Hoarseness Guidelines Continue to Draw Scrutiny: Panel members question evidence-based criteria

But he said that even in areas where randomized, controlled trials exist, they might not necessarily apply in a particular case. “The patients in studies do not always match the patients sitting in our chair or lying on our operating table,” Dr. Eibling said.

Some things simply cannot be studied, he said, mentioning the joke about how there have been no randomized trials showing that parachutes actually work.

“The bottom line is those who believe that all interventions must be evidence-based need to come down to earth with a bump,” he said. “You are all experts, and your expert opinion matters and, at times, must trump guidelines.”

The guidelines “do not supersede clinical judgement.”

—Gavin Setzen, MD

Concerns

Dr. Johns said the guidelines contain some “great elements,” such as advocating for voice therapy and Botox in the treatment of spasmodic dysphonia, but he reiterated the view that there can’t be much data available for the treatment of hoarseness because it’s a symptom rather than a diagnosis.

A big concern about the guidelines is their weak stance on laryngoscopy. The procedure is given a policy recommendation of “option,” rather than “recommendation” or “strong recommendation.” “I think most of us realize that if someone has chronic voice change, you need to examine the organ that’s involved,” Dr. Johns said. “We need a strong stance on laryngoscopy.”

Another worrisome guideline, Dr. Johns said, was that a three-month allowance or “safety net” of voice change prior to laryngoscopy is advocated, except where symptoms are considered to be “serious.” The problem, he said, is that primary care doctors relying on the guidelines might not know whether symptoms are serious or not.

Dr. Sulica pointed to the literature documenting the risk of delayed diagnosis that might come about if primary care doctors don’t refer patients promptly—and that literature might not pop up in a search of just the term “hoarseness.” “You don’t get this if you pull up ‘hoarseness,’ but you do if you pull up a specific diagnosis like ‘early glottic cancer,’” he said.

The authors of the guidelines have no plans to re-work them. “The hoarseness guideline itself is a very useful tool that will remain an important resource for the broader physician community, and there are no plans for revision,” Dr. Setzen said.