Hoarseness. Evidence-based Key points for Approach

Transcription

1 Hoarseness Evidence-based Key points for Approach Sasan Dabiri, Assistant Professor Department of otorhinolaryngology Head & Neck Surgery Amir A lam hospital Tehran University of Medial Sciences

2 Definition: Altered voice quality, pitch, loudness, or vocal effort that o impairs communication or Introduction o reduces voice-related QOL self-perceived decrement in physical, social, and emotional aspects

3 Grading of Evidence Introduction A: Well-designed RCTs or diagnostic studies performed on a population similar to the guideline s target population B: RCTs or diagnostic studies with minor limitations; overwhelmingly consistent evidence from observational studies C: Observational studies (case-control and cohort design) D: Expert opinion, case reports, reasoning from first principles (bench research or animal studies) or

4 History Taking Important underlying etiology of hoarseness Thyroid surgery Carotid endarterectomy Cervical spine surgery (anterior approach) Cardiac surgery Surgery for esophageal cancer Prolonged endotracheal intubation (four days injury)

5 History Taking Important underlying etiology of hoarseness Medications that may cause hoarseness Medication Biphosphonates ACE inhibitors Antihistamines and Anticholinergics Diuretics Antipsychotics Inhaled steroids Mechanism of impact on voice Chemical laryngitis Cough Drying effect on mucosa Drying effect on mucosa Laryngeal dystonia Dose-dependent mucosal irritation Fungal laryngitis

6 Physical Examination Laryngoscopy should be done when: Fails to resolve by a max. of 3 months after onset Serious underlying cause is suspected with a history of tobacco or alcohol use with unexplained weight loss with hemoptysis, dysphagia, odynophagia, otalgia, or airway compromise with accompanying neurologic symptoms with concomitant neck mass in an immunocompromised host in a neonate after trauma unresolving after surgery that is worsening possible aspiration of a foreign body

7 Physical Examination Office laryngoscopy transorally with a mirror rigid endoscope with either halogen light or transnasally with a flexible fiberoptic distal-chip laryngoscope Operative laryngoscopy Risks: cost; general anesthesia; airway distress; dental trauma; oral cavity and pharyngeal trauma; tongue dysesthesia; taste changes; cardiovascular risk stroboscopic light application

8 Radiologic Imaging Should be used after laryngoscopy and Not in all patients with hoarseness Risks of Computed Tomography Scan: radiation-induced malignancy IV contrast reaction Risks Of Magnetic Resonance Imaging: Magnetic effects (projectile, device, burning, artifact) Claustrophobia Gadolinium reaction Cost

9 Anti reflux o o o not prescribe for patients with hoarseness without signs or symptoms of GERD No consistent evidence for effectiveness In patients with GERD significantly reduces hoarseness Risks of Proton Pomp Inhibitors: o o Infection (GI, Lung) Calcium absorption o Neoplasm (?) Empiric Therapy High NNT If not esophagitis

10 Anti reflux Anti bacterial Empiric Therapy Routine use is strongly unwarranted o o o o No benefits in Cochrane reviews Risk of adverse effects Bacterial resistance Costs

11 Anti reflux Anti bacterial Anti inflammatory Empiric Therapy prescription of systemic or inhaled steroids for acute or chronic hoarseness or laryngitis should be avoided o Side effects o Some indications for specific disease entities

12 Voice Therapy should visualize the larynx before prescribing voice therapy o Excluding some non-responding diagnoses Diagnosis should be made o Usefulness for planning voice therapy

13 One of choices for managing hoarseness Approaches: Voice Therapy (for all ages) Hygienic : focus on eliminating behaviors considered to be harmful to the vocal mechanism Symptomatic : direct modification of aberrant features of pitch, loudness, and quality Physiologic : retrain and rebalance the subsystems of respiration, phonation, and resonance

14 Surgical Therapy should advocate for surgery as a therapeutic option in: Suspected malignancy Benign soft tissue lesions Glottic insufficiency Laryngeal dystonia Surgical method used is less important than experience and skill of surgeon in obtaining satisfactory outcomes

15 Surgical Therapy should advocate for surgery as a therapeutic option in: Suspected malignancy Benign soft tissue lesions Glottic insufficiency Laryngeal dystonia observational studies show comparable objective and subjective improvement in voice between injection laryngoplasty and laryngeal framework surgery

16 Surgical Therapy should advocate for surgery as a therapeutic option in: Suspected malignancy Benign soft tissue lesions Glottic insufficiency Laryngeal dystonia (Spasmodic dysphonia) Botulinum toxin as the first-line treatment

17 Surgical Therapy should advocate for surgery as a therapeutic option in: Suspected malignancy Benign soft tissue lesions Glottic insufficiency Laryngeal dystonia (Spasmodic dysphonia) Botulinum toxin: - not currently FDA approved for SD - moderate overall improvement - have a good safety record - used for other neurological voice disorders

18 Preventive Therapy Hydration avoidance of irritants voice training amplification avoidance of tobacco smoke (primary or secondhand)

19 Summary History taking Laryngoscopy (max after 3 months) Not imaging before laryngoscopy Not routine Steroid, Antibiotic, Anti reflux Voice therapy & Preventive recommendations Surgery

20 Thanks for Your Attention