Clinical Practice Guideline: Updates to improve quality of care for patients with Dysphonia

Adapted from the March 2018 supplement to Otolaryngology–Head and Neck Surgery. Read the guideline at www.otojournal.org.

Dysphonia affects nearly one-third of the population at some point in their lives. The primary purpose of the Clinical Practice Guideline Hoarseness (Dysphonia) (Update) is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm.

The 2018 guideline update was chaired by Robert J. Stachler, MD, with David O. Francis, MD, MS, serving as assistant chair, and Seth R. Schwartz, MD, MPH, as the methodologist.

The prior guideline was published in 2009 and allowed for up to three months of symptoms prior to laryngeal evaluation in patients without significant concerns, said Dr. Stachler, a clinical associate professor at Wayne State University. The update shortens the amount of time allowed before performing a laryngoscopy in all patients. The updated guideline incorporates new evidence profiles to include the role of patient preferences, confidence in the evidence, difference of opinion, and quality improvement opportunities. It also includes considerations from three related new guidelines, 16 new systematic reviews, and four new randomized controlled trials.

“A lot of work has gone into making sure that the perspective of all stakeholders has been taken into account,” said Dr. Stachler. “We addressed things that were contentious after publication of the first guideline. Primarily we address the timing of laryngoscopy for persistent dysphonia. As in the original guideline, physicians may perform diagnostic laryngoscopy at any time, especially for patients with higher level of concern. For all patients with dysphonia, we clarified that earlier evaluation of the larynx is beneficial.”

The guideline update was endorsed by the following organizations: 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 full guideline, and its other resources, are available at http://www.entnet.org/content/clinical-practice-guidelines and in the March Otolaryngology–Head and Neck Surgery journal at www.otojournal.org.

This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with dysphonia.

Guideline authors
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

AAO-HNSF Guideline development process and the obligations associated with the guideline recommendations are documented in the Clinical Practice Guideline Development Manual, Third Edition: a quality-driven approach for translating evidence into action (http://oto.sagepub.com/content/148/1_suppl/S1.long).

Disclaimer
The clinical practice guideline is provided for information and educational purposes only. It is not intended as 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 is not intended to replace clinical judgment or establish a protocol for all individuals with this condition and may not provide the only appropriate approach to diagnosing and managing this program of care. As medical knowledge expands and technology advances, clinical indicators and guidelines are promoted as conditional and provisional proposals of what is recommended under specific conditions, but they are not absolute. Guidelines are not mandates; these do not and should not purport to be a legal standard of care. The responsible physician, in light of all circumstances presented by the individual patient, must determine the appropriate treatment. Adherence to these guidelines will not ensure successful patient outcomes in every situation. The AAO-HNSF, Inc emphasizes that these clinical guidelines should not be deemed to include all proper treatment decisions or methods of care or to exclude other treatment decisions or methods of care reasonably directed to obtaining the same results.

Downloadable PDF Files:
voice_therapy.pdf | Hoarseness.pdf | Hoarseness_Prevention.pdf