The most common diagnoses assigned to individuals with nonorganic dysphonia have been LPR or muscle tension dysphonia. An allergic cause has often only been considered if proton pump inhibitors and voice therapy have failed to ameliorate the symptoms. Given the lack of conclusive evidence surrounding the existence of laryngeal allergy and the abundance of research activity supporting a role for LPR in the manifestation of dysphonia this has been an expedient approach. However, considering recent suggestions that LPR is being overdiagnosed, the growing body of literature indicating a relationship between allergy and dysphonia and a preliminary study demonstrating causality between allergen provocation and dysphonia, allergy should be considered as a possible source of nonorganic dysphonia earlier in the diagnostic process.
The treatment approach for allergy-related dysphonia requires further study. The current pathway is to first treat the sinus symptoms with nasal steroids and avoid the use of antihistamines if possible because of their potential drying effect on the laryngeal mucosa. For professional voice users this has included avoiding even the most recent generation of antihistamines. Although there is some indication that localized treatment of sinus symptoms may have a generalized effect of reducing inflammation throughout the airway, more information is necessary to determine whether systemic treatments such as immunotherapy may better control any localized reactions in the larynx. The cost–benefit ratio of treatment with antihistamines should also be evaluated to determine whether their therapeutic benefit outweighs any potential drying effect on the larynx.
The relationship between allergies and vocal dysfunction has received little attention in the literature in part because of practical and technological limitations in studying the phenomenon. A recent study demonstrated a well tolerated and practical method of oral inhaled allergy provocation that bypasses the nose and limits the potential for a pulmonary response by excluding patients with asthma and a positive methacholine challenge. Preliminary results have shown that allergy challenge can cause dysphonia. Further investigations into the underlying inflammatory mechanisms mediating the laryngeal response to allergy are necessary to advance current diagnostic and treatment methods. Once we are better able to understand and identify the processes involved in the laryngeal allergic response we will be in a better position to differentiate dysphonia related to allergy from that caused by LPR or other forms of dysphonia currently lacking specific findings. We will also be able to develop new treatment regimens based on knowledge of the underlying processes, allowing less trial and error in the treatment of patients' nonorganic dysphonia.
Thank you to Katherine Verdolini Abbott and Suzanne Morse for providing their feedback and suggestions in preparing this manuscript. Their time is greatly appreciated and helped improve the clarity of the document.
References and recommended reading
Papers of particular interest, published within the annual period of review, have been highlighted as:
• of special interest
•• of outstanding interest
Additional references related to this topic can also be found in the Current World Literature section in this issue (p. 217).
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