今日の臨床サポート

嗄声

著者: 横江正道 日本赤十字社愛知医療センター名古屋第二病院 総合内科

監修: 野口善令 豊田地域医療センター 総合診療科

著者校正済:2022/08/31
現在監修レビュー中
参考ガイドライン:
  1. 日本音声言語医学会/日本喉頭科学会:音声障害診療ガイドライン 2018年版. 金原出版、2018.
患者向け説明資料

概要・推奨   

  1. 急性喉頭炎の多くはウイルス性であり、抗菌薬の安易な投与は行うべきではない(推奨度4)
  1. 嗄声の患者を診察した場合には、喉頭ファイバーによる喉頭所見を評価することを考慮する。自分でできない場合には、できる医師にコンサルテーションするべきである(推奨度1)
  1. 喉頭ファイバーを行うより前にCTやMRIで評価をすべきではない(推奨度4)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
横江正道 : 未申告[2022年]
監修:野口善令 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 定期レビューを行い、ウイルス感染症につき図を追加した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 嗄声は、非常に曖昧で非特異的な症状である。
  1. 診療する医師の受け止め方により、嗄声と判断するかどうかはまちまちである。
  1. 嗄声の原因は、単なる感冒(ウイルス感染症)から悪性腫瘍まで多岐にわたる。しかし、その多くは感冒などのself-limitedな(自然治癒する)原因である。
  1. 急性の嗄声と慢性の嗄声では原因疾患が大きく異なる。
  1. 急性嗄声の原因には、急性上気道炎、アレルギー(アナフィラキシー)、気道内異物、突然の大声(応援やカラオケなど)、咽喉頭逆流、急性喉頭蓋炎、大動脈解離などがある。
  1. 急性喉頭蓋炎、アナフィラキシー、大動脈解離を見逃さないように注意する。
  1. 慢性嗄声の原因には、慢性喉頭炎、咽頭喉頭逆流、甲状腺機能低下症(粘液水腫)、喫煙、悪性腫瘍(喉頭腫瘍など)、声帯ポリープ、手術後の反回神経麻痺、神経筋疾患、職業性(教師、僧侶、弁護士、歌手など)などがある。
  1. 慢性的に進行する場合には、悪性腫瘍の評価が重要である。
問診・診察のポイント  
  1. 診察の基本は、問診であり、そのためには鑑別疾患の理解が必要である。

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文献 

I Syed, E Daniels, N R Bleach
Hoarse voice in adults: an evidence-based approach to the 12 minute consultation.
Clin Otolaryngol. 2009 Feb;34(1):54-8. doi: 10.1111/j.1749-4486.2008.01872.x.
Abstract/Text BACKGROUND: The hoarse voice is a common presentation in the adult ENT clinic. It is estimated that otolaryngology/voice clinics receive over 50 000 patients with dysphonia each year. Good vocal function is estimated to be required for around 1/3 of the labour force to fulfil their job requirements. The assessment and management of the patient with a hoarse voice is potentially a complex and protracted process as the aetiology is often multi-factorial. This article provides a guide for the clinician in the general ENT clinic to make a concise, thorough assessment of the hoarse patient and engage in an evidence based approach to investigation and management.
METHOD: Literature search performed on 4 October 2008 using EMBASE, MEDLINE, Cochrane databases using subject headings hoarse voice or dysphonia in combination with diagnosis, management, investigation, treatment, intervention and surgery.
RESULTS: General vocal hygiene is beneficial for non organic dysphonia but the evidence base for individual components is poor. There is a good evidence base for the use of voice therapy as first line treatment of organic dysphonia such as vocal fold nodules and polyps. There is little evidence for surgical intervention as first line therapy for most common benign vocal fold lesions. Surgery is, however, the treatment of choice for hoarseness due to papillomatosis. Both CO(2) laser and microdissection are equally acceptable modalities for surgical resection of common benign vocal fold lesions. Laryngopharyngeal reflux is commonly cited as a cause of hoarseness but the evidence base for treatment with gastric acid suppression is poor. Despite the widespread use of proton pump inhibitors for treating laryngopharyngeal reflux, there is high quality evidence to suggest that they are no more effective than placebo.
CONCLUSION: A concise and thorough approach to assessment in the general ENT clinic will provide the diagnosis and facilitate the management of the hoarse voice in the majority of cases. Voice therapy is an important tool that should be utilised in the general ENT clinic and should not be restricted to the specialist voice clinic. If there is no improvement after initial measures, the larynx appears normal and/or the patient has failed initial speech & language therapy, referral to a specialist voice clinic may be helpful. More research is still required particularly with regard to laryngopharyngeal reflux which is often cited as an important cause of hoarseness but is still poorly understood.

PMID 19260886
Ji-Eon Kim, Barry Rasgon
The hoarse patient: asking the right questions.
Perm J. 2010 Spring;14(1):51-3.
Abstract/Text
PMID 20740132
Raymond H Feierabend, Malik N Shahram
Hoarseness in adults.
Am Fam Physician. 2009 Aug 15;80(4):363-70.
Abstract/Text Numerous conditions can cause hoarseness, ranging from simple inflammatory processes to more serious systemic, neurologic, or cancerous conditions involving the larynx. Evaluation of a patient with hoarseness includes a careful history, physical examination, and in many cases, laryngoscopy. Any patient with hoarseness lasting longer than two weeks in the absence of an apparent benign cause requires a thorough evaluation of the larynx by direct or indirect laryngoscopy. The management of hoarseness includes identification and treatment of any underlying conditions, vocal hygiene, voice therapy, and specific treatment of vocal cord lesions. Vocal hygiene education is an integral aspect of the treatment of hoarseness in most cases. Referral to a speech-language pathologist for voice therapy may be particularly helpful for patients whose occupation depends on singing or talking loudly or for prolonged periods. Voice therapy is an effective method for improving voice quality and vocal performance in patients with nonorganic dysphonia and for treating many benign pathologic vocal cord lesions. Referral for surgical or other targeted interventions is indicated when conservative management of vocal cord pathology is unsuccessful, when dysplasia or carcinoma is suspected, or when significant airway obstruction is present.

PMID 19678604
Abstract/Text This study investigated the efficacy of a program of vocal hygiene education designed for an occupational group at risk for dysphonia, namely, kindergarten teachers. Twelve female teachers explored concepts and knowledge of vocal abuse and vocal hygiene in a workshop session and attempted to practice vocal hygiene for 2 months. They showed significant voice improvement as assessed instrumentally in terms of three acoustic and electroglottographic parameters. There was no significant change of voice in a control group of 13 teachers. The results suggest that teachers were able to improve their voices if they significantly reduced vocal abuses in daily life and practiced specific strategies to maintain classroom order and reduce the use of voice in teaching.

PMID 7987431
Young-Sun Yun, Min-Beom Kim, Young-Ik Son
The effect of vocal hygiene education for patients with vocal polyp.
Otolaryngol Head Neck Surg. 2007 Oct;137(4):569-75. doi: 10.1016/j.otohns.2007.03.043.
Abstract/Text OBJECTIVE: The authors aimed to assess the effect of vocal hygiene education for patients suffering with vocal polyp and to discover the meaningful factors that can predict better outcomes with performing vocal hygiene.
STUDY DESIGN AND SETTING: Voice evaluation and vocal hygiene education were provided to 340 consecutive patients with vocal polyp. Three months later, 175 of the 340 patients completed a follow-up evaluation. According to the change in polyp size, these patients were divided into two groups: the "improvement" and the "no improvement." The effect of vocal hygiene was assessed. Eight parameters were compared between these two groups.
RESULTS: The "improvement" group was composed of 20% of the 340 patients and 38% of the 175 patients. Multivariate analyses demonstrated that nonsmokers with a small polyp had the greatest possibility of improvement with vocal hygiene and so avoid unnecessary surgery.
CONCLUSION: Patients who do not smoke and who have a polyp that is small in size have a much better chance to improve their voice by performing vocal hygiene.

PMID 17903572
L Reveiz, A F Cardona, E G Ospina
Antibiotics for acute laryngitis in adults.
Cochrane Database Syst Rev. 2007 Apr 18;(2):CD004783. doi: 10.1002/14651858.CD004783.pub3. Epub 2007 Apr 18.
Abstract/Text BACKGROUND: Acute laryngitis is a common illness worldwide. Diagnosis is often made by case history alone and treatment is often directed towards controlling symptoms.
OBJECTIVES: The aim of this review was to assess the effectiveness of different antibiotic therapies in adults suffering acute laryngitis. A secondary objective was to report the rates of adverse events associated with these treatments.
SEARCH STRATEGY: We systematically screened the following electronic databases: the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2006); MEDLINE (January 1966 to December Week 2 2006); and EMBASE (1974 to June 2006), LILACS (from 1982 to December 2006 ) and BIOSIS (1980 to June 2002). Other strategies included hand searching relevant journals, searching ongoing trial databases and general databases such as Google scholar.
SELECTION CRITERIA: Randomized controlled trials comparing any antibiotic therapy with placebo in acute laryngitis. The main outcome measurement was objective voice scores.
DATA COLLECTION AND ANALYSIS: Data were independently extracted by two review authors and then descriptively synthesized.
MAIN RESULTS: Only two trials met study inclusion criteria after extensive literature searches. One hundred participants were randomly selected to receive either penicillin V (800 mg twice a day for five days), or an identical placebo, in a study of penicillin V in acute laryngitis in adults. A tape recording of each patient reading a standardized text was obtained during the first visit, subsequently during re-examination after one and two weeks, and at follow up after two to six months. No significant differences were found between the groups. The trial also measured symptoms reported by participants and found no significant differences. The second trial investigated erythromycin for treating acute laryngitis in 106 adults. The mean objective voice scores measured at the first visit, at re-examination after one and two weeks, and at follow up after two to six months did not significantly differ between control and intervention groups. At one week there were significant beneficial differences in the severity of reported vocal symptoms as judged by the participants (P = 0.042). Comparing the erythromycin and placebo groups on subjective voice scores the a priori relative risk (RR) was 0.7 (95% confidence interval (CI) 0.51 to 0.96, P = 0.034) and the number needed to treat (NNT) was 4.5.
AUTHORS' CONCLUSIONS: Antibiotics appear to have no benefit in treating acute laryngitis. Erythromycin could reduce voice disturbance at one week and cough at two weeks when measured subjectively. We consider that these outcomes are not relevant in clinical practice. The implications for practice are that prescribing antibiotics should not be done in the first instance as they will not objectively improve symptoms.

PMID 17443555
James Paul Dworkin
Laryngitis: types, causes, and treatments.
Otolaryngol Clin North Am. 2008 Apr;41(2):419-36, ix. doi: 10.1016/j.otc.2007.11.011.
Abstract/Text Inflammatory processes that affect the unified airway can concurrently exert significant influence on the larynx and surrounding mucosal surfaces. Laryngeal inflammation can be present secondary to direct effects of irritants, toxins, and antigens, but can also involve mechanical and infectious effects as well as secondary inflammation from behavioral mechanisms. This review examines laryngeal inflammation in the context of the unified airway and discusses pathophysiologic mechanisms that are central to the development of acute and chronic laryngitis.

PMID 18328379
Seth R Schwartz, Seth M Cohen, Seth H Dailey, Richard M Rosenfeld, Ellen S Deutsch, M Boyd Gillespie, Evelyn Granieri, Edie R Hapner, C Eve Kimball, Helene J Krouse, J Scott McMurray, Safdar Medina, Karen O'Brien, Daniel R Ouellette, Barbara J Messinger-Rapport, Robert J Stachler, Steven Strode, Dana M Thompson, Joseph C Stemple, J Paul Willging, Terrie Cowley, Scott McCoy, Peter G Bernad, Milesh M Patel
Clinical practice guideline: hoarseness (dysphonia).
Otolaryngol Head Neck Surg. 2009 Sep;141(3 Suppl 2):S1-S31. doi: 10.1016/j.otohns.2009.06.744.
Abstract/Text OBJECTIVE: This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness.
PURPOSE: The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology-Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology-head and neck surgery, pediatrics, and consumers.
RESULTS: The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patient's larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures.
DISCLAIMER: This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). 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 may not provide the only appropriate approach to diagnosing and managing this problem.

PMID 19729111
C Hopkins, U Yousaf, M Pedersen
Acid reflux treatment for hoarseness.
Cochrane Database Syst Rev. 2006 Jan 25;(1):CD005054. doi: 10.1002/14651858.CD005054.pub2. Epub 2006 Jan 25.
Abstract/Text BACKGROUND: Acid reflux is a common problem, and is thought to occur in 4% to 10% of patients presenting to ENT clinics. A recent study of reflux and voice disorders suggests that up to 55% of patients with hoarseness (dysphonia) have laryngopharyngeal reflux. Anti-reflux therapy is often used empirically in treating patients with hoarseness, where no other cause has been identified by examination.
OBJECTIVES: The aim of the review was to assess the effectiveness of anti-reflux therapy for patients with hoarseness, in the absence of other identifiable causes, whether or not a definitive diagnosis of laryngopharyngeal and gastro-oesophageal reflux has been made. This was assessed by evaluation of prospective randomised controlled studies that were identified by a systematic review of the literature. Both medical and surgical treatments were evaluated.
SEARCH STRATEGY: The Cochrane ENT Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 3, 2005), MEDLINE (1966 to 2005), EMBASE (1974 to 2005) and conference proceedings were searched with prespecified terms. The date of the last search was September 2005.
SELECTION CRITERIA: Randomised controlled trials recruiting patients with hoarseness in the absence of other identifiable causes, such as malignancy, cord palsy or nodules, whether or not a definitive diagnosis of laryngopharyngeal and gastro-oesophageal reflux has been made.
DATA COLLECTION AND ANALYSIS: Three reviewers examined the search results and identified studies before deciding which would be included in the review.
MAIN RESULTS: 302 potential studies were identified by the search strategy. No trials were identified which met our inclusion criteria. Six randomised controlled trials were identified in which some, but not all patients presented with hoarseness, and were treated with proton pump inhibition. As we could not determine with certainty whether all these patients had hoarseness among the other laryngeal symptoms, these were excluded. However, these studies suggest a significant placebo response, which is comparable to the benefit derived from anti-reflux therapy in some studies. As no trials met our criteria, we are unable to reach any firm conclusions regarding the effectiveness of anti-reflux treatment for hoarseness.
AUTHORS' CONCLUSIONS: There is a need for high quality randomised controlled trials to evaluate the effectiveness of anti-reflux therapy for patients with hoarseness which may be due to laryngopharyngeal and gastro-oesophageal reflux.

PMID 16437513
P C Belafsky, G N Postma, J A Koufman
Laryngopharyngeal reflux symptoms improve before changes in physical findings.
Laryngoscope. 2001 Jun;111(6):979-81. doi: 10.1097/00005537-200106000-00009.
Abstract/Text BACKGROUND: Patients with laryngopharyngeal reflux (LPR) undergoing treatment appear to have improvement in symptoms before the complete resolution of the laryngeal findings.
OBJECTIVE: To determine whether patients with LPR experience an improvement in symptoms before the complete resolution of the laryngeal findings.
METHODOLOGY: Forty consecutive patients with LPR documented by double-probe pH monitoring were evaluated prospectively. Symptom response to therapy with proton pump inhibitors was assessed at 2, 4, and 6 months of treatment with a self-administered reflux symptom index (RSI). In addition, transnasal fiberoptic laryngoscopy (TFL) was performed and a reflux finding score (RFS) was determined for each patient at each visit.
RESULTS: The mean RSI at entry was 19.3 (+/- 8.9 standard deviation) and it improved to 13.9 (+/- 8.8) at 2 months of treatment (P <.05). No further significant improvement was noted at 4 months (13.1 +/- 9.8) or 6 months (12.2 +/- 8.1) of treatment. The RFS at entry was 11.5 (+/- 5.2), and it improved to 9.4 (+/- 4.7) at 2 months, 7.3 (+/- 5.5) at 4 months, and 6.1 (+/- 5.2) after 6 months of treatment (P <.05 with trend).
CONCLUSIONS: Symptoms of LPR improve over 2 months of therapy. No significant improvement in symptoms occurs after 2 months. This preliminary report demonstrates that the physical findings of LPR resolve more slowly than the symptoms and this continues throughout at least 6 months of treatment. These data imply that the physical findings of LPR are not always associated with patient symptoms, and that treatment should continue for a minimum of 6 months or until complete resolution of the physical findings.

PMID 11404607
Ted Mau
Diagnostic evaluation and management of hoarseness.
Med Clin North Am. 2010 Sep;94(5):945-60. doi: 10.1016/j.mcna.2010.05.010.
Abstract/Text Hoarseness is a common symptom that can result from a wide spectrum of underlying causes ranging from the common cold to a malignancy. A framework for diagnostic evaluation is presented based on categorizing the myriad of causes by how they interfere with the voice production mechanism. Triaging of cases by necessity or urgency of laryngoscopy is assisted by forming a global index of suspicion based on targeted history taking. Laryngoscopy is required in most cases to obtain a diagnosis for the hoarseness. Treatments commonly prescribed for hoarseness are critically examined in this article. To listen to audio clips of patients with different types of hoarseness, please visit our website, www.medical.theclinics.com.

Copyright 2010 Elsevier Inc. All rights reserved.
PMID 20736105
Pieter M Pretorius, Chris A Milford
Investigating the hoarse voice.
BMJ. 2008 Oct 8;337:a1726. Epub 2008 Oct 8.
Abstract/Text
PMID 18842646

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