Key Treatment

The American Academy of Otolaryngology-Head and Neck Surgery produced a consensus statement of Clinical Practice Guidelines for Hoarseness (Dysphonia).


The quality of data supporting the benefits of treatment outweighing the potential harm is strong (Grade A, B):

1. Clinicians should not routinely prescribe oral antibiotics to treat hoarseness.

2. Voice therapy should be employed for patients with hoarseness that affects voice-related quality of life.


The benefits of treatment outweigh the risks, but the data are not as strong (Grade B, C):

1. Hoarseness should be diagnosed in a patient with an altered quality of voice.

2. Patients with hoarseness should be assessed with history or physical exam with attention to previous factors or treatments that may have affected the recurrent laryngeal nerve or larynx. This may include neck or chest surgery or radiation therapy, endotracheal intubation, tobacco use, or occupational vocal overuse.

3. The clinician may perform laryngoscopy (or refer) if hoarseness persists after 3 months, or sooner if suspicion of serious illness is high.

4. CT or MRI should not be performed until the larynx has been visualized (these tests may not be necessary).

5. Antireflux medications should not be prescribed in the absence of other signs or symptoms of reflux.

6. Clinicians should not routinely prescribe oral corticosteroids to treat hoarseness.

7. Laryngoscopy should be performed before recommending voice therapy.

8. Clinicians should advocate for surgery as an option in cases of suspected malignancy, soft tissue lesion, or glottic insufficiency.

9. Patients should be referred for possible treatment with botulinum toxin in cases of spasmodic dysphonia.


There is only weak evidence that the benefit of treatment outweighs the risk (Grade D):

1. The clinician may perform laryngoscopy (or refer) at any time after diagnosis of hoarseness.

2. Antireflux medications may be prescribed in patients with hoarseness if there are signs of chronic laryngitis with laryngoscopy.

3. Patients with hoarseness should be educated on control and prevention methods.

Bilateral vocal cord paralysis typically manifests with significant respiratory distress caused by obstruction of the glottis from bilateral medialization of vocal cords. Many of these patients need emergent establishment of the airway by intubation or tracheotomy. Causes of bilateral vocal cord paralysis include thyroid or cervical spine surgery or CNS disorders. Hydrocephalus or an Arnold-Chiari malformation can cause bilateral paralysis via brainstem herniation with stretching of the vagus nerves. Treatment in these circumstances is aimed at stabilizing the airway and treating the underlying problem, with the paralyzed cord usually returning to normal function after a few months.

There are numerous surgical techniques to improve vocalization. Endoscopic injection of autologous, allogenic, or allo-plastic substances can provide temporary and even permanent improvement by medializing the weak vocal cord so that the

Figure 19-7 Intraoperative photograph of true vocal cords with nodules in 25-year-old teacher.

mobile vocal cord can make contact. Open surgical approaches can also be performed for permanent unilateral paralysis, with excellent results. Medialization of the vocal cord with the use of alloplastic materials is now common. Surgical options to correct permanent bilateral vocal cord paralysis include removal of a portion of the arytenoids or vocal cords to open the airway; permanent tracheotomy is a last resort.

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