嘶哑：基于证据的医学和实践经验可以相处吗？
Soham Roy，医学博士，FACS，FAAP
Professor, Director
As we move toward a world where medical treatments are judged not by pizzazz but by efficacy and cost-effectiveness, evidence-based medicine (EBM) has become the new thrust of medical education and practice. Along with it, interest in clinical practice guidelines (CPGs) has burgeoned. When developed according to protocol, these guidelines serve to minimize unnecessary care and encourage high-yield investigations and interventions. There are times, however, when clinical acumen and common sense can both run afoul of such guidelines. Many consider this to be the case with the guideline for Hoarseness recently published inOtolaryngology-Head and Neck Surgery.
The临床实践指南：嘶哑（吞咽困难）1is one of the five developed in conjunction with the美国耳鼻喉科和颈部手术学会(AAO). Past guidelines have dealt with otitis media with effusion (2004), adult sinusitis (2007) and benign paroxysmal positional vertigo (BPPV) (2009). The AAO’s stated purpose is “to improve the quality of care for patients with hoarseness based on current best evidence” and at the outset, it defines hoarseness as a symptom and dysphonia as a diagnosis. A working group of otolaryngologists, other physicians, speech pathologists, voice teachers and allied health advocates was convened to survey and analyze the available evidence for evaluation and management of the spectrum of voice disorders. The panel then made eleven statements which were classified as strong recommendations, recommendations or options according to the literature on which they were based. The guideline was unveiled in the September edition of the Otolaryngology-Head & Neck Surgery and at a miniseminar at the 2009 AAO Annual Meeting. At this event, this new CPG was reviewed and each statement explained to the audience. Controversy abounded at this meeting as many seasoned veterans expressed dissatisfaction with the process as well as the product.
The guideline was recently the subject of another panel. This time, it was at the American Broncho-Esophagological Association (ABEA) Annual Meeting held at the 2010Combined Otolaryngology Spring Meeting（COSM）。在这个论坛中，对AAO Hoarseness指南的强烈批评者审查了其陈述，并探讨了其一些弱点。在ENT社区中，有两个营地 - 支持该准则的人，以及那些将其视为不完整的文献反映的人，这些文献既屈服于常识和积累的经验。小组开始审查医师思维过程的性质以及临床试验与日常实践之间的差异，并强调了经验丰富的从业者合成可用数据的独特方式以及患者制定行动计划的独特情况。该小组还表示关注的是，对不完整/不足文献的冷静分析不能很好地为患者提供服务，并且不应从这些经常复杂的疾病的管理中消除积累的经验。
The disagreement between these camps begins with the first statement about the diagnosis of hoarseness. While we all may use the ICD code for dysphonia, we also recognize that it is a symptom of an underlying disorder of laryngeal or vocal function rather than the end-game of our investigation. Other CPGs have dealt with disease entities rather than symptoms. The ABEA panel universally decried the CPG’s first statement as a misstep for this reason, asserting that this places the entire guideline on shaky ground since the literature on symptoms is not as precise as that for diagnoses.
声明3重新点燃冲突，因为它设置了应检查喉的3个月时间范围。有些人将其比作最多3个月，然后骨科外科医生应检查表现出关节疼痛和无法举重的患者的膝盖。当感知器官发生故障时，应在决策过程中直接对其进行直接检查。尽管CPG认为可以随时检查吞咽困难的喉部，并强调应触发及时评估的因素，但该陈述易于误解，因为那些对头部和颈部疾病的护理中没有经验的人都可以误解。
The CPG does also include ideas generally believed to align well with standard clinical experience. Statement 2 emphasizes the importance of the history for determining the cause of dysphonia and points out certain historical factors such as prior cervical surgery, prolonged intubation and esophagectomy which involve risk to the recurrent laryngeal nerve. Statement 4 recommends against the routine use of imaging for dysphonia prior to direct examination of the larynx with at least mirror laryngoscopy. Statements 5 and 6 refer to the use of anti-reflux medications and steroids, respectively. In the case of each, the analysis shows that the risks of these medications can easily outweigh the benefits and thus, they should be used selectively for specific pathology. Statement 7 admonishes against the routine use of antimicrobial agents until a definitive bacterial cause is identified while #8 recommends that the larynx be examined prior to recommending voice therapy, an intervention which was regarded as useful in the right circumstances. Statements 9 and 10 advocate appropriate use of surgical therapy and chemo-denervation for specific conditions. The final statement offers the option of educating patients about the nature of their voice problem and preventative measures that may be taken to avoid future occurrences.
CPG说的是耳鼻喉科学中的证据状态，而不是其他任何方面的证据。这些陈述是基于小组对汇总文献的分析。Of the 11, only 2 are based on level A evidence (well-designed randomized controlled trials or diagnostic studies performed on a population similar to the guideline’s target population) while 3 rise to level B (randomized controlled trials or diagnostic studies with minor limitations or overwhelmingly consistent evidence from observational studies). The CPG concludes by recognizing this trend in the extant otorhinolaryngology literature and identifying areas in need of structured research on which we can base our decisions. We should remember, however, that EBM is population-based and cannot always be extrapolated to every individual. Each patient we see is an individual with particular circumstances to which we must respond. Since these guidelines are tempting fodder for payors to use when determining pay structures, we should work to make sure that they are fair and balanced…with our thumbs on the scale in favor of our patients’ best interests. In the end, just as we temper justice with mercy, we must learn to practice evidence-based medicine that is tailored to the needs of our individual patients.
参考
1http://www.ncbi.nlm.nih.gov/pubmed/19729111