AAO-HNS Dysphonia Guideline Earns AAFP Affirmation of Value

March 13, 2018, 03:21 pm Chris Crawford – On March 1, the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) published an updated clinical practice guideline on dysphonia that provides substantially revised, evidence-based recommendations health care professionals can use to identify, diagnose and treat patients with hoarseness, as well as to prevent the condition.

The AAFP has given the guideline, which appeared in the March issue of Otolaryngology--Head and Neck Surgery, its affirmation of value designation.

Among the updates provided in the 2018 guideline is an algorithm that family physicians can use to determine when care should be accelerated. Such instances include soon after surgical procedures involving the head, neck or chest; in the presence of a neck mass, respiratory distress or a history of tobacco use; or when the patient is a professional voice user.

Additionally, as part of this update, the AAO-HNS has shortened the timeframe that hoarseness may be managed conservatively from 90 days to four weeks; after that, evaluation of the larynx is recommended to determine the underlying cause.

"One of the goals of the update is to provide clarity to health care providers on circumstances where early referral to an otolaryngologist for visualization of the larynx is necessary," said David Francis, M.D., M.S., assistant chair of the AAO-HNS guideline development group, in a news release.

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"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," he explained. "Failure to evaluate the larynx can delay cancer diagnosis, resulting in the need for more aggressive treatment and reduced survival."

The guideline also provides recommendations on treating patients who present with isolated hoarseness, which also indicates a need for laryngoscopy.

"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," Francis said.

"Physicians have an obligation to be good stewards when prescribing medication," he added. "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."

AAFP Affirmation of Value

The AAFP offered its affirmation of value designation for this guideline, meaning it didn't meet the requirements for full endorsement but does provide some benefit for family physicians.

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that although the AAO-HNS has an excellent guideline program, its guideline updates don't always follow the same rigorous methodology as its original guidelines.

"There were some questions about the methodology used, such as how the quality of the individual studies was assessed beyond simply study design," she said.

However, Frost said the guideline's recommendations, both for and against, are important for family physicians to understand.

Regarding the AAO-HNS' recommendation against treating isolated hoarseness with antibiotics, corticosteroids or anti-reflux medication without first visualizing the larynx, she said: "By empirically prescribing medication, you are exposing the patient to potential adverse effects of the medication as well as delaying accurate diagnosis."

Frost added that the AAO-HNS also recommends against using CT or MRI in patients with a primary complaint of dysphonia before visualizing the larynx.

Additional Key Recommendations

The AAFP's summary of key recommendations from the guideline said that dysphonia should be diagnosed in patients with altered voice quality, pitch, loudness or vocal effort that impairs communication or reduces voice-related quality of life.

In addition, after diagnostic laryngoscopy

voice therapy should be recommended for patients who have dysphonia from a cause amenable to voice therapy;
surgery should be considered for patients with suspected laryngeal malignancy, benign laryngeal soft tissue lesions or glottic insufficiency; and
botulinum toxin injections should be considered for treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia.