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Abstract：
Objective This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia. Purpose The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology-head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology. Action Statements The guideline update group made strong recommendations for the following key action statements (KASs): (1) 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. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) 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). (5) 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. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux 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. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia. Disclaimer This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia.
摘要：
目的本指南提供了关于治疗存在发音障碍的患者的循证建议。其特征是声音质量改变，螺距,响度,或影响沟通和/或生活质量的声音努力。在其生命的某个阶段，发声障碍会影响近三分之一的人口。本指南适用于在将识别或管理发音障碍的环境中评估的所有年龄组。它适用于所有可能诊断和治疗发声障碍患者的临床医生。目的本指南的主要目的是提高发声障碍患者的护理质量。基于目前最好的证据。填补证据空白的专家共识，使用时,明确说明，并有详细的透明度证据概况支持。该指南的具体目标是减少护理方面的不适当变化，产生最佳的健康结果，尽量减少伤害。对于此指南更新，美国耳鼻咽喉头颈外科基金会选择了一个代表高级实践护理领域的小组，支气管食管学，消费者宣传，家庭医学,老年医学，内科，喉科,神经学,耳鼻咽喉头颈外科,儿科,专业的声音,肺科,和语言病理学。行动声明指南更新小组对以下关键行动声明（KAS）提出了强有力的建议：（1）临床医生应通过病史和体格检查来评估发声障碍患者，以确定需要加快喉部评估的因素。这些包括,但不限于,最近涉及头部的外科手术，脖子,或胸部；最近气管插管；同时存在颈部肿块；呼吸窘迫或喘鸣；烟草滥用史；以及患者是否是专业的语音使用者。（2）临床医生应提倡对语音障碍患者进行语音治疗。指南更新小组对以下KAS提出了建议：（1）临床医生应识别语音质量改变的患者的发音障碍，螺距,响度,或影响沟通或降低生活质量（QOL）的声音努力。（2）临床医生应通过病史和体格检查评估发声障碍患者的潜在原因和改变治疗的因素。（3）临床医生应进行喉镜检查，或者是指可以进行喉镜检查的临床医生，如果怀疑有严重的潜在原因，则发音障碍在4周内未能解决或改善，或者与持续时间无关。（4）临床医生应进行诊断性喉镜检查，或指可以进行诊断性喉镜检查的临床医生，在开具语音治疗并将结果记录/传达给语言病理学家（SLP）之前。（5）临床医生应提倡手术作为适合手术干预的发声障碍患者的治疗选择，比如疑似恶性肿瘤，对保守治疗没有反应的有症状的良性声带病变，或声门功能不全。（6）临床医生应该提供，或者是指可以提供的临床医生，肉毒杆菌毒素注射用于治疗由痉挛性发声障碍和其他类型的喉肌张力障碍引起的发声障碍。（7）临床医生应告知发声障碍患者控制/预防措施。(8)临床医生应记录决议，改善或恶化的症状，治疗或观察后发声障碍患者的生活质量变化。指南更新小组对1项行动提出了强烈建议：（1）临床医生不应常规开抗生素治疗发音障碍。指南更新小组针对其他措施提出了建议：（1）在可视化喉部之前，临床医生不应对患有主要语音投诉的患者进行计算机断层扫描（CT）或磁共振成像（MRI）。（2）临床医生不应该开抗反流药物来治疗孤立性发音障碍，仅根据疑似胃食管反流病（GERD）或咽喉反流（LPR）的症状，没有可视化的喉。（3）在观察喉部之前，临床医生不应对发声困难的患者常规开皮质类固醇。关于喉镜检查的以下建议的政策级别是一种选择：（1）临床医生可以在任何时候对发声障碍患者进行诊断性喉镜检查。免责声明本临床实践指南不旨在作为治疗发音障碍（声音嘶哑）的详尽指导来源。相反，它旨在通过提供基于证据的决策策略框架来帮助临床医生.该指南并不旨在取代临床判断或为所有患有这种疾病的人建立治疗方案，并且它可能无法提供诊断和管理此问题的唯一适当方法。与先前指南的差异（1）纳入新的证据档案，以包括患者偏好的作用，对证据的信心,意见分歧,质量改进机会，以及行动声明不适用的任何排除(2)纳入3项新准则，16个新的系统审查，和4项新的随机对照试验(3)将消费者倡导者纳入指南更新组(4)从原来的指南改为9个KASs(5)新的KAS3(护理升级)和KAS13(结局)(6)为发声障碍患者添加概述KASs的算法.
