CPG: Hoarseness (Dysphonia) Update – Research Needs

Research Needs section from Hoarseness (Dysphonia) CPG

While there is a body of literature from which these recommendations were drawn, significant gaps in our knowledge about dysphonia and its management remain. The guideline committee identified several areas where further research would improve the ability of clinicians to optimally treat patients with dysphonia.

1. Escalation of Care and Laryngoscopy and Dysphonia (KASs 3 and 4)
   Little is known about the natural history of voice disorders;thus, research is needed to better understand the normal course of these conditions to determine when and if early referral is helpful and/or if early intervention (eg, voice therapy, medical management, surgery) is effective at increasing the QOL or reducing health consequences related to other underlying conditions. A need exists to better define what “warning signs” and indications should prompt early referral for laryngoscopy. Moreover, education and dissemination of these “warning signs” and indications are important, and effective approaches should be investigated.
2. Antireflux Medication and Dysphonia (KAS 6)
   There is a need for a consistent “gold standard” definition of what constitutes LPR to reduce heterogeneity among comparative studies. This would allow for better estimates of disease burden and the degree of association with dysphonia 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 treatment 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 effectiveness (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 heterogeneity in the number and quality of outcome measures used. This is an issue for patient-centered outcomes and for “objective 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 medical therapy) for these conditions.
5. Botulinum Toxin (KAS 11)
   A need exists to better understand the pathophysiology of laryngeal dystonia to develop more effective treatments. It is also necessary to learn about which patients and factors predict better or worse outcomes with botulinum toxin and what other alterative interventions might be beneficial to this patient population.
6. Education/Prevention (KAS 12)
   Prevention and education are paramount to reducing the burden of disease and disease recidivism. This requires a clearer understanding of preventive factors, healthy behaviors, and effective methods to effect and disseminate this information. In addition, it is important to better understand what factors increase the likelihood of developing voice disorders such that these groups can be targeted for educational and preventive interventions. Further work is needed to better understand the underpinnings of MTD and functional dysphonia to help in prevention, education, and the management of these conditions.
7. Outcomes (KAS 13)
   Outcome assessment in voice disorders needs to be better standardized and refined. Patient-centered outcome measures and instrumental assessment need to be carefully and rigorously evaluated to determine their usefulness and reasonableness at the point of care. Better standardization of measurement would allow for better comparison across treatment and to better define disease severity and affect patient QOL and function.