid reflux treatment for hoarse-ness Cochrane Database of Systematic Reviews 2006 Issue 1 ArtNo CD005054 DOI 10100214651858CD005054pub2

170 Belafsky PC Postma GN Koufman JA Laryngopharyngeal refluxsymptoms improve before changes in physical findings Laryngo-scope 2001111979ndash81

171 El-Serag HB Lee P Buchner A et al Lansoprazole treatment ofpatients with chronic idiopathic laryngitis a placebo-controlled trialAm J Gastroenterol 200196979ndash83

172 Vaezi MF Richter JE Stasney CR et al Treatment of chronicposterior laryngitis with esomeprazole Laryngoscope 2006116254 ndash 60

173 Kahrilas PJ Shaheen NJ Vaezi MF et al American Gastroenter-ological Association Institute technical review on the management ofgastroesophageal reflux disease Gastroenterology 20081351392ndash413

174 Kahrilas PJ Shaheen NJ Vaezi MF et al American Gastroenter-ological Association Medical Position Statement on the managementof gastroesophageal reflux disease Gastroenterology 20081351383ndash91

175 Qua CS Wong CH Gopala K et al Gastro-oesophageal refluxdisease in chronic laryngitis prevalence and response to acid-sup-pressive therapy Aliment Pharmacol Ther 200725287ndash95

176 Boustani M Hall KS Lane KA et al The association betweencognition and histamine-2 receptor antagonists in African AmericansJ Am Geriatr Soc 2007551248ndash53

177 Hanlon JT Landerman LR Artz MB et al Histamine2 receptorantagonist use and decline in cognitive function among communitydwelling elderly Pharmacoepidemiol Drug Saf 200413781ndash7

178 Garciacutea Rodriacuteguez LA Ruigoacutemez A Paneacutes J Use of acid-suppressingdrugs and the risk of bacterial gastroenteritis Clin GastroenterolHepatol 200751418ndash23

179 Loo VG Poirier L Miller MA et al A predominantly clonal multi-institutional outbreak of Clostridium difficile-associated diarrheawith high morbidity and mortality N Engl J Med 20053532442ndash9

180 Gulmez SE Holm A Frederiksen H et al Use of proton pumpinhibitors and the risk of community-acquired pneumonia a popula-tion-based case-control study Arch Intern Med 2007167950ndash5

181 Laheij RJ Sturkenboom MC Hassing RJ et al Risk of community-acquired pneumonia and use of gastric acid-suppressive drugsJAMA 20042921955ndash60

182 Gilard M Arnaud B Cornily JC et al Influence of omeprazole on theantiplatelet action of clopidogrel associated with aspirin the random-ized double-blind OCLA (Omeprazole CLopidogrel Aspirin) studyJ Am Coll Cardiol 200851256ndash60

183 Sarkar M Hennessy S Yang YX Proton-pump inhibitor use and therisk for community-acquired pneumonia Ann Intern Med 2008149391ndash8

184 Canani RB Cirillo P Roggero P et al Therapy with gastric acidityinhibitors increases the risk of acute gastroenteritis and community-acquired pneumonia in children Pediatrics 2006117e817ndash20

185 Yang YX Proton pump inhibitor therapy and osteoporosis CurrDrug Saf 20083204ndash9

186 Marcuard SP Albernaz L Khazanie PG Omeprazole therapy causesmalabsorption of cyanocobalamin (vitamin B12) Ann Intern Med1994120211ndash5

187 Hirschowitz BI Worthington J Mohnen J Vitamin B12 deficiency inhypersecretors during long-term acid suppression with proton pumpinhibitors Aliment Pharmacol Ther 2008271110ndash21

188 Khatib MA Rahim O Kania R et al Iron deficiency anemia inducedby long-term ingestion of omeprazole Dig Dis Sci 2002472596ndash7

189 Sundstroumlm A Blomgren K Alfredsson L et al Acid-suppressingdrugs and gastroesophageal reflux disease as risk factors for acutepancreatitismdashresults from a Swedish case-control study Pharmaco-

epidemiol Drug Saf 200615141ndash9


190 Ylitalo R Ramel S Extraesophageal reflux in patients with contactgranuloma a prospective controlled study Ann Otol Rhinol Laryngol2002111441ndash6

191 Hanson DG Jiang J Chi W Quantitative color analysis of laryngealerythema in chronic posterior laryngitis J Voice 19981278ndash83

192 Reichel O Dressel H Wiederaumlnders K et al Double-blind placebo-controlled trial with esomeprazole for symptoms and signs associatedwith laryngopharyngeal reflux Otolaryngol Head Neck Surg 2008139414ndash20

193 Park W Hicks DM Khandwala F et al Laryngopharyngeal refluxprospective cohort study evaluating optimal dose of proton-pumpinhibitor therapy and pretherapy predictors of response Laryngo-scope 20051151230ndash8

194 Maronian NC Azadeh H Waugh P et al Association of laryngo-pharyngeal reflux disease and subglottic stenosis Ann Otol RhinolLaryngol 2001110606ndash12

195 Vaezi MF Qadeer MA Lopez R et al Laryngeal cancer and gas-troesophageal reflux disease a case-control study Am J Med 2006119768ndash76

196 Qadeer MA Lopez R Wood BG et al Does acid suppressive therapyreduce the risk of laryngeal cancer recurrence Laryngoscope 20051151877ndash81

197 Kantas I Balatsouras DG Kamargianis N et al The influence oflaryngopharyngeal reflux in the healing of laryngeal trauma EurArch Otorhinolaryngol 2009266253ndash9

198 Wani MK Woodson GE Laryngeal contact granuloma Laryngo-scope 19991091589ndash93

199 Jin J Lee YS Jeong SW et al Change of acoustic parameters beforeand after treatment in laryngopharyngeal reflux patients Laryngo-scope 2008118938ndash41

200 Milstein CF Charbel S Hicks DM et al Prevalence of laryngealirritation signs associated with reflux in asymptomatic volunteersimpact of endoscopic technique (rigid vs flexible laryngoscope)Laryngoscope 20051152256ndash61

201 Branski RC Bhattacharyya N Shapiro J The reliability of the as-sessment of endoscopic laryngeal findings associated with laryngo-pharyngeal reflux disease Laryngoscope 20021121019ndash24

202 Stuck AE Minder CE Frey FJ Risk of infectious complications inpatients taking glucocorticosteroids Rev Infect Dis 198911954ndash63

203 Fardet L Kassar A Cabane J et al Corticosteroid-induced adverseevents in adults frequency screening and prevention Drug Saf200730861ndash81

204 Conn HO Poynard T Corticosteroids and peptic ulcer meta-analysisof adverse events during steroid therapy J Intern Med 1994236619ndash32

205 Messer J Reitman D Sacks HS et al Association of adrenocortico-steroid therapy and peptic-ulcer disease N Engl J Med 198330121ndash4

206 Warrington TP Bostwick JM Psychiatric adverse effects of cortico-steroids Mayo Clin Proc 2006811361ndash7

207 van Everdingen AA Jacobs JW Siewertsz Van Reesema DR et alLow-dose prednisone therapy for patients with early active rheuma-toid arthritis clinical efficacy disease-modifying properties and sideeffects a randomized double-blind placebo-controlled clinical trialAnn Intern Med 20021361ndash12

208 Williams AJ Baghat MS Stableforth DE et al Dysphonia caused byinhaled steroids recognition of a characteristic laryngeal abnormal-ity Thorax 198338813ndash21

209 Williamson IJ Matusiewicz SP Brown PH et al Frequency of voiceproblems and cough in patients using pressurized aerosol inhaledsteroid preparations Eur Respir J 19958590ndash2

210 Forrest LA Weed H Candida laryngitis appearing as leukoplakia andGERD J Voice 19981291ndash5

211 Toogood JH Inhaled steroid asthma treatment lsquoPrimum non nocerersquoCan Respir J 19985(Suppl A)50Andash3A

212 Jackson-Menaldi CA Dzul AI Holland RW Allergies and vocal fold

edema a preliminary report J Voice 199913113ndash22

213 Lavy JA Wood G Rubin JS et al Dysphonia associated with inhaledsteroids J Voice 200014581ndash8

214 Dubus JC Meacutely L Huiart L et al Cough after inhalation of corti-costeroids delivered from spacer devices in children with asthmaFundam Clin Pharmacol 200317627ndash31

215 DelGaudio JM Steroid inhaler laryngitis dysphonia caused by in-haled fluticasone therapy Arch Otolaryngol Head Neck Surg 2002128677ndash81

216 Sin DD Man SF Inhaled corticosteroids in the long-term manage-ment of patients with chronic obstructive pulmonary disease DrugsAging 200320867ndash80

217 Mirza N Kasper Schwartz S Antin-Ozerkis D Laryngeal findings inusers of combination corticosteroid and bronchodilator therapy La-ryngoscope 20041141566ndash9

218 Sulica L Laryngeal thrush Ann Otol Rhinol Laryngol 2005114369ndash75

219 Gallivan GJ Gallivan KH Gallivan HK Inhaled corticosteroidshazardous effects on voicemdashan update J Voice 200721101ndash11

220 Leung AK Kellner JD Johnson DW Viral croup a current perspec-tive J Pediatr Health Care 200418297ndash301

221 Jackson-Menaldi CA Dzul AI Holland RW Hidden respiratoryallergies in voice users treatment strategies Logoped Phoniatr Vocol20022774ndash9

222 Dean CM Sataloff RT Hawkshaw MJ et al Laryngeal sarcoidosisJ Voice 200216283ndash8

223 Ozcan KM Bahar S Ozcan I et al Laryngeal involvement insystemic lupus erythematosus report of two cases J Clin Rheumatol200713278ndash9

224 Higgins PB Viruses associated with acute respiratory infections1961-71 J Hyg (Lond) 197472425ndash32

225 Bove MJ Kansal S Rosen CA Influenza and the vocal performerUpdate on prevention and treatment J Voice 200822326ndash32

226 Schaleacuten L Eliasson I Kamme C et al Erythromycin in acute lar-yngitis in adults Ann Otol Rhinol Laryngol 1993102209ndash14

227 Reveiz L Cardona AF Ospina EG Antibiotics for acute laryngitis inadults Cochrane Database of Systematic Reviews 2007 Issue 2 ArtNo CD004783 DOI 10100214651858CD004783pub3

228 Arroll B Kenealy T Antibiotics for the common cold and acutepurulent rhinitis Cochrane Database of Systematic Reviews 2005Issue 3 Art No CD000247 DOI 10100214651858CD000247pub2

229 Glasziou PP Del Mar C Sanders S et al Antibiotics for acuteotitis media in children Cochrane Database of Systematic Reviews2004 Issue 1 Art No CD000219 DOI 10100214651858CD000219pub2

230 Horn JR Hansten PD Drug interactions with antibacterial agents JFam Pract 19954181ndash90

231 Brook I Foote PA Hausfeld JN Increase in the frequency of recov-ery of methicillin-resistant Staphylococcus aureus in acute andchronic maxillary sinusitis J Med Microbiol 2008571015ndash7

232 Asche C McAdam-Marx C Seal B et al Treatment costs associatedwith community-acquired pneumonia by community level of antimi-crobial resistance J Antimicrob Chemother 2008611162ndash8

233 Singh B Balwally AN Nash M et al Laryngeal tuberculosis inHIV-infected patients a difficult diagnosis Laryngoscope 19961061238ndash40

234 Tato AM Pascual J Orofino L et al Laryngeal tuberculosis in renalallograft patients Am J Kidney Dis 199831701ndash5

235 Wang BY Amolat MJ Woo P et al Atypical mycobacteriosis of thelarynx an unusual clinical presentation secondary to steroids inhala-tion Ann Diagn Pathol 200812426ndash9

236 Lightfoot SA Laryngeal tuberculosis masquerading as carcinomaJ Am Board Fam Pract 199710374ndash6

237 Silva L Damrose E Bairatildeo F et al Infectious granulomatous laryn-gitis a retrospective study of 24 cases Eur Arch Otorhinolaryngol2008265675ndash80

238 Sari M Yazici M Baglam T et al Actinomycosis of the larynx Acta

Otolaryngol 2007127550ndash2


239 Sotir MJ Cappozzo DL Warshauer DM et al A countywide out-break of pertussis initial transmission in a high school weight roomwith subsequent substantial impact on adolescents and adults ArchPediatr Adolesc Med 200816279ndash85

240 Postels-Multani S Schmitt HJ Wirsing von Koumlnig CH et al Symp-toms and complications of pertussis in adults Infection 199523139ndash42

241 Hopkins A Lahiri T Salerno R et al Changing epidemiology oflife-threatening upper airway infections the reemergence of bacterialtracheitis Pediatrics 20061181418ndash21

242 Royal College of Speech amp Language Therapists Clinical voicedisorders Royal College of Speech amp Language Therapists 2005httpwwwrcsltorgresourcesRCSLT_Clinical_Guidelinespdf (ac-cessed June 10 2009)

243 American Speech-Language-Hearing Association Preferred practicepatterns for the profession of speech-language pathology 2004httpwwwashaorgdocshtmlPP2004-00191html

244 Bastian RW Levine LA Visual methods of office diagnosis of voicedisorders Ear Nose Throat J 198867363ndash79

245 American Speech-Language-Hearing Association The use of voicetherapy in the treatment of dysphonia 2005 httpwwwashaorgdocshtmlTR2005-00158html

246 American Speech-Language-Hearing Association Training guide-lines for laryngeal videoendoscopystroboscopy 1998 httpwwwashaorgdocshtmlGL1998-00064html

247 Thomas G Mathews SS Chrysolyte SB et al Outcome analysis ofbenign vocal cord lesions by videostroboscopy acoustic analysis andvoice handicap index Indian J Otolaryngol 200759336ndash40

248 Woo P Colton R Casper J et al Diagnostic value of stroboscopicexamination in hoarse patients J Voice 19915231ndash8

249 Thomas LB Stemple JC Voice therapy Does science support theart Communicative Disorders Review 2007149ndash77

250 Anderson T Sataloff RT The power of voice therapy Ear NoseThroat J 200281433ndash4

251 Speyer R Weineke G Hosseini EG et al Effects of voice therapy asobjectively evaluated by digitized laryngeal stroboscopic imagingAnn Otol Rhinol Laryngol 2002111902ndash8

252 Pedersen M Beranova A Moslashller S Dysphonia medical treatmentand a medical voice hygiene advice approach A prospective ran-domised pilot study Eur Arch Otorhinolaryngol 2004261312ndash5

253 Boone DR McFarlane SC Von Berg SL The voice and voicetherapy 7th ed Boston Allyn and Bacon 2005

254 Stemple JC Glaze LE Klaben BG Clinical voice pathology Theoryand management 3rd ed San Diego Singular 2000

255 Roy N Gray SD Simon M et al An evaluation of the effects of twotreatment approaches for teachers with voice disorders a prospectiverandomized clinical trial J Speech Lang Hear Res 200144286ndash96

256 Verdolini-Marston K Burke MK Lessac A et al Preliminary studyof two methods of treatment for laryngeal nodules J Voice 1995974ndash85

257 Fox CM Ramig LO Ciucci MR et al The science and practice ofLSVTLOUD neural plasticity-principled approach to treating indi-viduals with Parkinson disease and other neurological disordersSemin Speech Lang 200627283ndash99

258 Kim J Davenport P Sapienza C Effect of expiratory muscle strengthtraining on elderly cough function Arch Gerontol Geriatr 200948361ndash6

259 Sullivan MD Heywood BM Beukelman DR A treatment for vocalcord dysfunction in female athletes an outcome study Laryngoscope20011111751ndash5

260 Boutsen F Cannito MP Taylor M et al Botox treatment in adductorspasmodic dysphonia a meta-analysis J Speech Lang Hear Res200245469ndash81

261 Pearson EJ Sapienza CM Historical approaches to the treatment ofAdductor-Type Spasmodic Dysphonia (ADSD) review and tutorial

NeuroRehabilitation 200318325ndash38

262 Zeitels SM Casiano RR Gardner GM et al Management of com-mon voice problems committee report Otolaryngol Head Neck Surg2002126333ndash48

263 Johns MM Update on the etiology diagnosis and treatment of vocalfold nodules polyps and cysts Curr Opin Otolaryngol Head NeckSurg 200311456ndash61

264 McCrory E Voice therapy outcomes in vocal fold nodules a retro-spective audit Int J Lang Commun Disord 200136(Suppl)19ndash24

265 Havas TE Priestley J Lowinger DS A management strategy forvocal process granulomas Laryngoscope 1999109301ndash6

266 Johns MM Garrett CG Hwang J et al Quality-of-life outcomesfollowing laryngeal endoscopic surgery for non-neoplastic vocal foldlesions Ann Otol Rhinol Laryngol 2004113597ndash601

267 Zeitels SM Akst LM Bums JA et al Pulsed angiolytic laser treat-ment of ectasias and varices in singers Ann Otol Rhinol Laryngol2006115571ndash80

268 Bennett S Bishop SG Lumpkin SM Phonatory characteristics fol-lowing surgical treatment of severe polypoid degeneration Laryngo-scope 198999525ndash32

269 Ragab SM Elsheikh MN Saafan ME et al Radiophonosurgery ofbenign superficial vocal fold lesions J Laryngol Otol 2005119961ndash6

270 Dedo HH Yu KC CO2 laser treatment in 244 patients with respira-tory papillomas Laryngoscope 20011111639ndash44

271 Pasquale K Wiatrak B Woolley A et al Microdebrider versus CO2

laser removal of recurrent respiratory papillomas a prospective anal-ysis Laryngoscope 2003113139ndash43

272 Steinberg B Topp W Schneider P Laryngeal papilloma virus infec-tion during clinical remission N Engl J Med 19833081261ndash4

273 Benninger MS Microdissection or microspot CO2 laser for limitedbenign vocal fold lesions a prospective randomized trial Laryngo-scope 20001101ndash37

274 OrsquoLeary MA Grillone GA Injection laryngoplasty Otolaryngol ClinNorth Am 20063943ndash54

275 Morgan JE Zraick RI Griffin AW et al Injection versus medializa-tion laryngoplasty for the treatment of unilateral vocal fold paralysisLaryngoscope 20071172068ndash74

276 Hertegaringrd S Halleacuten L Laurent C et al Cross-linked hyaluronanversus collagen for injection treatment of glottal insufficiency 2-yearfollow-up Acta Otolaryngol 20041241208ndash14

277 Kimura M Nito T Sakakibara K et al Clinical experience withcollagen injection of the vocal fold a study of 155 patients AurisNasus Larynx 20083567ndash75

278 Cantarella G Mazzola RF Domenichini E et al Vocal fold augmen-tation by autologous fat injection with lipostructure procedure Oto-laryngol Head Neck Surg 2005132

279 Karpenko AN Dworkin JP Meleca RJ et al Cymetra injection forunilateral vocal fold paralysis Ann Otol Rhinol Laryngol 2003112927ndash34

280 Lee SW Son YI Kim CH et al Voice outcomes of polyacrylamidehydrogel injection laryngoplasty Laryngoscope 20071171871ndash5

281 Patel NJ Kerschner JE Merati AL The use of injectable collagen inthe management of pediatric vocal unilateral fold paralysis Int J Pe-diatr Otorhinolaryngol 2003671355ndash60

282 Sittel C Echternach M Federspil PA et al Polydimethylsiloxaneparticles for permanent injection laryngoplasty Ann Otol RhinolLaryngol 2006115103ndash9

283 Rosen CA Gartner-Schmidt J Casiano R et al Vocal fold augmen-tation with calcium hydroxylapatite (CaHA) Otolaryngol Head NeckSurg 2007136198ndash204

284 Kasperbauer JL Slavit DH Maragos NE Teflon granulomas andoverinjection of Teflon a therapeutic challenge for the otorhinolar-yngologist Ann Otol Rhinol Laryngol 1993102748ndash51

285 Varvares MA Montgomery WW Hillman RE Teflon granuloma ofthe larynx etiology pathophysiology and management Ann Otol

Rhinol Laryngol 1995104511ndash5


286 Schneider B Bigenzahn W End A et al External vocal fold medi-alization in patients with recurrent nerve paralysis following cardio-thoracic surgery Eur J Cardiothorac Surg 200323477ndash83

287 Zeitels SM Mauri M Dailey SH Medialization laryngoplasty with Gore-Tex for voice restoration secondary to glottal incompetence indications andobservations Ann Otol Rhinol Laryngol 2003112180ndash4

288 Cummings CW Purcell LL Flint PW Hydroxylapatite laryngealimplants for medialization Preliminary report Ann Otol RhinolLaryngol 1993102843ndash51

289 Gray SD Barkmeier J Jones D et al Vocal evaluation of thyroplas-tic surgery in the treatment of unilateral vocal fold paralysis Laryn-goscope 1992102415ndash21

290 Kelchner LN Stemple JC Gerdeman E et al Etiology pathophys-iology treatment choices and voice results for unilateral adductorvocal fold paralysis a 3-year retrospective J Voice 199913592ndash601

291 Chester MW Stewart MG Arytenoid adduction combined with me-dialization thyroplasty An evidence-based review Otolaryngol HeadNeck Surg 2003129305ndash10

292 Gardner GM Altman JS Balakrishnan G Pediatric vocal fold me-dialization with silastic implant intraoperative airway managementInt J Pediatr Otorhinolaryngol 20005237ndash44

293 Link DT Rutter MJ Liu JH et al Pediatric type I thyroplasty anevolving procedure Ann Otol Rhinol Laryngol 19991081105ndash10

294 Schiratzki H Fritzell B Treatment of spasmodic dysphonia by meansof resection of the recurrent laryngeal nerve Acta Otolaryngol Suppl1988449115ndash7

295 Sapir S Aronson AE Clinical reliability in rating voice improvementafter laryngeal nerve section for spastic dysphonia Laryngoscope198595200ndash2

296 Biller HF Som ML Lawson W Laryngeal nerve crush for spasticdysphonia Ann Otol Rhinol Laryngol 198392469

297 Dedo HH Izdebski K Evaluation and treatment of recurrent spas-ticity after recurrent laryngeal nerve section A preliminary reportAnn Otol Rhinol Laryngol 198493343ndash5

298 Berke GS Blackwell KE Gerratt BR et al Selective laryngeal adductordenervation-reinnervation a new surgical treatment for adductor spasmodicdysphonia Ann Otol Rhinol Laryngol 1999108227ndash31

299 Truong DD Bhidayasiri R Botulinum toxin therapy of laryngealmuscle hyperactivity syndromes comparing different botulinumtoxin preparations Eur J Neurol 200613(Suppl 1)36ndash41

300 Blitzer A Sulica L Botulinum toxin basic science and clinical usesin otolaryngology Laryngoscope 2001111218ndash26

301 Sulica L Contemporary management of spasmodic dysphonia CurrOpin Otolaryngol Head Neck Surg 200412543ndash8

302 Stong BC DelGaudio JM Hapner ER et al Safety of simultaneousbilateral botulinum toxin injections for abductor spasmodic dyspho-nia Arch Otolaryngol Head Neck Surg 2005131793ndash5

303 Blitzer A Brin MF Fahn S et al Localized injections of botulinumtoxin for the treatment of focal laryngeal dystonia (spastic dyspho-nia) Laryngoscope 198898193ndash7

304 Troung DD Rontal M Rolnick M et al Double-blind controlledstudy of botulinum toxin in adductor spasmodic dysphonia Laryn-goscope 1991101630ndash4

305 Cannito MP Woodson GE Murry T et al Perceptual analyses ofspasmodic dysphonia before and after treatment Arch OtolaryngolHead Neck Surg 20041301393ndash9

306 Courey MS Garrett CG Billante CR et al Outcomes assessmentfollowing treatment of spasmodic dysphonia with botulinum toxinAnn Otol Rhinol Laryngol 2000109819ndash22

307 Watts C Whurr R Nye C Botulinum toxin injections for the treat-ment of spasmodic dysphonia Cochrane Database of SystematicReviews 2004 Issue 3 Art No CD004327 DOI 10100214651858CD004327pub2

308 Blitzer A Brin MF Stewart CF Botulinum toxin management ofspasmodic dysphonia (laryngeal dystonia) a 12-year experience in

more than 900 patients Laryngoscope 19981081435ndash41

309 Adler CH Bansberg SF Krein-Jones K et al Safety and efficacy ofbotulinum toxin type B (Myobloc) in adductor spasmodic dysphoniaMov Disord 2004191075ndash9

310 Thomas JP Siupsinskiene N Frozen versus fresh reconstituted botox forlaryngeal dystonia Otolaryngol Head Neck Surg 2006135204ndash8

311 Blitzer A Brin MF Laryngeal dystonia a series with botulinum toxintherapy Ann Otol Rhinol Laryngol 199110085ndash9

312 Inagi K Ford CN Bless DM et al Analysis of factors affecting botulinumtoxin results in spasmodic dysphonia J Voice 199610306ndash13

313 Koriwchak MJ Netterville JL Snowden T et al Alternating unilat-eral botulinum toxin type A (BOTOX) injections for spasmodicdysphonia Laryngoscope 19961061476ndash81

314 Holzer SE Ludlow CL The swallowing side effects of botulinumtoxin type A injection in spasmodic dysphonia Laryngoscope 199610686ndash92

315 Woodson G Hochstetler H Murry T Botulinum toxin therapy forabductor spasmodic dysphonia J Voice 200620137ndash43

316 Lundy DS Lu FL Casiano RR et al The effect of patient factors onresponse outcomes to Botox treatment of spasmodic dysphonia JVoice 199812460ndash6

317 Fisher KV Giddens CL Gray SD Does botulinum toxin alter laryn-geal secretions and mucociliary transport J Voice 199812389ndash98

318 Park JB Simpson LL Anderson TD et al Immunologic character-ization of spasmodic dysphonia patients who develop resistance tobotulinum toxin J Voice 200317(2)255ndash64

319 Ferreira LP de Oliveira Latorre MD Pinto Giannini SP et alInfluence of abusive vocal habits hydration mastication and sleep inthe occurrence of vocal symptoms in teachers J Voice 2009 Jan 8[Epub ahead of print]

320 Ori Y Sabo R Binder Y et al Effect of hemodialysis on thethickness of vocal folds a possible explanation for postdialysishoarseness Nephron Clin Pract 2006103c144ndash8

321 Yiu EM Chan RM Effect of hydration and vocal rest on the vocalfatigue in amateur karaoke singers J Voice 200317216ndash27

322 Joacutensdottir V Laukkanen AM Siikki I Changes in teachersrsquo voicequality during a working day with and without electric sound ampli-fication Folia Phoniatr Logop 200355267ndash80

323 Ruotsalainen JH Sellman J Lehto L et al Interventions for prevent-ing voice disorders in adults Cochrane Database of Systematic Re-views 2007 Issue 4 Art No CD006372 DOI 10100214651858CD006372pub2

324 Duffy OM Hazlett DE The impact of preventive voice care programsfor training teachers a longitudinal study J Voice 20041863ndash70

325 Bovo R Galceran M Petruccelli J et al Vocal problems among teachersevaluation of a preventive voice program J Voice 200721705ndash22

326 Landes BA McCabe BF Dysphonia as a reaction to cigaret smokeLaryngoscope 195767155ndash6

327 de la Hoz RE Shohet MR Bienenfeld LA et al Vocal cord dys-function in former World Trade Center (WTC) rescue and recoveryworkers and volunteers Am J Ind Med 200851161ndash5

APPENDIX

Frequently Asked Questions About Voice

Therapy

Why is voice therapy recommended for hoarseness Voicetherapy has been demonstrated to be effective for hoarse-ness across the lifespan from children to older adultsA1A2

Voice therapy is the first line of treatment for vocal foldlesions like vocal nodules polyps or cystsA3A4 Theselesions often occur in people with vocally intense occupa-

A5

tions like teachers attorneys or clergymen Another pos-


sible cause of these lesions is vocal overdoing often seen insports enthusiasts in socially active aggressive or loud chil-dren or in high-energy adults who often speak loudlyA6-A9

Voice therapy specifically the Lee Silverman VoiceTherapy method has been demonstrated to be the mosteffective method of treating the lower volume lower en-ergy and rapid-rate voicespeech of individuals with Par-kinson diseaseA10A11

Voice therapy has been used to treat hoarseness concur-rently with other medical therapies like botulinum toxin injec-tions for spasmodic dysphonia andor tremorA12A13 Voicetherapy has been used alone in the treatment of unilateral vocalfold paralysisA14A15 and has been used to improve the out-come of surgical procedures as in vocal fold augmentationA16

or thyroplastyA17 Voice therapy is an important component ofany comprehensive surgical treatment for hoarsenessA18

What happens in voice therapy Voice therapy is a programdesigned to reduce hoarseness through guided change in vocalbehaviors and lifestyle changes Voice therapy consists of avariety of tasks designed to eliminate harmful vocal behaviorshape healthy vocal behavior and assist in vocal fold woundhealing after surgery or injury Voice therapy for hoarsenessgenerally consists of 1 to 2 therapy sessions each week for 4 to8 weeksA19 The duration of therapy is determined by theorigin of the hoarseness and severity of the problem co-occurring medical therapy and importantly patient commit-ment to the practice and generalization of new vocal behaviorsoutside the therapy sessionA20

Who provides voice therapy Certified and licensed speech-language pathologists are healthcare professionals with theexpertise needed to provide effective behavioral treatmentfor hoarsenessA21

How do I find a qualified speech-language pathologistwho has experience in voice The American Speech-Lan-guage-Hearing Association (ASHA) is an excellent resourcefor finding a certified speech-language pathologist by goingto the ASHA website (wwwashaorg) or by accessingASHArsquos online search engine called ProSearch at httpwwwashaorgproserv You may also contact ASHArsquos Ac-tion Center Monday through Friday (830 am-530 pm) at1-800-638-8255 fax 301-296-8580 TTY (Text TelephoneCommunication Device) 301-296-5650 e-mail actioncenterashaorg

Does insurance cover voice therapy Generally Medicareunder the guidelines for coverage of speech therapy will covervoice therapy if provided by a certified and licensed speech-language pathologist ordered by a physician and deemedmedically necessary for the diagnosis Medicaid varies fromstate to state but generally covers voice therapy under the rulesfor speech therapy up to the age of 18 years It is best tocontact your local Medicaid office as there are state differ-

ences and program differences Private insurance companies

vary and the consumer is guided to contact his or her insurancecompany for specific guidelines for their purchased policies

Are speech therapy and voice therapy the same Speech ther-apy is a term that encompasses a variety of therapies includingvoice therapy Most insurance companies refer to voice ther-apy as speech therapy but they are the same thing if providedby a certified and licensed speech-language pathologist

REFERENCES

A1 Thomas LB Stemple JC Voice therapy Does science support theart Communicative Disorders Review 2007149ndash77

A2 Ramig LO Verdolini K Treatment efficacy voice disorders JSpeech Lang Hear Res 199841S101ndash16

A3 Johns MM Update on the etiology diagnosis and treatment of vocalfold nodules polyps and cysts Curr Opin Otolaryngol Head NeckSurg 200311456ndash61

A4 Anderson T Sataloff RT The power of voice therapy Ear NoseThroat J 200281433ndash4

A5 Roy N Gray SD Simon M et al An evaluation of the effects of twotreatment approaches for teachers with voice disorders a prospectiverandomized clinical trial J Speech Lang Hear Res 200144286ndash96

A6 Trani M Ghidini A Bergamini G et al Voice therapy in pediatricfunctional dysphonia a prospective study Int J Pediatr Otorhinolar-yngol 200771379ndash84

A7 Rubin JS Sataloff RT Korovin GW Diagnosis and treatment ofvoice disorders 3rd ed San Diego Plural Publishing Group 2006

A8 Stemple J Glaze L Klaben B Clinical voice pathology Theory andmanagement 3rd ed San Diego Singular 2000

A9 Boone DR McFarlane SC Von Berg S The voice and voice therapy7th ed Boston Allyn and Bacon 2005

A10 Fox CM Ramig LO Ciucci MR et al The science and practice ofLSVTLOUD neural plasticity-principled approach to treating indi-viduals with Parkinson disease and other neurological disordersSemin Speech Lang 200627283ndash99

A11 Dromey C Ramig LO Johnson AB Phonatory and articulatorychanges associated with increased vocal intensity in Parkinson dis-ease a case study J Speech Hear Res 199538751ndash64

A12 Pearson EJ Sapienza CM Historical approaches to the treatment ofAdductor-Type Spasmodic Dysphonia (ADSD) review and tutorialNeuroRehabilitation 200318325ndash38

A13 Murry T Woodson GE Combined-modality treatment of adductorspasmodic dysphonia with botulinum toxin and voice therapy JVoice 19959460ndash5

A14 Schindler A Bottero A Capaccio P et al Vocal improvement aftervoice therapy in unilateral vocal fold paralysis J Voice 200822113ndash8

A15 Miller S Voice therapy for vocal fold paralysis Otolaryngol ClinNorth Am 200437105ndash19

A16 Rosen CA Phonosurgical vocal fold injection procedures and ma-terials Otolaryngol Clin North Am 2000331087ndash96

A17 Billiante CR Clary J Sullivan C et al Voice therapy followingthyroplasty with long standing vocal fold immobility Aurus NasusLarynx 200229341ndash5

A18 Branski RC Murray T Voice therapy 2008 Available at httpemedicinemedscapecomarticle866712-overview Accessed May18 2009

A19 Hapner E Portone-Maira C Johns MM A study of voice therapydropout J Voice 200923337ndash40

A20 Behrman A Facilitating behavioral change in voice therapy therelevance of motivational interviewing Am J Speech Lang Pathol200615215ndash25

A21 American Speech-Language-Hearing Association The use of voicetherapy in the treatment of dysphonia 2005 httpwwwashaorg

docshtmlTR2005-00158html Accessed May 18 2009


GUIDELINE PURPOSE


GENERAL METHODS AND LITERATURE SEARCH

Classification of Evidence-Based Statements

Financial Disclosure and Conflicts of Interest

HOARSENESS (DYSPHONIA) GUIDELINE ACTION STATEMENTS

Supporting Text

Supporting Text

Supporting Text

Laryngoscopy and Hoarseness


Techniques for Visualizing the Larynx

Supporting Text

Supporting Text

Anti-Reflux Medications and the Empiric Treatment of Hoarseness

Anti-Reflux Medications and Treatment of Chronic Laryngitis

Supporting Text

Supporting Text


Advocating for Voice Therapy

Supporting Text

Suspected malignancy

Benign soft tissue lesions

Glottic insufficiency

Laryngeal dystonia

Supporting Text

Supporting Text


RESEARCH NEEDS

DISCLAIMER

ACKNOWLEDGEMENT


DISCLOSURES

REFERENCES

APPENDIX

Frequently Asked Questions About Voice Therapy

Why is voice therapy recommended for hoarseness

What happens in voice therapy

Who provides voice therapy

Does insurance cover voice therapy

Are speech therapy and voice therapy the same

REFERENCES


cation for patients with hoarseness and signs of chronic laryngitisand 3) the clinician may educatecounsel patients with hoarsenessabout controlpreventive measuresDISCLAIMER This clinical practice guideline is not intendedas 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 isnot intended to replace clinical judgment or establish a protocol forall individuals with this condition and may not provide the onlyappropriate approach to diagnosing and managing this problem

copy 2009 American Academy of OtolaryngologyndashHead and NeckSurgery Foundation All rights reserved

Nearly one-third of the population has impaired voiceproduction at some point in their lives12 Hoarse-

ness is more prevalent in certain groups such as teachersand older adults but all age groups and both genders can beaffected1-6 In addition to the impact on health and quality oflife (QOL)78 hoarseness leads to frequent health care visitsand several billion dollars in lost productivity annually fromwork absenteeism9 Hoarseness is often caused by benign orself-limited conditions but may also be the presentingsymptom of a more serious or progressive condition requir-ing prompt diagnosis and management

The terms hoarseness and dysphonia are often used in-terchangeably although hoarseness is a symptom of alteredvoice quality and dysphonia is a diagnosis Dysphonia maybe broadly defined as an alteration in the production ofvoice that impairs social and professional communicationIn contrast hoarseness is a coarse or rough quality to thevoice Although the two terms are not synonymous theguideline working group decided to use the term hoarsenessfor this guideline because it is more recognized and under-stood by patients most clinicians and the lay press

The target patient for this guideline is anyone presentingwith hoarseness (dysphonia)

Hoarseness (dysphonia) is defined as a disorder charac-terized by altered vocal quality pitch loudness or vocaleffort that impairs communication or reduces voice-re-lated QOL

Impaired communication is defined as a decreased orlimited ability to interact vocally with others

Reduced voice-related QOL is defined as a self-perceiveddecrement in physical emotional social or economicstatus as a result of voice-related dysfunction

This working definition developed by the guidelinepanel assumes that hoarseness affects people differentlySome individuals may have altered voice quality vocaleffort pitch or loudness others may experience problemswith communication and diminished voice-related QOL

The guideline is intended for all clinicians who are likelyto diagnose and manage patients with hoarseness and ap-plies to any setting in which hoarseness would be identifiedmonitored treated or managed The guideline does notapply to patients with hoarseness with the following condi-

tions history of laryngectomy (total or partial) craniofacial

anomalies velopharyngeal insufficiency and dysarthria(impaired articulation) However the guideline will discussthe relevance of these conditions in managing patients withhoarseness

There are a number of patients with modifying factorsfor whom many of the recommendations of the guidelinemay not apply There is some discussion of these factors andhow they might modify management A partial list includesprior laryngeal surgery recent surgical procedures involv-ing the neck or affecting the recurrent laryngeal nerverecent endotracheal intubation radiation treatment to theneck and patients who are singers or performers

GUIDELINE PURPOSE

The primary purpose of this guideline is to improve thequality of care for patients with hoarseness based on currentbest evidence Expert consensus to fill evidence gaps whenused is explicitly stated and is supported with a detailedevidence profile for transparency Specific objectives of theguideline are to reduce inappropriate variations in careproduce optimal health outcomes and minimize harm

The guideline is intended to focus on a limited number ofquality improvement opportunities deemed most importantby the working group and is not intended to be a compre-hensive general guide for managing patients with hoarse-ness In this context the purpose is to define actions thatcould be taken by clinicians regardless of discipline todeliver quality care Conversely the statements in thisguideline are not intended to limit or restrict care providedby clinicians based on assessment of individual patients

While there is evidence to guide management of certaincauses of hoarseness there are currently no evidence-basedclinical practice guidelines There are variations in the useof the laser voice therapy steroids and postoperative voicerest and in the treatment of reflux-related laryngitis10-13

Differences in training preference and resource availabilityinfluence management decisions A guideline is necessarygiven this practice variation and the significant public healthburden of hoarseness

This guideline addresses the identification diagnosistreatment and prevention of hoarseness (dysphonia) (Table1) In addition it highlights needs and management optionsin special populations or in patients who have modifyingfactors Furthermore this guideline is intended to enhancethe accurate diagnosis of hoarseness (dysphonia) promoteappropriate intervention in patients with hoarseness high-light the need for evaluation and intervention in specialpopulations promote appropriate therapeutic options withoutcomes assessment and improve counseling and educa-tion for prevention and management of hoarseness Thisguideline may also be suitable for deriving a performance

measure on hoarseness









1

Table 1


development











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35

issue



ACTION STATEMENTS



Table 2











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Table 5

continued






Table 5












historian)Anxiety














Table 6



on voice





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105

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Table 7







neck surgery)







































































Supporting Text


















Chronic Laryngitis

































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220

Table 8
















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289














299









































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AUTHOR INFORMATION






DISCLOSURES






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GUIDELINE PURPOSE






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DISCLOSURES

REFERENCES

APPENDIX







REFERENCES









1

Table 1


development











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Table 2











Implication


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Table 4

















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Table 5

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Table 5












historian)Anxiety














Table 6



on voice





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105

tion of the larynx


















Table 7







neck surgery)







































































Supporting Text


















Chronic Laryngitis

































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289














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RESEARCH NEEDS





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APPENDIX


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GUIDELINE PURPOSE






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RESEARCH NEEDS

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REFERENCES

APPENDIX







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35

issue



ACTION STATEMENTS



Table 2











Implication


me clearly






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Table 5

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Table 5












historian)Anxiety














Table 6



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Cough55



























105

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Table 7







neck surgery)







































































Supporting Text


















Chronic Laryngitis

































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220

Table 8
















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289














299









































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APPENDIX







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ACTION STATEMENTS



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Table 4

















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Table 5

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Table 5












historian)Anxiety














Table 6



on voice





Cough55



























105

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Table 7







neck surgery)







































































Supporting Text


















Chronic Laryngitis

































roid use






220

Table 8
















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289














299









































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REFERENCES

APPENDIX







REFERENCES




Table 3








Table 4

















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of GE

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Table 5

continued






Table 5












historian)Anxiety














Table 6



on voice





Cough55



























105

tion of the larynx


















Table 7







neck surgery)







































































Supporting Text


















Chronic Laryngitis

































roid use






220

Table 8
















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289














299









































RESEARCH NEEDS





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AUTHOR INFORMATION






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Supporting Text

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REFERENCES

APPENDIX







REFERENCES








Table 5

continued






Table 5












historian)Anxiety














Table 6



on voice





Cough55



























105

tion of the larynx


















Table 7







neck surgery)







































































Supporting Text


















Chronic Laryngitis

































roid use






220

Table 8
















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289














299









































RESEARCH NEEDS





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GUIDELINE PURPOSE






Supporting Text

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Supporting Text

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RESEARCH NEEDS

DISCLAIMER

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DISCLOSURES

REFERENCES

APPENDIX







REFERENCES









Table 6



on voice





Cough55



























105

tion of the larynx


















Table 7







neck surgery)







































































Supporting Text


















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roid use






220

Table 8
















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289














299









































RESEARCH NEEDS





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AUTHOR INFORMATION






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Supporting Text

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RESEARCH NEEDS

DISCLAIMER

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DISCLOSURES

REFERENCES

APPENDIX







REFERENCES











105

tion of the larynx


















Table 7







neck surgery)







































































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Chronic Laryngitis

































roid use






220

Table 8
















Supporting Text
















































































289














299









































RESEARCH NEEDS





ranted







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AUTHOR INFORMATION






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GUIDELINE PURPOSE






Supporting Text

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RESEARCH NEEDS

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DISCLOSURES

REFERENCES

APPENDIX







REFERENCES






Table 7







neck surgery)







































































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roid use






220

Table 8
















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289














299









































RESEARCH NEEDS





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AUTHOR INFORMATION






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RESEARCH NEEDS

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DISCLOSURES

REFERENCES

APPENDIX







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Supporting Text


















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220

Table 8
















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289














299









































RESEARCH NEEDS





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AUTHOR INFORMATION






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GUIDELINE PURPOSE






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RESEARCH NEEDS

DISCLAIMER

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DISCLOSURES

REFERENCES

APPENDIX







REFERENCES
















Chronic Laryngitis

































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220

Table 8
















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289














299









































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AUTHOR INFORMATION






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GUIDELINE PURPOSE






Supporting Text

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RESEARCH NEEDS

DISCLAIMER

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DISCLOSURES

REFERENCES

APPENDIX







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roid use






220

Table 8
















Supporting Text
















































































289














299









































RESEARCH NEEDS





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AUTHOR INFORMATION






DISCLOSURES






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Therapy



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GUIDELINE PURPOSE






Supporting Text

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Laryngeal dystonia

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RESEARCH NEEDS

DISCLAIMER

ACKNOWLEDGEMENT


DISCLOSURES

REFERENCES

APPENDIX







REFERENCES






220

Table 8
















Supporting Text
















































































289














299









































RESEARCH NEEDS





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ACKNOWLEDGEMENT


AUTHOR INFORMATION






DISCLOSURES






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APPENDIX


Therapy



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GUIDELINE PURPOSE






Supporting Text

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RESEARCH NEEDS

DISCLAIMER

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DISCLOSURES

REFERENCES

APPENDIX







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289














299









































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ACKNOWLEDGEMENT


AUTHOR INFORMATION






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APPENDIX


Therapy



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GUIDELINE PURPOSE






Supporting Text

Supporting Text

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Supporting Text



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Laryngeal dystonia

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RESEARCH NEEDS

DISCLAIMER

ACKNOWLEDGEMENT


DISCLOSURES

REFERENCES

APPENDIX







REFERENCES








































RESEARCH NEEDS





ranted







DISCLAIMER



ACKNOWLEDGEMENT


AUTHOR INFORMATION






DISCLOSURES






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APPENDIX


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GUIDELINE PURPOSE






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Laryngeal dystonia

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RESEARCH NEEDS

DISCLAIMER

ACKNOWLEDGEMENT


DISCLOSURES

REFERENCES

APPENDIX







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DISCLAIMER



ACKNOWLEDGEMENT


AUTHOR INFORMATION






DISCLOSURES






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Therapy



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GUIDELINE PURPOSE






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Laryngeal dystonia

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RESEARCH NEEDS

DISCLAIMER

ACKNOWLEDGEMENT


DISCLOSURES

REFERENCES

APPENDIX







REFERENCES




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APPENDIX


Therapy



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GUIDELINE PURPOSE






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RESEARCH NEEDS

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DISCLOSURES

REFERENCES

APPENDIX







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APPENDIX


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GUIDELINE PURPOSE






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RESEARCH NEEDS

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DISCLOSURES

REFERENCES

APPENDIX







REFERENCES





























































































































































































































































APPENDIX


Therapy



A5














REFERENCES
























GUIDELINE PURPOSE






Supporting Text

Supporting Text

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Supporting Text

Supporting Text



Supporting Text

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Supporting Text




Laryngeal dystonia

Supporting Text

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RESEARCH NEEDS

DISCLAIMER

ACKNOWLEDGEMENT


DISCLOSURES

REFERENCES

APPENDIX







REFERENCES













REFERENCES
























GUIDELINE PURPOSE






Supporting Text

Supporting Text

Supporting Text




Supporting Text

Supporting Text



Supporting Text

Supporting Text



Supporting Text




Laryngeal dystonia

Supporting Text

Supporting Text


RESEARCH NEEDS

DISCLAIMER

ACKNOWLEDGEMENT


DISCLOSURES

REFERENCES

APPENDIX







REFERENCES

Dysphonia Hoarseness Guideline

Documents

Transcript of Dysphonia Hoarseness Guideline