Evaluating Dysphonia Referrals to Otolaryngology Providers: Is There a Need For Improved Referral Guideline Implementation?

OBJECTIVE: Evaluate referring physicians' adherence to the 2018 Hoarseness/Dysphonia Clinical Practice Guideline when referring to an academic otolaryngology department. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary academic medical center. METHODS: Adult patients (≥ 18 years old) referred to the University of Missouri Department of Otolaryngology-Head and Neck Surgery for a primary complaint of dysphonia between January 2015 and December 2022 were included. Patients referred from otolaryngologists or primary complaints other than dysphonia were excluded. Demographics, diagnoses, referral reason, and prior management were assessed. Referral practices before and after the 2018 update were examined across recommendations relevant to referring physicians: timely referral, avoidance of pre-laryngoscopy imaging, avoidance of empiric antireflux therapy, corticosteroids, and antibiotics, and performance of laryngoscopy before prescribing voice therapy. Adherence to each recommendation and all recommendations combined was compared between pre- and post-guideline cohorts. RESULTS: In all, 528 patients were included: 141 (26.7%) were referred before and 387 (73.3%) after the 2018 update. Following guideline publication, adherence significantly decreased for timely referral (71.3% vs 80.9%; p = .027), avoidance of imaging (96.6% vs 100%; p = .028), and avoidance of antibiotics (89.7% vs 95.7%; p = .028). No significant changes were observed for antireflux therapy, corticosteroid use, or referral before prescribing voice therapy. Adherence to all analyzed guidelines did not improve (52.5% vs 61.7%; p = .059). CONCLUSION: Referral patterns to otolaryngology physicians for dysphonia do not reflect high fidelity to updated clinical practice guidelines. These findings underscore the limitations of passive dissemination and the need for targeted implementation strategies.