What are the treatment guidelines for dysphonia?

Dysphonia Treatment Guidelines

Clinicians should perform laryngoscopy or refer for laryngoscopy when dysphonia persists beyond 4 weeks or immediately if serious underlying causes are suspected, and advocate for voice therapy as first-line treatment for causes amenable to behavioral intervention, while avoiding empiric antibiotics, corticosteroids, or antireflux medications prior to laryngeal visualization. 1

Initial Identification and Assessment

• Identify dysphonia by assessing altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life 1

• Conduct targeted history and physical examination focusing on:

  • Recent head/neck/chest surgery or endotracheal intubation 2, 3
  • Concomitant neck mass, respiratory distress, or stridor 2, 3
  • Tobacco or alcohol abuse history 2, 3
  • Professional voice user status 2, 3
  • Hemoptysis, dysphagia, odynophagia, otalgia, or unexplained weight loss 3
  • Progressive worsening or immunocompromised status 3

• Solicit proxy input when evaluating children, cognitively impaired patients, or those with severe emotional distress, as 52% of vocal fold cancer patients initially dismissed their symptoms and 16.7% sought treatment only after encouragement from others 1

Laryngoscopy: Timing and Indications

Perform laryngoscopy or refer when:

• Dysphonia fails to resolve or improve within 4 weeks 1
• Immediately if serious underlying cause suspected, regardless of duration 1, 3
• Any red flag symptoms present (listed above) 2, 3

Laryngoscopy may be performed at any time in a patient with dysphonia at clinician discretion 1

Critical Timing Considerations

• Delaying laryngoscopy beyond 4 weeks can miss laryngeal cancer, leading to higher disease stages and worse prognosis 2, 4
• Delaying otolaryngology referral beyond 3 months more than doubles healthcare costs ($271 to $711) 3
• 56% of primary care diagnoses change after specialist laryngoscopy 3

What NOT to Do Before Laryngoscopy

Strong recommendations against:

• Do NOT routinely prescribe antibiotics to treat dysphonia 1
• Do NOT prescribe antireflux medications for isolated dysphonia based on symptoms alone attributed to suspected GERD or LPR without laryngeal visualization 1
• Do NOT routinely prescribe corticosteroids prior to laryngeal visualization 1
• Do NOT obtain CT or MRI for primary voice complaints prior to laryngeal visualization 1

Exception for Antibiotics

Antibiotics may be appropriate only in select cases: immunosuppressed patients or confirmed bacterial infections, and diagnosis must be established prior to initiating therapy 2

Treatment Modalities After Laryngoscopy

Voice Therapy (First-Line for Amenable Causes)

Advocate for voice therapy for patients with dysphonia from causes amenable to behavioral intervention 1, 4

• Perform diagnostic laryngoscopy before prescribing voice therapy and document/communicate results to the speech-language pathologist 1
• Voice therapy improves both quality of life and vocal performance, and is first-line even for benign vocal fold nodules 5

Specific voice therapy techniques include: 1

• Gentle phonation exercises: humming, sighing, yawning with phonation
• Postural manipulations: phonating while bending over or looking at ceiling
• Redirection of attentional focus: bubble blowing with vocalization, large body movements
• Circumlaryngeal massage with concurrent vocalization
• Automatic phrases with minimal communicative responsibility
• Communication counseling addressing predisposing, precipitating, and perpetuating psychosocial issues

Surgical Intervention

Advocate for surgery as a therapeutic option for: 1

• Suspected malignancy
• Symptomatic benign vocal fold lesions that do not respond to conservative management
• Glottic insufficiency

Botulinum Toxin Injections

Offer or refer for botulinum toxin injections for dysphonia caused by: 1, 6

• Spasmodic dysphonia
• Other types of laryngeal dystonia

This is the most common intervention for spasmodic dysphonia, temporarily reducing muscle overactivity and improving voice quality 6

Patient Education and Prevention

• Inform patients about control/preventive measures including vocal hygiene 1, 4
• Educate about the self-limited nature of viral laryngitis, which typically resolves within 7-10 days 2
• Voice rest and hydration are supportive measures, though formal evidence for efficacy is limited 2

Outcomes Documentation

Document resolution, improvement, or worsening of dysphonia symptoms or change in quality of life after treatment or observation 1, 4

Special Populations and Circumstances

Professional Voice Users

• May require more urgent evaluation due to occupational impact 2, 4
• Dysphonia is responsible for several billion dollars in lost productivity annually from work absenteeism 1

Functional (Psychogenic) Dysphonia

• Can present similarly to viral aphonia but requires different management 2
• Requires voice therapy and sometimes psychological support 2
• If evidence of long-standing anxiety, comorbid depression, or ongoing medicolegal issues, referral to mental health professionals may be essential 1

Muscle Tension Dysphonia

• Caused by excessive tension of (para)laryngeal musculature 7
• Etiological factors include psychological/personality factors, vocal misuse/abuse, and compensation for underlying disease 7
• Requires multidisciplinary approach with close cooperation between laryngologist and speech-language pathologist 7

Common Pitfalls to Avoid

• Assuming all aphonia is viral can lead to incorrect management of functional dysphonia 2
• Treating symptoms as "laryngitis" or "reflux" without confirming diagnosis via laryngoscopy 3
• Failing to recognize risk factors requiring expedited evaluation 3
• Overlooking occupational voice demands when developing treatment plans 3
• Empiric treatment without visualization is inappropriate and potentially harmful 2