Effects of Exercise-Induced Laryngeal Obstruction in Adolescents: A Qualitative Study.

PURPOSE: The purpose of this study was to examine the influence of exercise-induced laryngeal obstruction (EILO) on adolescents. METHOD: Twenty patients (< 17 years) diagnosed with EILO participated in this study. Patients completed semistructured interviews examining their experience with the health care system, treatment, and the effects of EILO symptoms on quality of life. Interviews were analyzed using a combination of directed and conventional content analyses. Researchers identified seven overarching themes either prior to or during analysis, and 24 subthemes were inductively identified from patient interviews using open, axial, and selective coding. RESULTS: On average, patients went 1.9 years between symptom onset and EILO diagnosis. Patients described symptom onset as frightening and confusing. Even after initially reporting symptoms to a medical provider, patients went an average of 10.5 months before diagnosis. Patients perceived that delays in diagnosis prevented efficient management and allowed symptoms to escalate. Patients reported that EILO detrimentally influenced athletic performance, forcing them to pace themselves or cease participation altogether. Social and academic effects of EILO included missed classes, difficulty in physical education courses, and resentment from teammates if athletic performance declined. Both athletes and nonathletes indicated that EILO elicited feelings of fear, frustration, dread, guilt, and embarrassment. Patients reported that therapy with a speech-language pathologist (SLP) effectively addressed symptoms; however, employing rescue breathing techniques was often more difficult than anticipated. CONCLUSIONS: Physical and emotional sequelae associated with EILO may have widespread influence on patient quality of life. Therapy with an SLP reportedly ameliorated EILO symptoms; however, patients indicated that delayed diagnosis allowed negative effects to intensify prior to treatment.

Diagnostic utility of spirometry for children with induced laryngeal obstruction or chronic non-specific cough.

PURPOSE: To determine the diagnostic utility of spirometry in distinguishing children with Induced Laryngeal Obstruction (ILO) or chronic non-specific cough (a.k.a. tic cough) from those with mild or moderate to severe asthma. METHODS: Retrospective cross sectional design. Children diagnosed with ILO (N = 70), chronic non-specific cough (N = 70), mild asthma (N = 60), or moderate to severe asthma (N = 60) were identified from the electronic medical record of a large children's hospital. Spirometry was completed before ILO, non-specific cough, or asthma diagnoses were made by pediatric laryngologists or pulmonologists. Spirometry was performed following American Thoracic Society guidelines and was interpreted by a pediatric pulmonologist. Forced Vital Capacity (FVC), Forced Expiratory Volume in 1 Second (FEV1), FEV1/FVC Ratio (FEV1/FVC), Forced Mid-Expiratory Flow 25--75 % (FEF25-75%), pulmonologist interpretation of flow volume loops, and overall exam findings were extracted from the medical record. RESULTS: Ninety seven percent of children with ILO or chronic non-specific cough presented with spirometry values within normative range. Patients with ILO, non-specific cough, and mild asthma presented with FVC, FEV1, FEV1/FVC, and FEF25-75% values in statistically similar range. Children with moderate to severe asthma presented with significantly reduced FVC (p < .001), FEV1 (p < .001), FEV1/FVC (p < .001), and FEF25-75% (p < .001) values when compared with patients in the other groups. Flow volume loops were predominantly normal for children with ILO and non-specific cough. CONCLUSIONS: Findings indicate that ILO and chronic non-specific cough can neither be diagnosed nor differentiated from mild asthma using spirometry alone. Spirometry should therefore be used judiciously with this population, bearing in mind the limitations of the procedure. Future research should determine the most effective and efficient ways of delineating ILO and non-specific cough from other respiratory conditions in children.

Anxiety, Depression, and Posttraumatic Stress Disorder in Patients With Induced Laryngeal Obstruction.

Importance: Patients with induced laryngeal obstruction (ILO) present with a variety of behavioral health profiles. Identifying these profiles is crucial in that behavioral health conditions may affect treatment duration and outcomes. Objective: To characterize the prevalence of anxiety, depression, posttraumatic stress disorder (PTSD), and physical somatic symptoms in adult and pediatric patients with ILO and determine the factors associated with anxiety, depression, PTSD, and physical somatic symptoms in patients with ILO? Design, Setting, and Participants: This cross-sectional study included a nonprobability sample of 83 adult and 81 pediatric patients diagnosed with ILO at outpatient adult and pediatric otolaryngology clinics between 2021 and 2023. Exclusion criteria included a comorbid respiratory diagnosis other than asthma, head or neck cancer, or neurological impairments. Recruitment took place between September 2021 and March 2023. The analyses were run in January 2024. Main Outcome Measures: Patients were prospectively screened for anxiety, depression, PTSD, and somatic physical symptoms. In addition, any past behavioral health diagnoses were extracted from the medical record. Comorbidities, ILO symptoms triggers, and onset details were gathered from ILO evaluations. Adult patients completed the Screen for Adult Anxiety Related Disorders (SCAARED), depression (Patient Health Questionnaire [PHQ]-9), and somatic physical symptoms portions of the Patient Health Questionnaires (PHQ-15), and the PTSD Checklist for the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) (PCL-5). Pediatric patients completed the Screen for Child Anxiety Related Disorders (SCARED), depression (PHQ-9A) and somatic physical symptoms portions of the Patient Health Questionnaires for Adolescents (PHQ-15A), and the UCLA PTSD Reaction Index brief screeners. Results: Eighty-three adult patients participated in this study (mean [SD] age, 45.8 [14.3] years; 64 female, 19 male). Eighty-one pediatric patients participated (mean [SD] age, 13.83 [2.55] years; 67 female, 14 male). Adult and pediatric patients with ILO screened positive for elevated rates of anxiety (53 adults [63%]; 49 children [60%]), depression (27 adults [32%]; 25 children [30%]), and PTSD (29 adults [34%]; 13 children [16%]). Most of the patients with anxiety and depression symptoms were formally diagnosed prior to ILO evaluation, with rates of previously diagnosed anxiety, depression, and PTSD also above published norms. Adults were twice as likely as children to present with PTSD (odds ratio, 2.1; 95% CI, 0.05-4.48). Elevated rates of physical somatic symptoms were also evident, with 38 adults (45%) and 32 children (39%) scoring in the moderate to severe range. Conclusions and Relevance: This study found high rates of adult and pediatric patients with ILO screened positive for anxiety, depression, and PTSD symptoms. Future work should investigate how behavioral health and ILO treatments can best be coordinated to maximize treatment outcomes.

Economic Burden of Induced Laryngeal Obstruction in Adolescents and Children.

PURPOSE: Diagnosing pediatric induced laryngeal obstruction (ILO) requires equipment typically available in specialist settings, and patients often see multiple providers before a diagnosis is determined. This study examined the financial burden associated with the diagnosis and treatment of ILO in pediatric patients with reference to socioeconomic disadvantage. METHODS: Adolescents and children (<18 years of age) diagnosed with ILO were identified through the University of Madison Voice and Swallow Outcomes Database. Procedures, office visits, and prescribed medications were collected from the electronic medical record. Expenditures were calculated for two time periods (1) pre-diagnosis (first dyspnea-related visit to diagnosis), and (2) the first year following diagnosis. The Area Deprivation Index (ADI) was used to estimate patient socioeconomic status to determine if costs differed with neighborhood-level disadvantage. RESULTS: A total of 113 patients met inclusion criteria (13.9 years, 79% female). Total pre-diagnosis costs of ILO averaged $6486.93 (SD = $6604.14, median = $3845.66) and post-diagnosis costs averaged $2067.69 (SD = $2322.78; median = $1384.12). Patients underwent a mean of 3.01 (SD = 1.9; median = 2) procedures and 5.8 (SD = 4.7; median = 5) office visits prior to diagnosis. Pharmaceutical, procedure/office visit, and indirect costs significantly decreased following diagnosis. Patients living in neighborhoods with greater socioeconomic disadvantage underwent fewer procedures and were prescribed more medication than those from more affluent areas. However, total expenditures did not differ based on ADI. CONCLUSIONS: Pediatric ILO is associated with considerable financial costs. The source of these costs, however, differed according to socioeconomic advantage. Future work should determine how ILO diagnosis and management can be more efficient and equitable across all patients. Laryngoscope, 2024.

Clinical Profiles of Children and Adolescents With Induced Laryngeal Obstruction (ILO) and Exercise Induced Laryngeal Obstruction (EILO).

PURPOSE: To compare clinical profiles of pediatric patients with Induced Laryngeal Obstruction (ILO), Exercise Induced Laryngeal Obstruction (EILO), and EILO with non-exertion related secondary triggers (EILO+). METHODS: A retrospective observational cohort design was employed. Four-hundred and twenty-three patients <18 years of age were identified from the electronic medical record of a large children's hospital. All patients underwent evaluations with a laryngologist and speech-language pathologist and were diagnosed with EILO/ILO. Patients were divided into 3 groups based on dyspnea triggers reported in initial evaluations. Groups consisted of patients with EILO (N = 281), ILO (N = 30), and EILO+ (N = 112). Patient demographics, EILO/ILO symptoms, endoscopy findings, medical comorbidities, medical history, and EILO/ILO treatment information were extracted and compared across EILO/ILO subtypes. RESULTS: Patients with EILO experienced higher rates of hyperventilation (P < .001), sore throat (P = .023), and chest pain (P = .003). Patients with ILO were significantly younger in age (P = .017) and presented with increased rates of nighttime symptoms (P < .001), globus sensation (P = .008), self-reported reflux symptoms (P = .023), and history of gastrointestinal conditions (P = .034). Patients with EILO+ were more likely to be female (P = .037) and presented with higher prevalence of anxiety (P = .003), ADHD (P = .004), chest tightness (P = .030), and cough (P < .001). CONCLUSIONS: Patients with EILO, ILO, and EILO+ present with overlapping but unique clinical profiles. A prospective study is warranted to determine the etiology of these differences and clarify how the efficacy of EILO, ILO, and EILO+ treatment can be maximized. LEVEL OF EVIDENCE: 4.

Examining therapy duration in adults with induced laryngeal obstruction (ILO).

OBJECTIVE: This study examined the number of therapy sessions required to sufficiently improve (exercise) induced laryngeal obstruction (EILO/ILO) symptoms for discharge. Factors predicting therapy duration were examined as was the likelihood of patients returning for additional therapy sessions following initial discharge. METHODS: Retrospective observational cohort design. Data for 350 patients were gathered from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. Patients (>18 years of age) diagnosed with EILO/ILO received therapy from a Speech-Language Pathologist (SLP) and were successfully discharged. EILO/ILO treatment details, symptoms, triggers, medical comorbidities, and patient demographics were collected from initial evaluations and subsequent course of therapy. RESULTS: Patients required an average of 3.59 (SD = 3.7) therapy sessions prior to discharge. A comorbid behavioral health diagnosis (p = .026), higher Vocal Handicap Index Score (p = .009) and reduced physical activity due to EILO/ILO symptoms (p = .032) were associated with increased therapy duration. Patients with ILO or EILO with secondary environmental triggers required significantly more sessions than those with exercise-induced symptoms (p < .01). Eight percent of patients returned for additional sessions following discharge. Patients returning for additional sessions all came from affluent neighborhoods as measured by the Area Deprivation Index (ADI). CONCLUSIONS: Patients with EILO/ILO required an average of 3.59 therapy sessions prior to discharge. As such, 4 sessions is a reasonable estimate for clinicians to provide patients. Six sessions may be a more conservative estimate for patients who present with a behavioral health diagnosis, a voice complaint, or reduced physical activity from EILO/ILO symptoms.

Factors influencing behavioral cough suppression therapy in children with nonspecific chronic cough.

BACKGROUND: Behavioral cough suppression therapy (BCST) with a speech-language pathologist is a common treatment for chronic nonspecific cough (a.k.a., tic cough) in children. Yet, the outcomes and duration of pediatric BCST have eluded formal investigation. This study examined whether BCST improves cough in children with nonspecific cough and factors that predict the course of treatment. Additionally, the cough characteristics and comorbidities associated with the condition were examined. METHODS: A retrospective, observational cohort design was utilized. Cough characteristics, medical history, and BCST treatment details and outcomes for 151 children were extracted from the electronic medical record of a large outpatient pediatric otolaryngology clinic. RESULTS: Cough was dry and onset unaccompanied by illness in most cases. Roughly half of patients reported gradual onset and cough proceeded by tickle. On average, patients experienced symptoms for 19 months (SD = 20.09) before diagnosis. Rates of comorbid General Anxiety Disorder were elevated compared to pediatric norms. Additionally, high rates of asthma (22.1%), reflux (62.3%), and disordered sleep breathing (19.2%) were observed. Common findings on laryngoscopy included interarytenoid edema and erythema. Vocal fold changes were observed in 22.9% of children. BCST reduced cough in 92.5% of patients following an average of 1.7 sessions. Comorbid behavioral health diagnoses (p = 0.013) or induced laryngeal obstruction symptoms (p = 0.025) were significant predictors of increased therapy sessions. Cough proceeded by tickle significantly predicted fewer sessions in therapy (p = 0.011). INTERPRETATION: Although randomized clinical trials are needed, these data suggest that BCST is a low-risk, effective treatment for children with nonspecific cough.

Examining Therapy Duration in Adults With Voice Disorders.

PURPOSE: This study examined the number of voice therapy sessions and the number of weeks in treatment to achieve desired voice outcomes in adults with voice disorders. Factors that may predict therapy duration were examined, as was the percentage of patients returning to the clinic for additional voice therapy after initial discharge. METHOD: An observational cohort design was utilized. Data from 558 patients were extracted from the University of Wisconsin-Madison Voice and Swallow Outcomes Database. Patients diagnosed with muscle tension dysphonia, vocal fold paralysis, benign vocal fold lesions, laryngospasm/irritable larynx, and presbyphonia were examined. Patient demographics, auditory-perceptual assessments, acoustics, aerodynamics, videostroboscopy ratings, self-reported scales, and medical comorbidities were collected. RESULTS: Patients required an average of 5.32 (SD = 3.43) sessions of voice therapy before voice outcomes were sufficiently improved for discharge. Average number of sessions ranged from 4.3 for presbyphonia to 6.7 for benign vocal fold lesions. Baseline overall Grade Roughness Breathiness Asthenia and Strain rating (p < .001), Dysphonia Severity Index (p < .001), Voice Handicap Index score (p < .01), age (p = .006), and occupational voice user status (p < .001) significantly predicted the number of therapy sessions required. Overall, 14.5% of patients returned for additional voice therapy following an initial discharge from treatment. CONCLUSIONS: Findings inform our understanding of how many sessions patients with voice disorders require to achieve desired voice outcomes. Additional research is needed to optimize the efficacy of voice treatment and determine how recurrence of dysphonia might best be prevented.

Therapy Outcomes for Teenage Athletes With Exercise-Induced Laryngeal Obstruction.

PURPOSE: This study examined treatment outcomes of speech-language pathology intervention addressing exercise-induced laryngeal obstruction (EILO) symptoms in teenage athletes. METHOD: A prospective cohort design was utilized; teenagers diagnosed with EILO completed questionnaires during initial EILO evaluations, posttherapy, 3-month posttherapy, and 6-month posttherapy. Questionnaires examined the frequency of breathing problems, the use of the techniques taught in therapy, and the use of inhaler. Patients completed the Pediatric Quality of Life (PedsQL) inventory at all time points. RESULTS: Fifty-nine patients completed baseline questionnaires. Of these, 38 were surveyed posttherapy, 32 at 3-month posttherapy, and 27 at 6-month posttherapy. Patients reported more frequent and complete activity participation immediately posttherapy (p = .017) as well as reduced inhaler use (p = .036). Patients also reported a significant reduction in the frequency of breathing problems 6-month posttherapy (p = .015). Baseline PedsQL physical and psychosocial scores were below normative range and were not impacted by therapy. Baseline physical PedsQL score significantly predicted frequency of breathing difficulty 6-month posttherapy (p = .04), as better baseline scores were associated with fewer residual symptoms. CONCLUSIONS: Therapy with a speech-language pathologist for EILO allowed for more frequent physical activity following therapy completion and decreased dyspnea symptoms 6-month posttherapy. Therapy was associated with a decrease in inhaler use. PedsQL scores indicated mildly poor health-related quality of life even after EILO symptoms improved. Findings support therapy as an effective treatment for EILO in teenage athletes and suggest that dyspnea symptoms may continue to improve following discharge as patients continue using therapy techniques.

Videostroboscopy Versus High-Speed Videoendoscopy: Factors Influencing Ratings of Laryngeal Oscillation.

PURPOSE: The purpose of this study was to determine whether patient voice-related diagnosis, severity of dysphonia, and rater's experience influence the relationship between laryngeal oscillation ratings made from videostroboscopic and high-speed videoendoscopic (HSV) exams. METHOD: Stroboscopy and HSV exams from 15 patients with adductor spasmodic dysphonia (ADSD) and 15 with benign vocal fold lesions were rated for laryngeal oscillation and closure by 10 licensed speech-language pathologists (SLPs). Raters were divided into low- (< 5 years) and high-experience (> 5 years) groups. Ratings of vocal fold amplitude, mucosal wave, periodicity, phase symmetry, nonvibrating portion of the vocal fold, and glottal closure were examined using an online form adapted from the Voice Vibratory Assessment of Laryngeal Imaging (VALI). RESULTS: Stroboscopy and HSV ratings were more strongly positively correlated for patients with benign vocal fold lesions (r between .43 and .75) than for those with ADSD (r between .40 and .68). Differences between stroboscopy and HSV exams were significantly greater for ratings of amplitude, mucosal wave, and periodicity in patients with ADSD than for patients with benign vocal fold lesions. Raters with < 5 years of experience showed significantly greater differences between stroboscopy and HSV ratings of amplitude and nonvibrating portion of the vocal fold for patients with ADSD only. Significantly greater differences between ratings of periodicity and phase symmetry were observed in patients with more severe dysphonia. CONCLUSIONS: Differences in laryngeal ratings made between HSV and stroboscopy exams may be influenced by patient diagnosis, severity of dysphonia, and rater experience. Future study is warranted to determine how the differences observed influence clinical diagnosis and outcomes.

Relationship Between Auditory-Perceptual and Objective Measures of Resonance in Children with Cleft Palate: Effects of Intelligibility and Dysphonia.

To investigate the relationship between auditory-perceptual ratings of resonance and nasometry scores in children with cleft palate. Factors which may impact this relationship were examined including articulation, intelligibility, dysphonia, sex, and cleft-related diagnosis.Retrospective, observational cohort study.Outpatient pediatric cranio-facial anomalies clinic.Four hundred patients <18 years of age identified with CP ± L, seen for auditory-perceptual and nasometry evaluations of hypernasality as well as assessments of articulation and voice.Relationship between auditory-perceptual ratings of resonance and nasometry scores.Pearson's correlations indicated that auditory-perceptual resonance ratings and nasometry scores were significantly correlated across oral-sound stimuli on the picture-cued portion of the MacKay-Kummer SNAP-R Test (r values .69 to.72) and the zoo reading passage (r = .72). Linear regression indicated that intelligibility (p ≤ .001) and dysphonia (p = .009) significantly impacted the relationship between perceptual and objective assessments of resonance on the Zoo passage. Moderation analyses indicated that the relationship between auditory-perceptual and nasometry values weakened as severity of speech intelligibility increased (P < .001) and when children presented with moderate dysphonia (p ≤ .001). No significant impact of articulation testing or sex were observed.Speech intelligibility and dysphonia alter the relationship between auditory-perceptual and nasometry assessments of hypernasality in children with cleft palate. SLPs should be aware of potential sources of auditory-perceptual bias and shortcomings of the Nasometer when following patients with limited intelligibility or moderate dysphonia. Future study may identify the mechanisms by which intelligibility and dysphonia affect auditory-perceptual and nasometry evaluations.

A Review of Factors Associated with Voice Problems in the Fitness Instructor Population.

There is a high prevalence of reported dysphonia symptomology in the fitness instructor population. This is concerning as these reported symptoms of dysphonia, aphonia, and vocal fatigue can significantly compromise quality of life. The purpose of this review is to explore key factors that may contribute to voice problems in the fitness instructor population. Voicing with concurrent phonation and exercise may be influenced by (1) the increased cardiovascular requirement during exercise, (2) the increased cognitive load associated with dual tasking, (3) the altered hydration state associated with prolonged exercise, and (4) the phonatory dose associated with continued voicing with loud background music. This manuscript will explore the literature on these key factors (ie, phonatory dose, dehydration, metabolic bioenergetics, cognitive load, and psychosocial stress) as they pertain to fitness instructors.

Voice Therapy Improves Acoustic and Auditory-Perceptual Outcomes in Children.

PURPOSE: This study employed acoustic measures as well as auditory-perceptual assessments to examine the effects of voice therapy in children presenting with benign vocal fold lesions. METHODS: A retrospective, observational cohort design was employed. Sustained vowels produced by 129 children diagnosed with benign vocal fold lesions were analyzed, as well as connected speech samples produced by 47 children. Treatment outcome measures included Consensus of Auditory-Perceptual Evaluation of Voice (CAPE-V), jitter, shimmer, Noise-to-Harmonic Ratio (NHR), cepstral peak prominence (CPP), and Low-to-High Ratio (LHR) on sustained vowels, and CPP and LHR on connected speech. RESULTS: Following voice therapy, significant improvements in CAPE-V ratings (p < 0.001) were observed. Additionally, jitter (p = 0.041), NHR (p = 0.019), and CPP (p < 0.01) on sustained vowels, and CPP (p = 0.002), and LHR (p = 0.008) on connected speech significantly improved following voice therapy. CPP increased with age in males but did not change in females. CAPE-V ratings and perturbation measures indicated that dysphonia was more severe in younger children pre and post-therapy. CONCLUSIONS: Auditory-perceptual and acoustic measures demonstrated improved voice quality following voice therapy in children with dysphonia. CPP effectively quantified voice therapy gains and allowed for analysis of connected speech, in addition to sustained vowels. These findings demonstrate the value of CPP as a tool in assessing therapy outcomes and support the efficacy of voice therapy for children presenting with vocal fold lesions. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:977-983, 2023.

Examining Relationships Between GRBAS Ratings and Acoustic, Aerodynamic and Patient-Reported Voice Measures in Adults With Voice Disorders.

OBJECTIVE: To determine if auditory-perceptual voice ratings performed using the GRBAS scale correlate with acoustic and aerodynamic measures of voice. A secondary aim was to examine the relationship between GRBAS ratings and patient-reported quality of life scales. METHODS: GRBAS ratings, acoustic, aerodynamic and patient-reported quality of life ratings were collected from the University of Wisconsin Madison Voice and Swallow Outcomes Database for 508 adults with voice disorders. Acoustic measures included noise to harmonic ratio, jitter%, shimmer%, highest fundamental frequency (F0) of vocal range, lowest F0 of vocal range, maximum phonation time and dysphonia severity index. Aerodynamic measures included phonation threshold pressure, subglottal pressure, mean transglottal airflow and laryngeal airway resistance. Patient-reported quality of life measures included the Vocal Handicap Index (VHI) and Glottal Function Index (GFI). RESULTS: GRBAS ratings were significantly correlated with several acoustic and aerodynamic measures, VHI and GFI. The strongest significant correlations for acoustic measures were observed between GRBAS ratings of overall voice quality and perturbation measures (jitter% r = 0.58, shimmer% r = 0.45, noise to harmonic ratio r = 0.36, Dysphonia Severity Index r = -0.56). The strongest significant correlation for aerodynamic voice measures was observed between GRBAS ratings of breathiness and transglottal airflow (r = 0.23), subglottal pressure (r = 0.49), and phonation threshold pressure (r = 0.26). GRBAS ratings were also significantly correlated with both VHI and the GFI scales. R values were higher for the VHI, but remained largely in low range for both scales. CONCLUSIONS: Although GRBAS ratings were significantly correlated with multiple objective voice and patient related quality of life ratings, r values were low. These findings support the need for multiple voice measures when performing voice evaluations as no single voice measure was highly correlated with voice quality as measured by the GRBAS scale.

Are Children with Cleft Palate at Increased Risk for Laryngeal Pathology?

To determine the prevalence of laryngeal pathology in children presenting with cleft palate with or without cleft lip (CP ± L) who underwent nasoendoscopy to assess palatal function. A secondary aim was to determine the relationship between patient demographics, resonance, articulation, and prevalence of laryngeal pathology in this population.Retrospective, observational cohort study.Outpatient pediatric cranio-facial anomalies clinic.Children ≤18 years of age presenting with CP ± L (N = 215) who underwent nasoendoscopy, speech language pathology, plastic surgery, and otolaryngological evaluations between 2009 and 2020.Laryngeal diagnosis by pediatric otolaryngologists.21.9% of children presented with laryngeal pathology. Diagnoses included benign vocal fold lesions and laryngeal edema sufficiently severe to alter vocal fold edge contour. Likelihood of laryngeal pathology increased by approximately 12% with every increase of 1 year in age (P = .001, OR = 1.12). Children with laryngeal pathology were 50% more likely to have undergone palatal repair (P < .001, OR = 1.50). In addition, children with severely hypernasal resonance were 78% less likely to present with laryngeal pathology (P =.046, OR = 0.22).This population is at increased risk for laryngeal pathologies as determined by nasoendoscopy. This finding underscores the importance of careful laryngeal imaging in assessing these children. Additional research is warranted to identify the mechanisms underlying the increased risk for morphological vocal fold changes.

Pediatric Voice Therapy: How Many Sessions to Discharge?

PURPOSE: Voice therapy is the primary treatment for children presenting with benign morphological vocal fold changes. This study examined the number of voice therapy sessions required to meet treatment goals and identified factors that predicted treatment length for pediatric voice patients. METHOD: An observational cohort design was employed. Data were extracted from the University of Wisconsin-Madison Voice and Swallow Outcome Database. This study examined 62 children who completed a course of voice therapy with a speech-language pathologist (SLP) addressing dysphonia caused by benign vocal fold lesions. Extracted data included patient demographics, auditory-perceptual assessments, acoustic and aerodynamic voice measures, videostroboscopy ratings, and medical comorbidities. Linear regression was used to identify predictors of number of therapy sessions. RESULTS: Patients received an average of 7.5 sessions of voice therapy prior to discharge. Baseline auditory-perceptual assessment of dysphonia (p = .032), phonation threshold pressure (PTP, p = .005), Glottal Function Index (GFI) score (p = .006), and glottic closure pattern (p = .023) were significant predictors of number of voice therapy sessions. These measures, as well as hourglass glottic closure, predicted longer intervention duration. The regression model had an overall r 2 of .62. CONCLUSIONS: Pediatric voice therapy addressing benign vocal fold lesions and/or laryngeal edema required an average of 7.54 sessions before voice outcomes were sufficiently improved for discharge. More severe overall SLP ratings of dysphonia, GFI scores, PTP, or hourglass glottic closure pattern significantly predicted increased number of therapy sessions prior to discharge. Future work should determine what other factors affect treatment duration and how the efficiency of pediatric voice therapy can be maximized.

The effects of vocal exertion on lung volume measurements and acoustics in speakers reporting high and low vocal fatigue.

PURPOSE: Vocal exertion is common and often results in reduced respiratory and laryngeal efficiency. It is unknown, however, whether the respiratory kinematic and acoustic adjustments employed during vocal exertion differ between speakers reporting vocal fatigue and those who do not. This study compared respiratory kinematics and acoustic measures in individuals reporting low and high levels of vocal fatigue during a vocal exertion task. METHODS: Individuals reporting low (N = 20) and high (N = 10) vocal fatigue participated in a repeated measures design study over 2 days. On each day, participants completed a 10-minute vocal exertion task consisting of repeated, loud vowel productions at elevated F0 sustained for maximum phonation time. Respiratory kinematic and acoustic measures were analyzed on the 1st vowel production (T0), and the vowels produced 2 minutes (T2), 5 minutes (T5), 7 minutes (T7), and 10 minutes (T10) into the vocal exertion task. Vowel durations were also measured at each time point. RESULTS: No differences in respiratory kinematics were observed between low and high vocal fatigue groups at T0. As the vocal exertion task progressed (T2-T10), individuals reporting high vocal fatigue initiated phonation at lower lung volumes while individuals with low vocal fatigue initiated phonation at higher lung volumes. As the exertion task progressed, total lung volume excursion decreased in both groups. Differences in acoustic measures were observed, as individuals reporting high vocal fatigue produced softer, shorter vowels from T0 through T10. CONCLUSIONS: Individuals reporting high vocal fatigue employed less efficient respiratory strategies during periods of increased vocal demand when compared with individuals reporting low vocal fatigue. Individuals reporting high vocal fatigue had shorter maximum phonation time on loud vowels. Further study should examine the potential screening value of loud maximum phonation time, as well as the clinical implications of the observed respiratory patterns for managing vocal fatigue.

Patient-Reported Qualitative Analysis of Chronic Refractory Cough.

PURPOSE: Chronic cough has been shown to be associated with adverse effects on quality of life. There is a paucity of research characterizing quality-of-life factors associated with chronic refractory cough (CRC), a cough persisting > 8 weeks despite evaluation and treatment of possible etiologies. The purpose of this study was to elucidate the features of CRC from the patient's perspective, including presenting symptoms, past treatment methods, and quality-of-life factors. METHOD: Prospective semistructured interviews were conducted, recorded, and transcribed for 20 patients diagnosed with CRC. Exclusion criteria included lung disease, smoking history, laryngeal cancer, and neurological disease. Grounded theory analysis was completed on transcribed interviews. RESULTS: Eighteen participants were women. Mean participant age was 53.5 years (SD = 1.41), and average cough duration was 52 months (SD = 71.6 months). Responses to 30 open-ended questions revealed four dominant themes with 24 subthemes. CONCLUSIONS: CRC affects patient quality of life. Understanding patient perspective on CRC diagnosis and treatment helps providers better understand the physical and emotional toll CRC takes on patients. Findings suggest that providers should spend more time counseling patients regarding their treatment and diagnosis, as patients with CRC do not always fully understand their diagnosis and resort to self-blame.

Eliciting and Characterizing Porcine Vocalizations: When Pigs Fly.

BACKGROUND/OBJECTIVES: While voice-related therapeutic interventions are often researched preclinically in the porcine model, there are no well-established methods to induce porcine glottic phonation. Described approaches, such as training animals to phonate for positive reinforcement are time-consuming and plagued by inherent variability in the type of phonation produced and contamination of background noise. Thus, a reliable method of assessing glottic phonation in the porcine model is needed. METHODS: In this study, we have created a novel pulley-based apparatus with harness for "pig-lifting" with surrounding acoustic insulation and high-directional microphone with digital recorder for recording phonation. Praat and Matlab were used to analyze all porcine vocalizations for fundamental frequency (F0), intensity, duration of phonation and cepstral peak prominence (CPP). Glottic phonation was detected using F0 (≥2000 hz), duration (≥3 seconds) and researcher perceptual judgment. Partial-glottic phonations were also analyzed. Reliability between researcher judgment and acoustic measures for glottic phonation detection was high. RESULTS: Acoustic analysis demonstrated that glottic and partial-glottic phonation was consistently elicited, with no formal training of the minipigs required. Glottic vocalizations increased with multiple lifts. Glottic phonation continued to be elicited after multiple days but became less frequent. Glottic and partial-glottic phonations had similar CPP values over the 6 experimental days. CONCLUSION: Our cost-effective, reliable method of inducing and recording glottic phonation in the porcine model may provide a cost effective, preclinical tool in voice research.

Factors impacting therapy duration in children and adolescents with Paradoxical Vocal Fold Movement (PVFM).

PURPOSE: Paradoxical Vocal Fold Movement (PVFM) may cause airway restriction and resulting dyspnea in the pediatric population. Therapy with a speech-language pathologist (SLP) is the primary treatment for children and adolescents diagnosed with Paradoxical Vocal Fold Movement (PVFM). This study examined treatment duration and factors predicting number of therapy sessions required. METHODS: Data were drawn from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. One hundred and twelve children and adolescents were included in this study. Participants were diagnosed with PVFM, followed for therapy with a SLP, and were subsequently discharged from therapy with successful outcomes. Extracted data included number of therapy sessions, PVFM symptoms, patient demographics, medical history, and comorbid diagnoses. Regression was used to determine factors predicting therapy duration. RESULTS: Patients completed an average of 3.4 therapy sessions before discharge. Comorbid behavioral health diagnosis (ß = 1.96, t = 3.83, p < .01) and a history of upper airway surgeries (ß = 1.26, t = 2.615, p = .01) were significant predictors of the number of therapy sessions required before discharge; both factors significantly increased therapy duration. Age, symptom trigger-type, reflux symptoms, and dysphonia did not predict therapy duration. Overall, our regression model accounted for 42% of the variance in number of sessions required (r2 = 0.42). CONCLUSIONS: On average, 3.4 sessions of therapy with an SLP resolved PVFM symptoms. Children with a behavioral health diagnosis required an average of 5.45 sessions and those with a history of upper airway surgery an average of 4.3 sessions. Future work should examine the relationship between behavioral health care and PVFM treatment, as well as how PVFM treatment efficiency can be maximized.