Voice problems: Updates to treatment and care of patients with hoarseness

Hoarseness is responsible for frequent healthcare visits and several billion dollars in lost productivity annually from work absenteeism. With such a prevalence of occurrence, there are several important takeaways from the updated guideline that healthcare providers should be aware of when treating patients with hoarseness, including recommendations for escalation of care, the need for laryngoscopy for persistent hoarseness, and treatment.

The 2018 update provides an algorithm for healthcare providers to determine when acceleration of care is needed. These include but are not limited to recent surgical procedures involving the head, neck, or chest; presence of a neck mass; respiratory distress; history of tobacco use; or whether the patient is a professional voice user. In addition, the update shortens the timeframe that hoarseness can be managed conservatively, from 90 days to four weeks, before evaluation of the larynx is recommended to determine the underlying cause.

"One of the goals of the update is to provide clarity to healthcare providers on circumstances where early referral to an otolaryngologist for visualization of the larynx is necessary," said David O. Francis, MD, MS, guideline development group assistant chair. "Hoarseness is often caused by benign conditions, like the common cold, voice overuse, age-related changes, and others; however, it may also be a symptom of a more serious condition, like head and neck cancer. Failure to evaluate the larynx can delay cancer diagnosis, resulting in the need for more aggressive treatment and reduced survival."

Voice problems affect one in 13 adults annually, however, it can affect patients of all ages and sex. There is an increased prevalence in singers, teachers, call-center operators, older adults, and other persons with significant vocal demands. The guideline also provides recommendations on treating patients presenting with isolated hoarseness.

"An important component of this update are the recommendations that patients with isolated hoarseness should not be empirically treated with anti-reflux, antibiotic, or steroid medications before visualizing the larynx," said Dr. Francis. "Physicians have an obligation to be good stewards when prescribing medication. There is very little evidence of benefit in treating isolated hoarseness with these medications, and in fact, they can offer more harm than good. The updated guideline provides physicians with the resources and tools to educate patients about prevention of hoarseness and how to manage it conservatively, without the use of unnecessary medication."

The update is endorsed by American Academy of Otolaryngic Allergy (AAOA); Society of Otorhinolaryngology and Head-Neck Nurses (SOHN); National Association of Teachers of Singing (NATS); National Spasmodic Dysphonia Association (NSDA); American Broncho-Esophagological Association (ABEA); American Laryngological Association (ALA); American Speech-Language-Hearing Association (ASHA); American Society of Pediatric Otolaryngology (ASPO); American Academy of Pediatrics (AAP); American College of Chest Physicians (ACCP); and American Academy of Physical Medicine and Rehabilitation (AAPM&R). An Affirmation of Value for the guideline update was received from the American Academy of Family Physicians (AAFP).

The guideline authors are: Robert J. Stachler, MD; David O. Francis, MD, MS; Seth R. Schwartz, MD, MPH; Cecelia C. Damask, DO; German P. Digoy, MD; Helene J. Krouse, PhD, RN, ANP-BC, CORLN; Scott J. McCoy, DMA; Daniel R. Ouellette, MD; Rita R. Patel, PhD, CCC-SLP; Charles (Charlie) W. Reavis; Libby J. Smith, DO; Marshall Smith, MD; Steven W. Strode, MD, MEd, MPH; Peak Woo, MD; and Lorraine C. Nnacheta, MPH