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Voice Problems: Updates to Treatment and Care of Patients with Hoarseness

Voice Problems: Updates to Treatment and Care of Patients with Hoarseness

ALEXANDRIA, VA — The American Academy of Otolaryngology—Head and Neck Surgery Foundation published the Clinical Practice Guideline: Hoarseness (Dysphonia) (Update) today in Otolaryngology–Head and Neck Surgery. The updated guideline provides some substantially revised, evidence-based recommendations for healthcare providers when treating patients with hoarseness, a very common complaint that affects nearly one-third of the population at some point in their life.

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. 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.

David O. Francis, MD, MS (guideline development group assistant chair)

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 ChestPhysicians (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

Members of the media who wish to obtain a copy of the guideline or request an interview should contact: Tina Maggio at 703-535-3762, or [email protected]. Upon release, the guideline can be found at


  1. What is the purpose of this guideline?
    The primary purpose of this guideline is to improve the quality of care for patients with hoarseness, based on current best evidence. Specific objectives include:

    • Reduce excessive variation in care
    • Produce optimal health outcomes
    • Prevent delay in the evaluation, diagnosis, and treatment
    • Improve education among all health professionals
  2. What is hoarseness (dysphonia)?
    Dysphonia is characterized by a change in voice quality, pitch (how high or low the voice is), volume (loudness), or vocal effort that makes it difficult to communicate as judged by a healthcare provider, and it may affect quality of life.

    • The symptom of hoarseness is related to problems in the sound-producing parts (vocal cords or folds) of the voice box or larynx. A voice may have a raspy, weak, or airy quality that makes it hard to make smooth vocal sounds.
  3. What is the difference between dysphonia and hoarseness?
    Healthcare providers will use the clinical term dysphonia, but patients and the public often use the more common term hoarseness.

    • Dysphonia describes impaired voice production.
    • Hoarseness is a symptom of a change in voice quality.
  4. What causes hoarseness?
    Hoarseness is a symptom common to many diseases. Most hoarseness is related to upper respiratory tract infection and goes away on its own in seven to 10 days. If the hoarseness does not go away or get better in four weeks, there may be a more serious medical condition that requires further evaluation by an otolaryngologist.
  5. What is the prevalence of hoarseness?
    • Hoarseness affects nearly one-third of the population at some point in their life.
    • An estimated 28 million workers in the United States experience voice problems daily.
    • Hoarseness can affect patients of all ages and sex
      • Some evidence suggests that risks are higher in pediatric and elderly populations
        • An estimated 23.4 percent of children have hoarseness at some point, with increased prevalence among boys and those in the eight to 14 age range.
    • People in vocations with high vocal demands have increased likelihood of developing hoarseness. This includes, but is not limited to, singers and entertainers, legal professionals, teachers, telemarketers, aerobics instructors, clergy, coaches, and healthcare providers.
    • Voice problems affect one in 13 adults annually.
    • Hoarseness is responsible for frequent healthcare visits and several billion dollars in lost productivity annually from work absenteeism.
      • 20 Percent of teachers miss work due to hoarseness, and absenteeism in this occupation alone has an associated economic ramification of $2.5 billion in the Unites States annually.
  6. What are the common causes of hoarseness?
    • Common cold, upper respiratory tract infection
    • Voice overuse (using the voice too much, too loudly, or for a long period of time)
    • Acid reflux
    • Allergic laryngitis, which is inflammation of the larynx due to allergies
    • Smoking and secondhand smoke
    • Head and neck cancer
    • Medication side effects
    • Age-related changes
    • Neurological conditions (e.g., Parkinson’s disease, amyotrophic lateral sclerosis)
    • Intubation (process of inserting a tube through the mouth and into the airway) and postsurgical injury
  7. How can hoarseness be prevented?
    • Quit smoking and avoid secondhand smoke
    • Avoid beverages that can dehydrate the body, such as alcohol and caffeine
    • Drink plenty of water, especially in dry areas
    • Use a humidifier
    • Avoid spicy foods
    • Avoid excessive throat clearing or coughing
    • Try to limit voice usage, including volume
    • Use a microphone if possible
    • Avoid drying medications such as some antihistamines and diuretics
  8. Why is the update to this guideline important?
    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. For example, the prior guideline allowed for up to three months prior to recommending laryngeal evaluation in patients without significant concerns. The update shortens the amount of time allowed, to four weeks, before performing a laryngoscopy in all patients.
  9. What are the significant points made in the guideline:
    • Identification of Abnormalvoice:
      Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life.
    • Identifying Underlying Cause of Dysphonia:
      Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management.
    • Escalation of Care:
      Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include but are not limited to recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user.
    • Laryngoscopy and Dysphonia:
      Clinicians may perform diagnostic laryngoscopy at any time for a patient with dysphonia.
    • Need for Laryngoscopy in Persistent Dysphonia:
      Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within four weeks or irrespective of duration if a serious underlying cause is suspected.
    • Imaging:
      Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) among patients with a primary voice complaint prior to visualization of the larynx.
    • Anti-Reflux Medication and Dysphonia:
      Clinicians should not prescribe anti-reflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx.
    • Corticosteroid Therapy:
      Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx.
    • Antimicrobial Therapy:
      Clinicians should not routinely prescribe antibiotics to treat dysphonia.
    • Laryngoscopy Prior To Voice Therapy:
      Clinicians should perform diagnostic laryngoscopy or refer to a clinician who can perform diagnostic laryngoscopy before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP).
    • Advocating for Voice Therapy:
      Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy.
    • Surgery:
      Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency.
    • Botulinum Toxin:
      Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia (SD) and other types of laryngeal dystonia.
    • Education/Prevention:
      Clinicians should inform patients with dysphonia about control/preventive measures.
    • Outcomes:
      Clinicians should document resolution, improvement, or worsened symptoms of dysphonia or change in quality of life among patients with dysphonia after treatment or observation.
  10. Where can I get more information?
    Patients and healthcare providers should discuss all evaluation, testing, and follow-up options to find the best approach for the patient. There is a printable patient handout that explains preventing hoarseness and an FAQ on voice therapy that can help with discussions between patients and providers. Visit for this information. More information can be found on the National Spasmodic Dysphonia Association website at

About the AAO-HNS/F
The American Academy of Otolaryngology—Head and Neck Surgery, one of the oldest medical associations in the nation, represents about 12,000 physicians and allied health professionals who specialize in the diagnosis and treatment of disorders of the ears, nose, throat, and related structures of the head and neck. The Academy serves its members by facilitating the advancement of the science and art of medicine related to otolaryngology and by representing the specialty in governmental and socioeconomic issues. The AAO-HNS Foundation works to advance the art, science, and ethical practice of otolaryngology-head and neck surgery through education, research, and lifelong learning. The organization’s vision: “Empowering otolaryngologist-head and neck surgeons to deliver the best patient care.”
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