Considerations When Providing Voice Services in the Absence of Endoscopic Evaluation During COVID-19

Due to concerns regarding the spread of COVID-19 through aerosolizing procedures, otolaryngologists and speech-language pathologists (SLPs) are deferring laryngeal visualization except when deemed vital and the benefits are judged to outweigh the risks. Examples of this include time sensitive, urgent, and emergent medical conditions as determined by the physician on a case-by-case basis. Under normal circumstances, best practice indicates visualization of the larynx, ideally via stroboscopy, is necessary prior to starting therapy.  The American Speech-Language-Hearing Association (ASHA) Voice Disorders Practice Portal states, “all patients/clients with voice disorders are examined by a physician, preferably in a discipline appropriate to the presenting complaint. The physician's examination may occur before or after the voice evaluation by the speech-language pathologist.”

However, this presents a dilemma. If a person is negatively impacted by their voice disorder, and SLPs could provide treatment either in-person or via telepractice, can and should they do so without laryngeal visualization occurring first, or do they need to defer all voice therapy until after the larynx can be visualized?

Each situation should be evaluated individually, consistent with the ASHA Code of Ethics. Clinicians should follow state laws and regulations, and facilities and clinics should establish their protocols during the COVID-19 pandemic. The following are points for consideration during the COVID-19 pandemic:

  1. Based on a review of the medical history and a voice evaluation, the SLP may recommend voice therapy to improve communication and/or quality of life prior to stroboscopic evaluation. Prior to initiation of treatment, individuals/caregivers need to be informed that
    • the etiology of the voice disorder, as well as structure and function of the larynx, cannot be adequately evaluated without visualization;
    • the care team will initiate treatment based on the knowledge gained from perceptual (and if available, acoustic) assessment, and trial therapy;  
    • every effort will be made to perform a full instrumental evaluation as soon as clinically possible; 
    • there are risks and benefits (to be detailed by the SLP) of providing treatment in the absence of laryngeal visualization; and
    • the SLP will carefully monitor patient progress.
  1. Based on a review of the medical history and a voice evaluation, the care team (including the otolaryngologist/laryngologist and SLP) may determine that laryngeal visualization is essential prior to initiation of therapy in time sensitive, urgent or emergent medical conditions (e.g., persistent stridor, suspected laryngeal cancer, etc.). 
    • This decision would be made on a case-by-case basis after weighing the risks and benefits carefully. 
    • Considerations for virtual visits are recommended, as much as it is feasible. 
    • If in-person visits are necessary, ASHA recommends that employers provide SLPs adequate protection from droplet transmission during AGPs consistent with the CDC recommended guidelines for personal protective equipment (PPE).

The Special Interest Group 3 Coordinating Committee (Voice and Upper Airway Disorders) assisted with the development of this guidance. 

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