Prospective Determination of Normative Value of the Singing Voice Handicap Index-10 (SVHI-10).

OBJECTIVES/HYPOTHESIS: To prospectively establish a normative value for the validated Singing Voice Handicap Index-10 (SVHI-10) patient reported outcome measure (PROM). STUDY DESIGN: Prospective cross-sectional study. METHODS: Adult singers without voice complaints were prospectively invited to complete a demographics questionnaire followed by the SVHI-10. Participants were excluded if they had sought medical care for voice changes within the last year or currently had throat problems. Statistical analysis was completed to establish a normative value and the distribution of demographics by singing experience, primary genre, and gender. RESULTS: One hundred forty-nine healthy participants from diverse backgrounds (including singing, financial, educational, and geographic location) successfully completed the SVHI-10. The mean (SD) score of this cohort was 9.13 (5.15). We defined a normative value as two standard deviations above the mean: 19.43 There was no difference in SVHI-10 score in different age groups. CONCLUSIONS: A normative value for the SVHI-10 questionnaire has been missing from the current literature and will be of great utility both in clinical practice and research. In previous research, singers have been shown to be more perceptive to quality change in their singing voices, which may be why the normative score is higher than one may expect. A SVHI-10 score ≥20 should be considered abnormal.

Exploring Patient's Preference of Patient-Reported Outcome Measures in Laryngeal Movement Disorders.

BACKGROUND: Despite many available patient-reported outcome measures (PROMs) for laryngeal movement disorders, there is a lack of patient input regarding which PROM most accurately and conveniently captures aspects related to their vocal disease. This study aimed to assess patients' preferences among a selection of voice-related PROMs (Voice Handicap Index-10 [VHI-10], OMNI-Vocal Effort Scale [OMNI-VES], Communicative Participation Item Bank-General Short Form [CPIB-10], and Visual Analog Scales [VAS]) within the laryngeal movement disorder population and investigate associations between selected instruments. METHODS: Prior to botulinum toxin A injection, patients with laryngeal dystonia and/or essential tremor of the vocal tract were administered the VHI-10, OMNI-VES, CPIB-10, and three novel VAS questions in a randomized order. Patients rank ordered the four PROMs based on the PROMs' reflection of their voice problems. Pearson's correlation coefficients evaluated pairwise associations among PROM scores. Fisher's exact test compared the preferred PROM rankings. RESULTS: Seventy patients (53 female, mean age = 60.7 years) participated. The VHI-10 and CPIB-10 were most preferred at 33.9% and 27.4% respectively. The OMNI-VES and VAS scales were less favored (19.4%, each). When analyzed by age ≥60 years, the CPIB-10 was most favored (33.3%), but for age <60 years, VHI-10 was most preferred (42.3%). There was a strong correlation between scores of all administered PROMs (strongest correlation between OMNI-VES and VAS, r = 0.8, p < 0.001; the weakest correlation between OMNI-VES and VHI-10, r = 0.6, p < 0.001). CONCLUSIONS: With an increasing trend in PROMs usage and a strong correlation between all evaluated outcome instruments, insight regarding patients' PROM preferences is an area for further consideration. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1448-1454, 2023.

An Ex Vivo Investigation of Tactile Aesthesiometer Force in Laryngopharyngeal Sensory Testing.

BACKGROUND/OBJECTIVE: Cheung-Bearelly aesthesiometers can deliver buckling-force stimuli to the laryngopharynx and objectively evaluate sensation. Ambiguity surrounds the transformation of stimuli in the laryngopharyngeal environment. This study aims to evaluate the effect of aesthesiometer size, saliva, successive compressions, and angles of tissue contact on stimulus force delivered. METHODS: An ex vivo stimulus delivery device was constructed to measure the buckling force of aesthesiometers. Dry and saliva-saturated aesthesiometers (6-0, 5-0, 4.5-0, and 4-0) were each compressed six times on cadaveric buccal mucosa on an electronic balance. The force for each compression was recorded at 0, 15, 30, 45, and 60° from the vertical plane. 240 compressions were analyzed utilizing a mixed-effects statistical model. RESULTS: The mean force delivered by the 6-0, 5-0, 4.5-0, and 4-0 aesthesiometers were 0.017, 0.082, 0.120, and 0.268 g respectively (p < 0.001). Mean force significantly reduced for the 4-0 aesthesiometer at 30° (p = 0.003) and 60° (p = 0.001). Force decreased by the 4th compression for the 5-0 aesthesiometer (p = 0.004) and after one compression for the 4.5-0 (p = 0.004) and 4-0 (p < 0.001) aesthesiometer. By the 4th compression, the 4.5-0 aesthesiometer was indistinguishable (p > 0.05) from the 5-0 aesthesiometer. The effect of saliva was insignificant (p = 0.83). CONCLUSION: Aesthesiometers can deliver discrete buckling-force stimuli to evaluate laryngopharynx sensory function. Up to 60° (15° for 4-0 aesthesiometer) deviation from orthogonal tissue contact and salivary forces do not significantly alter force delivered. 4.5-0 aesthesiometers should be exchanged after three compressions. For all other aesthesiometers, force reduction after six compressions is likely clinically insignificant given current laryngopharyngeal sensory testing protocols. LEVEL OF EVIDENCE: N/A Ex Vivo Laboratory Design Laryngoscope, 133:1933-1937, 2023.

Abnormal Laryngopharyngeal Sensation in Adductor Laryngeal Dystonia Compared to Healthy Controls.

BACKGROUND/OBJECTIVES: Laryngeal sensory abnormality has been implicated as a component of adductor laryngeal dystonia (AdLD). The study objective was to assess laryngopharyngeal sensation in AdLD utilizing a calibrated, tactile aesthesiometer to deliver differential stimuli to lateral pyriform sinus (LPS), aryepiglottic fold (AEF), and false vocal fold (FVF). METHODS: Patients with known Botox-responsive AdLD underwent sensory testing using a previously-validated methodology involving calibrated tactile stimuli (6-0, 5-0, 4.5-0, 4-0 nylon monofilaments). Laryngeal adductor reflex (LAR) and participant-rated perceptual strength of stimulI were evaluated. Responses were compared to normative controls (n = 33). Two-samples, Mann-Whitney and Fisher exact tests compared mean strength ratings and LAR between AdLD and control groups. Mixed-effects logistic regression and linear models assessed association of filament size, stimulus site, age, sex, and LD status on LAR and perceptual strength rating respectively. RESULTS: Thirteen AdLD patients (nine women, mean age 60+/-15 years) completed testing. Average LAR response rates were higher amongst all filament sizes in AdLD versus controls at LPS (56.3% vs. 35.7%) and AEF (96.1% vs. 70.2%) with comparable rates at FVF (90.2% vs. 91.7%). AdLD had 3.3 times the odds of observed LAR compared to controls (p = 0.005), but differences in subjective detection of stimuli, perceptual strength ratings, and cough/gag rates were insignificant on multivariate modeling (p > 0.05). CONCLUSIONS: This is the first study to objectively assess laryngopharyngeal sensation in AdLD. Findings demonstrated increased laryngopharyngeal sensation in AdLD compared to controls. The identification of increased laryngeal hypersensitivity in these patients may improve understanding of AdLD pathophysiology and identify future targets for intervention. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:2271-2278, 2023.

Comparison of Outcome Measures (Subjective, Objective, and Patient-Based) in Laryngeal Dystonia Treatment With Botulinum Toxin A Injection.

BACKGROUND: Outcome assessment in laryngeal dystonia is hindered by lack of consensus on a core set of outcome measures to quantify treatment effect and disease severity on quality of life. Potential outcome measure domains include objective voice, clinician reported, and patient reported outcome measures (PROMs) for determining treatment success and longitudinal disease tracking. We aim to determine correlations between a selections of outcome measure tools following Botulinum toxin injection. METHODS: A selection of instruments were administered to assess adductor laryngeal dystonia patient outcomes before and after Botulinum toxin injection. Voice samples recorded using a cellular telephone application were used for objective acoustic measures (CPPS, acoustic voice quality index) and speech language pathologist perceptual analysis (CAPE-V). Additionally, patients completed a PROMs battery consisting of the Voice Handicap Index-10, Communicative Participation Item Bank-10, OMNI-Vocal Effort Scale, 3 visual analog scale (VAS) questions. Changes in these outcome measures pre-post treatment were compared between each other and with a global rating of change questionnaire (GRCQ) using Spearman's rank correlation coefficients. RESULTS: Twenty six patients (20 female, mean age 57.7 years) participated. Using an anchor based GRCQ, patients reported Botox efficacy was the only outcome measure found to have significant correlation (r = 0.54, P = 0.022); all other outcome measures did not meet statistically significant correlation. Amongst the selected outcome tools, several moderate-strong correlations were identified, largely for outcome measures within the same domain. Most notable were correlations between the patient reported OMNI-VES and VAS questions (r > 0.68, P < 0.05), clinician CAPE-V strain and overall severity (r = 0.900, P < 0.001), and acoustic voice quality index with sustained vowel CPPs (r = -0.797, P = 0.002). CONCLUSION: Correlation between outcome measures instruments used for patients with adductor laryngeal dystonia requires further attention. Weak correlations with an anchor based GRCQ were found for this study's selected outcome instruments. A select number of correlations were found between outcome instruments within each of the individual outcome measure domains (patient perception, clinical perception, objective acoustics), but there was largely a lack of correlation found for instruments between these three separate domains.

Interventions and Outcomes in Glottic Versus Multi-level Airway Stenosis: A Multi-institutional Review.

OBJECTIVE: Airway stenosis-particularly multi-level-presents complex management challenges. This study assessed rates of tracheostomy, decannulation, and the number of surgeries required in patients with posterior glottic stenosis (PGS), multi-level airway stenosis (MLAS), and bilateral vocal fold paralysis (BVFP). METHODS: Airway stenosis patients treated between 2016 and 2021 at three tertiary medical centers were identified. Demographics, etiology of stenosis, medical comorbidities, and patient-reported outcome measures (PROMs) were collected. RESULTS: 158 patients (84 women, mean age 56.98 ± 15.5 years) were identified (54 PGS, 38 MLAS, and 66 BVFP). 72.3% required tracheostomy, including 72.2%, 86.8%, and 63.6% in these groups, respectively. Decannulation rates were 43.6%, 21.2%, and 32.5% in these groups, respectively. Patients with MLAS had higher rates of tracheostomy than BVFP (p < 0.05). However, decannulation rates were not different between groups (p > 0.05). MLAS required more surgeries (mean 4.0 ± 3.9) than PGS (2.4 ± 2.2, p = 0.02) or BVFP (1.0 ± 1.8, p < 0.0001). Mean PROMs scores at the latest follow-up were abnormal: 15.4 ± 12.2 (Dyspnea Index), 19.9 ± 12.2 (Voice Handicap Index-10), and 9.67 ± 11.1 (Eating Assessment Tool-10). Co-morbidities present included body mass index >30 (41.4%), diabetes (31.8%), pulmonary disease (50.7%), gastroesophageal reflux disease (39.4%), autoimmune disease (22.9%), and tobacco use history (55.2%). CONCLUSIONS: Airway stenosis is a challenging clinical problem that negatively impacts patients' quality of life and often requires numerous surgeries. PGS more frequently requires tracheostomy compared to BVFP, but patients can often decannulate successfully. Patients with multi-level stenosis have lower decannulation rates and require more surgeries than glottic stenosis alone; these patients may benefit from earlier and/or more aggressive intervention. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:528-534, 2023.

Assessment of Laryngeal Sensory Function using a Tactile Aesthesiometer in Healthy Adults.

INTRODUCTION: Laryngeal sensory function in healthy adults was assessed through the delivery of tactile stimuli using Cheung-Bearelly monofilaments. METHODS: 37 healthy adults were recruited with 340 tactile stimuli analyzed. Four calibrated tactile stimuli were delivered to three laryngeal sites: false vocal fold (FVF), aryepiglottic fold (AEF), and lateral pyriform sinus (LPS). Primary outcome was the elicitation of laryngeal adductor reflex (LAR). Secondary outcomes were gag, patient-reported laryngeal sensation (PRLS), and perceptual strength. Analysis was performed with mixed effects logistic regression modeling. RESULTS: Positive LAR was observed in 35.7%, 70.2%, and 91.2% of stimuli at LPS, AEF, and FVF respectively. LAR rates were significantly associated with laryngopharyngeal subsite (p < 0.001), tactile force (p = 0.001), age (p = 0.022) and sex (p = 0.022). LAR, gag, PRLS, and perceptual strength significantly increased as a more medial laryngeal subsite was stimulated and as stimulus force increased. Each of the ten years of age increase was associated with 19% reduction in odds of LAR (aOR = 0.81, 95% CI [0.68, 0.97]; p = 0.022). Male gender was associated with a 55% reduction in odds of LAR (aOR = 0.45, 95% CI [0.23, 0.89]; p = 0.022). CONCLUSION: LAR elicitation capability decreases in the male gender, aging, and a more lateral subsite. This study provides insight into the pathophysiology of hypo- and hyper-sensitive laryngeal disorders and is paramount to making accurate diagnostic assessments and finding novel treatment options for various laryngological disorders. Laryngoscope, 133:2525-2532, 2023.

Longitudinal Analysis of Swallowing Displacement Kinematics After Oropharyngeal Cancer Treatment.

BACKGROUND/OBJECTIVE: Quantitative swallowing displacement kinematics evolve in patients treated for oropharyngeal squamous cell carcinoma (OPSCC). We aimed to longitudinally assess these measurements and correlate them with functional swallowing outcomes. METHOD: A retrospective review was conducted on patients with OPSCC treated with definitive (chemo)radiation ([C]RT) or surgery with adjuvant (chemo)radiation (S-[C]RT) who completed at least two videofluoroscopic swallow studies (VFSS). Longitudinal analysis was accomplished via mixed-effects logistic regression for the Functional Oral Intake Scale (FOIS), and Penetration Aspiration Scale (PAS), and mixed-effects linear regression for kinematic measures. Spearman's correlation was conducted between changes in FOIS/PAS and kinematic measures. RESULTS: Ninety-seven patients (76 males; mean age 61) completed 245 VFSS studies. A total of 94% had human papillomavirus (HPV)/p16 positive OPSCC and 74% were T0-T2. Sixty-four patients underwent [C]RT while 33 patients underwent S-[C]RT. After treatment, posterior pharyngeal wall at hold (PPWhold) increased 3.2 standard deviation (SD) between 0 and 6 months (p < 0.001), then decreased 2.2 SD between 6 and 12 months (p < 0.001) and did not return to baseline. Hyoid-to-larynx (HL) (p = 0.046) and maximal hyoid displacement (Hmax) + HL (p = 0.042) increased between 6 and 12 months. Hmax (p = 0.020) and Hmax + HL (p < 0.001) decreased between 12-24 months beyond baseline values. The decrease in HL and increase in PPWhold (p < 0.05) correlated with an increase in PAS. From baseline, increased pharyngeal constriction ratio correlated with decreased FOIS and PPWhold (p < 0.05). CONCLUSIONS: Quantitative swallowing kinematic measures can effectively track changes in swallowing physiology. Increased PPWhold and restricted hyolaryngeal movement were seen in patients with OPSCC after treatment and correlated with a change in swallowing outcome, emphasizing the need for serial VFSS monitoring and targeted intervention. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:1339-1348, 2023.