2018 Section 6 - Laryngology, Voice Disorders, and Bronchoesophalogy

Stachler et al

KAS = Key Action Statement

*Examples of Alarm Symptoms: Neck mass Stridor (breathing difficulties) History of smoking History of anterior neck, neurosurgical, or thoracic surgery Recent intubation Unexpected weight loss Concomitant dysphagia or dyspnea Concomitant neurological symptoms (e.g., dysarthria)

Patient Presents with Hoarseness

KAS1

Identify or Diagnose Dysphonia

KAS2

H&P to Evaluate Underlying Cause

No

Yes

Alarm Symptoms* or Professional Voice?

KAS4a

KAS5

KAS3

Do Not Image

Escalation of Care

KAS6

Do Not Prescribe Anti-reflux Medications

KAS7

Do Not Prescribe Steroids

KAS8

Do Not Prescribe Antibiotics

KAS12

Education/Prevention

KAS4b/9a

No

Improvement/Resolution in 4 Weeks?

Laryngoscopy or Referral for Laryngoscopy

Yes

Triage and Treat Based on Findings

Medical Management

KAS6, 7, 8

KAS13

Voice Therapy

KAS9b

Document Improvement/Resolution

Surgery KAS10 Botulinum Toxin for Laryngeal Dystonia KAS11 Education/Prevention KAS12

Figure 1. Hoarseness (dysphonia) clinical practice guideline algorithm. H&P, history and physical examination; KAS, key action statement.

and to determine what indications and what interventions are effective at treating this condition. Without an agreed-on definition, it is difficult to design rigorous comparative treat- ment and outcome studies. 3: Corticosteroids and Antibiotics in Treatment of Dysphonia (KASs 7 and 8) Research is needed to better understand the variation and overuse of antibiotics and steroids for acute laryngitis. Educational efforts should be directed at reducing their use and promoting conservative management in acute laryngitis. Despite frequency of corticosteroid therapy for acute or chronic laryngitis and for other voice disorders by various clinical specialties, little literature supports its use for these

indications. Research is needed to better understand its effec- tiveness (benefits and harms) in this setting and for which indications they should be considered and/or avoided. 4: Surgery (KAS 10) Outcomes are difficult to compare for surgery, due to hetero- geneity in the number and quality of outcome measures used. This is an issue for patient-centered outcomes and for “objec- tive measures” (eg, cepstral analysis, aerodynamics). A better understanding of and standardization of what benign lesions are amenable to surgery is needed. Furthermore, more research is needed to understand the effectiveness (benefits and harms) of less invasive treatments (office based or medi- cal therapy) for these conditions.

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