Indications and Short-Term Outcomes for In-Office Therapeutic Superior Laryngeal Nerve Block.

OBJECTIVE: Superior laryngeal nerve (SLN) block consists of injection of steroid and anesthetic at the internal branch of the SLN entry site. Prior case series have demonstrated beneficial effects on neurogenic cough. SLN blocks have also recently shown benefit for paralaryngeal pain. We describe short-term outcomes for multiple symptoms of irritable larynx syndrome (ILS) including neurogenic cough, dysphonia related to laryngeal hypersensitivity, inducible laryngeal obstruction (ILO), paralaryngeal pain, and isolated globus. METHODS: Retrospective review from 2 institutions of patients undergoing a single SLN block for the indications listed. Variables include age, sex, indication(s), known vagus neuropathy, and patient-reported outcomes at short-term follow-up. RESULTS: A total of 209 patients were included (59 males, 150 females; age: 58 ± 13 years). Twenty-six patients (12%) had a history of a vagus nerve injury. Indications included neurogenic cough (n = 149), dysphonia related to laryngeal hypersensitivity (n = 66), paralaryngeal pain (n = 50), ILO (n = 23), and isolated globus (n = 3). Some patients had multiple indications. Significant improvements in patient-reported measures occurred after a single SLN block within 2 to 4 weeks for neurogenic cough (cough severity index; 25.2 ± 11.2 to 19.0 ± 12.8; P < .001), dysphonia (voice handicap index-10; 22.1 ± 12.2-18.0 ± 13.3; P = .005), and ILO (dyspnea index; 21.0 ± 14.9-14.7 ± 15.7; P = .017). Subjective pain improved in 23 of 39 patients with paralaryngeal pain. There was no observed improvement for isolated globus. Presence of known vagal neuropathy or therapy around the time of SLN block did not affect outcome. CONCLUSION: SLN block can be an effective component of treatment for a variety of ILS symptoms. Patients may experience some improvement after 1 injection. LAY SUMMARY: Symptoms of irritable larynx syndrome, such as neurogenic cough, paralaryngeal pain, inducible laryngeal obstruction, and dysphonia related to laryngeal hypersensitivity can be challenging to manage. In-office Superior Laryngeal Nerve blocks can serve as a quick, well tolerated, adjunctive treatment with positive short-term outcomes. LEVEL OF EVIDENCE: 4.

Reliability of Phonemically Loaded Sentences in Spanish for Identifying Laryngeal Dystonia by Non-Spanish Speaking Speech-Language Pathologists.

INTRODUCTION: Laryngeal dystonia (LD) is a focal dystonia affecting the intrinsic laryngeal muscles. Clinical diagnosis requires subjective evaluation by experienced clinicians and is primarily based on auditory-perceptual assessment. Several speech tasks are widely accepted to elicit diagnosis specific auditory-perceptual symptoms of glottal stops in adductor LD or breathy breaks in abductor LD in spoken English. With the growing Spanish speaking population in the US and lack of Spanish speech tasks to assist in identifying LD in Spanish speaking subjects, assessing the reliability of phonemically loaded sentences in Spanish for use by non-Spanish speaking providers is critical. The first aim of this study was to develop and assess the reliability of a set of Spanish language phonemically loaded sentences designed to elicit signs and symptoms of LD. The second aim was to determine the effectiveness of non-Spanish speaking speech-language pathologists (SLPs) in identifying LD in Spanish speaking subjects using these stimuli. METHODS: Phonemically loaded sentences were developed for this study following current guidelines for assessment of LD. Voice samples were obtained from native Spanish speaking individuals. Participant-speakers included 20 people with LD and 20 people without LD who served as controls. All participant-speakers were assessed by a Spanish-speaking laryngologist. Audio samples were presented to non-Spanish speaking SLPs with expertise in working with people with LD who served as raters and classified the samples as either presence or absence of LD. Kappa and the intra-class correlation coefficient were calculated and mixed effects logistic regression was used for prediction. RESULTS: The inter and intra-rater reliability indicated statistically significant agreement. Sensitivity, specificity, and predictive values for the diagnosis of LD by the raters were overall strong. CONCLUSIONS: Findings demonstrate that non-Spanish speaking SLPs with expertise in the assessment and treatment of LD can reliably identify the presence of LD using Spanish language stimuli in Spanish-speaking individuals. This study supports the use of newly developed Spanish language phonemically loaded voiced and voiceless sentences by English speaking clinicians as an effective tool for identifying LD in Spanish speakers, perhaps mitigating diagnostic delays experienced by patients with LD.

Membranous Vocal Fold Lesions in Patients With Chronic Cough: A Case Series.

OBJECTIVES: Trauma related to chronic cough and forceful glottal closure has been associated with lesions of the vocal process; however, there is limited description of cough leading to membranous vocal fold lesions. We present a series of mid-membranous vocal fold lesions in a cohort of patients with chronic cough, with a proposed mechanism of lesion formation. METHODS: Patients treated for chronic cough with membranous vocal fold lesions affecting phonation were identified. Presentation, diagnosis, treatment strategies (behavioral, medical, and surgical), patient-reported outcome measures (PROMs), and videostroboscopy were reviewed. RESULTS: Five patients are included (four females, one male, aged 56±16 years). Mean cough duration was 2.6±3.5 years. All patients were on acid suppressive medications for existing gastroesophageal reflux disease (GERD) prior to referral. All lesions were identified at the mid-membranous vocal folds and morphologically encompassed a wound healing spectrum between ulceration and/or granulation tissue (granuloma) formation. Patients were treated in an interdisciplinary fashion with behavioral cough suppression therapy, superior laryngeal nerve block, and neuromodulators. Three had persistent lesions requiring procedural intervention (one office-based steroid injection and two surgical excisions). At the completion of treatment, all five patients had improvement in Cough Severity Index with an average decrease of 15.2±4.8. All but one patient had improvement in their Voice Handicap Index-10 with an average decrease of 13.2±11.1. One patient undergoing surgical intervention was noted to have a persistent lesion on follow-up. CONCLUSION: Mid-membranous vocal fold lesions in patients with chronic cough are uncommon. When they do occur, they represent epithelial change arising in context of shear injury and are distinct from phonotraumatic lesions in the lamina propria. An interdisciplinary approach including behavioral cough suppression therapy, neuromodulators, superior laryngeal nerve block, and acid suppression are reasonable for initial management, reserving surgical intervention for refractory lesions once the inciting source of injury has been controlled.

VHI-10 Scores in a Treatment-Seeking Population With Dysphonia.

INTRODUCTION: The VHI-10 is a patient-reported outcome measure used to record the patient's perception of impairment or handicap due to a voice problem. Scores above 11 are abnormal and indicate voice handicap. Amongst a treatment-seeking population in a large tertiary voice center, scores below the VHI-10 cutoff score of 11 were frequently noted. The aim of this study was to examine the number of people seeking voice therapy for dysphonia who scored below the established VHI-10 cutoff score. METHODS: A retrospective chart review was completed of all patients attending a voice evaluation with a speech-language pathologist by referral of a laryngologist between February 1, 2017 and February 28, 2018. Patients aged 18+ years with a primary diagnosis of dysphonia were included. Sex, age, primary diagnosis, and VHI-10 score were recorded. Patients were categorized as scoring above or below the cutoff score of 11. Logistic regression was performed to determine the variables that predicted scoring below the VHI-10 cutoff. RESULTS: A total of 225 patients were included. There were 91 males (40.4%) and 134 females (59.6%). Sixty-one patients (27.1%) scored below the VHI-10 cutoff of 11 at their evaluation. Younger age and male sex were predictive of scoring below the VHI-10 cutoff score. Diagnosis was not predictive of scoring above or below the cutoff score. CONCLUSION: A notable proportion of treatment-seeking patients scored below the VHI-10 cutoff of 11. If treatment-seeking behavior is related to patient perception of voice handicap, one would expect fewer patients to score below the cutoff. Possible explanations might include that the VHI-10 did not sufficiently capture patient perception of handicap in the study population or the published cutoff score may be too high. Alternatively, another motivator besides handicap may have spurred treatment-seeking behavior. Given these findings, additional or alternative patient-reported outcome measures may be useful in developing a complete clinical picture regarding voice handicap.

The Impact of Referral Source on Voice Therapy.

INTRODUCTION: Adherence to voice therapy is essential in achieving successful voice outcomes. Previous studies within the field of voice therapy have suggested that shorter wait times and utilization of an interprofessional practice (IPP) model of care have a positive effect on voice therapy completion rates. While the implementation of IPP has gained popularity, especially at academic voice centers, the majority of speech-language pathologists (SLP) practice in a traditional (T) setting where they are unaffiliated with the referring otolaryngologist. PURPOSE: This study aims to further examine how SLP practice models (interprofessional vs traditional) affect voice therapy initiation and completion rates. The secondary aim is to determine if voice therapy attendance rates have changed since the authors' initial investigations over 10 years ago. METHODS: A retrospective chart review of 452 patients was conducted. Data was collected on patient demographics (sex, age), diagnosis, severity of dysphonia (CAPE-V), quality of life impact (V-RQOL raw score), practice setting (IPP vs T), date of referral, date of voice therapy initial evaluation, number of therapy sessions completed, and attendance to therapy sessions defined as completion or dropout. RESULTS/CONCLUSIONS: Initiation of voice therapy treatment was the point in the referral process that was most impacted by practice model. Over half (53%) of referrals to voice therapy in a traditional practice model did not lead to initiation of treatment, while only 23% of the referrals taking place in an IPP model failed to initiate (P < 0.001). This study also demonstrated an improving, but continued rate of noninitiation and dropout from voice therapy when compared to data that was collected 10 years prior.

Phonation Resistance Training Exercises (PhoRTE) With and Without Expiratory Muscle Strength Training (EMST) For Patients With Presbyphonia: A Noninferiority Randomized Clinical Trial.

OBJECTIVES: Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone. STUDY DESIGN: Prospective, randomized, controlled, single-blinded, non-inferiority. MATERIALS AND METHODS: Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10. RESULTS: Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P < 0.001; PhoRTE + EMST M = -9.58, P < 0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm H2O, PhoRTE + EMST M = 32.63 cm H2O; P= 0.015). Some secondary acoustic and aerodynamic outcomes displayed trends toward improvement. CONCLUSION: This study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

Flexible Versus Rigid Laryngoscopy: A Prospective, Blinded Comparison of Image Quality.

OBJECTIVE: To compare flexible distal-chip laryngoscopy (FDL) and rigid telescopic laryngoscopy (RTL) in image quality and diagnostic ability. STUDY DESIGN: Prospective cohort study; blinded comparison. METHODS: Eighteen normal adult subjects were recruited to undergo both FDL and RTL and normalized videos were recorded. Three blinded laryngologists compared the videos for color fidelity, illumination, resolution, and vascularity, and indicated superiority with FDL, RTL, or no difference. Raters also reported if an abnormality was seen and in which video it was better visualized. Videos for two subjects were repeated to assess intra-rater reliability, making 20 video comparisons across 3 raters for a total of 60 ratings. Differences in responses were analyzed via Mann-Whitney U and Pearson Χ2. Inter-rater reliability was assessed via Fleiss' kappa, and intra-rater reliability was assessed via percent agreement. RESULTS: RTL was rated superior in all categories of image quality (47 vs 5 vs 8, P < 0.01; 47 vs 7 vs 6, P < 0.01; 51 vs 5 vs 4, P<0.01; 44 vs 9 vs 7, P < 0.01, respectively). An abnormality was seen 33 times with both modalities and 6 times with RTL only. When seen with both modalities, visualization was superior in RTL compared with FDL (29 vs 4, P <0.01). CONCLUSIONS: There was significant superiority of RTL in all categories of image quality, with slight inter-rater agreement for color fidelity, resolution, and vascularity. RTL was also significantly better for visualization of abnormalities. These findings suggest superior image quality in RTL compared with FDL, but further research is required to determine if this difference is clinically significant.

Effect of Medialization on Dyspnea Index in Unilateral Vocal Fold Paralysis.

OBJECTIVE: Patients with unilateral vocal fold paralysis commonly report dysphonia and dysphagia. Dyspnea also occurs, with studies on treatment-related change producing mixed results. Studies including patient-reported outcomes have focused on single-question global scales. The Dyspnea Index (DI) includes 10 questions, is specific to upper airway-related dyspnea, and may better capture these patients' symptoms. We evaluated change in DI after treatment. STUDY DESIGN: Retrospective review. SETTING: Academic medical center. METHODS: Forty-three patients with unilateral vocal fold paralysis underwent injection augmentation (n = 25) or framework surgery (n = 18). DI was recorded preprocedure, 2 to 4 weeks afterward, and at approximately 3 months afterward in 19 patients. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 were also recorded. Change in parameters and correlations were assessed. Obesity, cardiac disease, pulmonary disease, and procedure (injection vs framework surgery) were evaluated for effect on DI. RESULTS: Twenty-four patients had an abnormal baseline DI (>10). DI decreased from 14.9 ± 13.8 to 6.5 ± 9.3 after treatment (P < .001; 95% CI, 4.7-12.1). Twenty-eight scores decreased, 9 remained unchanged, and 6 increased. Change in DI was influenced by the presence of cardiac disease. Decreased DI persisted at 3-month follow-up. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 scores decreased and were correlated with change in DI. CONCLUSION: Upper airway-related dyspnea is common in unilateral vocal fold paralysis, occurring in half of this cohort. Correcting glottic insufficiency may alleviate symptoms. Treatment decision making should consider postprocedural change in dyspnea, especially in patients for whom dyspnea is a motivating factor for seeking treatment.

Linguistic Relevance and Applicability of the Spanish VHI-10 in a Population outside Spain.

INTRODUCTION: The Voice Handicap Index 10 (VHI-10) has been translated to many languages. There are substantial differences between the translation methods. Translated questionnaires without appropriate linguistic validation may not capture cultural differences or be understood by the participants in the manner intended by the original developers. This also holds true between dialects within a language. There are two versions of the VHI-10 in Spanish, both translated in Spain. Considering the cultural and dialectical differences amongst Spanish speakers, it is hypothesized that these translations may not be applicable globally. The purpose of this study was to determine the linguistic relevance and applicability of the currently available versions of the VHI-10 in Spanish amongst Spanish speakers outside of Spain. METHODS: This study used mixed methods qualitative and quantitative procedures consisting of semi-structured interviews and quantitative analysis of data. Sixty-nine participants met the inclusion criteria. Participants with and without a diagnosis of dysphonia were included. Demographic data collected included age, gender, cultural/dialectical background, level of education, and number of years residing in Southern California. Participants were provided the currently available translated versions of the VHI-10 in Spanish (V1 and V2). After reading both questionnaires, a semi-structured interview was conducted by a bilingual SLP. Semi-structured interview responses were coded to determine patterns of words marked as problematic/not understood or non-representative of the Spanish dialect spoken by the participants. RESULTS: The majority of participants marked at least one word in both versions as problematic/not understood or non-representative of the Spanish dialect spoken (60/69, 87.0% for V1 and 63/69, 92.3%, for V2). The two words most frequently marked as problematic/not understood or non-representative of the Spanish dialect spoken were "hándicap" (marked by 51/69 participants, 73.9%) and "minusvalía" (marked by 52/69 participants, 75.4%). CONCLUSIONS: Data analysis demonstrates that the majority of participants marked words as not understood/non-representative of their dialect on either V1 or V2. One question not understood or not answered could have an impact on how we interpret this patient-reported outcome measure in clinical practice. Use of currently available Spanish translations of the VHI-10 may yield unreliable results when used amongst Spanish speakers outside Spain due to dialectal and cultural differences. Future work will include validation of a voice patient-reported outcome measure that is culturally and linguistically appropriate for Spanish speakers outside Spain.

The Voice Problem Impact Scales (VPIS).

INTRODUCTION: Patient-reported outcome measures (PROMs) are important for systematically assessing a person's perspectives and experiences with disease to inform clinical decision-making. However, PROMs can occasionally fail to capture subtle differences amongst subgroups. In response to this problem, the aim of the current study was to examine the convergent validity of four patient-reported voice activity and participation scales to better reflect and describe the impact of a voice problem in a patient's work, home, social and overall life. It was hypothesized that augmenting the validated PROM with a directed situational short instrument may enhance patient and clinician communication. This would allow for further description of individual areas of activity limitations or participation restrictions that are relevant to the patient, potentially informing therapeutic goals. METHODS: The Voice Problem Impact Scales (VPIS) were developed following the criteria outlined by Francis et al (2016). A retrospective chart review was completed for voice therapy treatment seeking patients at the USC Voice Center. Results from the Voice Handicap Index-10 (VHI-10) and VPIS scores were recorded at the time of the evaluation. Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) assessment was performed by an SLP with fellowship training in voice. RESULTS: Three hundred four charts were reviewed, and 198 met inclusion criteria. When considering all patients, VHI-10 scores were significantly correlated with each domain of the VPIS, including overall (R = 0.635, P < 0.001), work (R = 0.436, P < 0.001), social (R = 0.714, P < 0.001), and home (R = 0.637, P < 0.001). For females aged 18-39 and aged ≥60, the VHI-10 was correlated with all domains except work. CAPE-V score was significantly correlated with the social domain (R = 0.236, P = 0.001). Using the corrected significance level, it was not correlated with the overall (R = 0.165, P = 0.022), home (R = 0.197, P = 0.006), or work domains (R = 0.042, P = 0.567). The VHI-10 was not correlated with any of the VPIS domains for males aged 18-39, was correlated with all domains for males aged 40-59, and was correlated with all domains except work for males aged ≥60. Age was the only significant predictor of the work domain (ß = -4.631 P < 0.001), with a model fit of R2 = 0.101. CONCLUSIONS: Scores from each domain of the VPIS are significantly correlated with VHI-10 scores thus confirming the instrument's convergent validity. There are certain groups for which currently used questionnaires may underrepresent the impact of dysphonia on the patient's life. The VPIS represents a broad tool that might allow the patient to interpret each scale within their individual context and cultural background. The VPIS emphasizes the significance of the dysphonia on quality of life in four common environments. Using this instrument can augment questionnaires and initiate conversations between the provider and patient to determine the area(s) where voice impairment is most important enhancing shared decision-making on therapeutic goals for plan of care.

Laryngologists' Reported Decision-Making in Presbyphonia Treatment.

OBJECTIVE: Decision-making regarding behavioral versus procedural intervention in the treatment of presbyphonia has not been well defined. The study objective was to survey laryngologists' reported practice patterns and decision-making in presbyphonia. METHODS: All laryngology faculty in U.S. academic medical centers with residency programs were recruited to complete an anonymous 29-item survey regarding decision-making in presbyphonia treatment. The survey included 5 sections: demographics, first-line treatment distribution, factors that drive decision-making toward procedural intervention, treatment progression if first-line treatment is insufficient, durable treatment. RESULTS: Of 153 laryngologists surveyed, 89 responded (58%). Voice therapy (VT) was the most often reported first-line treatment, with 57% of respondents indicating the majority of their patients receive VT initially. Most respondents (83%) indicated they occasionally use procedural intervention as first-line treatment. Factors driving first-line procedural intervention were severe glottal insufficiency (87%), high occupational/social voice demands (76%), voice not stimulable for change (73%), difficulty attending VT (70%), severe dysphonia (65%), and dysphagia (61%). The majority of respondents indicated the following do not affect their decision to pursue procedural intervention: patient age (88%); medical comorbidities (63%); patient's desire for a "quick fix" (55%); patient-reported outcome measures (51%). Most respondents (81%) use trial injection augmentation before durable treatment. Of durable treatments, bilateral thyroplasty was preferred (71%), followed by CaHA (15%) and lipoinjection (11%). CONCLUSIONS: This study is the first to our knowledge to examine factors that influence decision-making in presbyphonia treatment. While VT remains the most frequent first-line treatment, study results better inform decision-making regarding first-line procedural intervention.

Mapping Meta-Therapy in Voice Interventions onto the Rehabilitation Treatment Specification System.

Meta-therapy refers to the clinical dialogue via which direct and indirect voice treatments are introduced and discussed, and which helps build a useful conceptual framework for voice therapy. Meta-therapy was idiosyncratically defined in previous work. However, the current colloquial narrative of meta-therapy is not standardized or specific enough to be reliably taught, rigorously studied, or clinically delivered with high fidelity. Therefore, this article uses a standard framework (the Rehabilitation Treatment Specification System or RTSS) to further articulate and operationalize meta-therapy in vocal rehabilitation. Meta-therapy's conceptual framework generally aligns with the RTSS's treatment theory and associated concepts; e.g., the treatment component and its underlying ingredients, mechanisms of action, and target. Because the treatment theories in meta-therapy most frequently involve mechanisms of action related to information processing, they primarily map onto the RTSS's Representations treatment components. The treatment targets in meta-therapy are often focused on changes in the patient's cognitions, knowledge, beliefs, attitudes, intentions, and/or awareness regarding voice-related modifications. The ingredients in meta-therapy are frequently clinician actions conveying information with the goal of appropriately shaping the patient's mental representations, and are delivered with verbal cues, stories, analogies, etc. This manuscript provides specific examples of how meta-therapy is applied in clinical voice practice. Considerations for future investigation of meta-therapy are proposed.

Pilot Evaluation of Community-Based Vocal Health Screenings.

INTRODUCTION: Community-based health fairs can help identify at-risk populations, improve health literacy, and facilitate access to medical services. No community-based screenings specifically targeting vocal health were identified in the literature. The purpose of this study is to compare the results of community-based vocal health screenings across two populations: a group of community members with unknown risk of voice problems, and a group of actors belonging to a profession with a known increased risk of voice problems. METHODS: Vocal health screenings were conducted at two free, community-based health fair events in the Los Angeles area. One was open to the public, and one was organized specifically for actors who are members of the Screen Actors Guild-American Federation of Television and Radio Artists. A total of 142 community members (94 nonactors and 48 actors) were administered a questionnaire on current vocal health and voice-related quality of life indices (Vocal Handicap Index-10, Vocal Fatigue Index), followed by review and discussion with a laryngologist or a speech pathologist trained in assessment and treatment of voice disorders. RESULTS: A significantly higher percentage of actors (55.1%) reported current voice problems than nonactors (33.0%; χ2 = 7.122, df = 1, P = 0.008). Additionally, as measured by the Vocal Fatigue Index 2 subscale, actors reported a greater amount of perceived pain with phonation than the nonactors. Despite over half of the actors reporting current voice concerns, only 7% reported having sought medical advice regarding these concerns. CONCLUSIONS: The results of this study suggest that vocal health screenings can help identify persons with voice complaints. However, in order to determine if vocal health screenings help close prevalence-presentation gap and are useful to both medical professionals and participants, more research is needed.

Effect of Vitamin B12 Injection on the Vocal Performance of Professional Singers: A Randomized, Double-blind, Placebo-Controlled, Crossover Trial.

Importance: One-third of singers and vocal professionals report experiencing a benefit from empirical vitamin B12 injections for improvement of mild singing-related symptoms (eg, reduced stamina, vocal fatigue, and effort). However, there is no objective evidence to support or refute these claims. Objective: To assess the presence and magnitude of the effect of empirical vitamin B12 injection on the vocal performance of singers. Design, Setting, and Participants: A randomized, double-blind, placebo-controlled, crossover trial was conducted from November 7, 2017, to November 30, 2018, at an academic voice center among 20 active adult singers without dysphonia but with mild vocal symptoms. Individuals with known or suspected vitamin B12 deficiency or active or recent vitamin B12 treatment were excluded. Analysis was on a per-protocol basis. Interventions: Participants were randomized to receive an intramuscular (deltoid) injection of either vitamin B12 (1000 µg of cyanocobalmin) or placebo (0.9% sodium chloride). After a washout period of at least 4 weeks, participants were crossed over to receive the opposite injection. Both the investigators and participants were blinded to the order of injections. Main Outcomes and Measures: The participants completed the Singing Voice Handicap Index-10 (SVHI-10), the Voice Fatigue Index (VFI), and the Evaluation of the Ability to Sing Easily (EASE) before each injection and at intervals of 1 hour, 3 hours, 24 hours, 72 hours, and 1 week after the injection. The primary time point assessment was 72 hours after injection, and the SVHI-10 score was the primary outcome measure. Results: Twenty singers (10 men; median age, 22 years [range, 19-42 years]) were enrolled. The improvements after either placebo or vitamin B12 injections were comparable to each other. At 72 hours after the vitamin B12 injection, the median difference in the SVHI-10 score was 1 (95% CI, -1 to 2) compared with 3 (95% CI, 0-4) after placebo. The median difference between differences at 72 hours between placebo and vitamin B12 injections were 1.5 (95% CI, -2 to 5) for the SVHI-10, 1 (95% CI, -9 to 9) for the VFI, and -1 (95% CI, -3 to 2) for the EASE. The improvements after both injections failed to reach the estimated minimal clinically important difference. Of the 20 participants, 4 (20%) reached the estimated minimal clinically important difference in their SVHI-10 score after 72 hours for both vitamin B12 and placebo injections. Conclusions and Relevance: This randomized, double-blind, placebo-controlled, crossover trial found that after empirical vitamin B12 injection to improve mild voice-related symptoms, the improvement in self-reported voice measures in singers shows no meaningful difference compared with placebo. Trial Registration: ClinicalTrials.gov Identifier: NCT03437824.

Flexible versus rigid laryngoscopy: A randomized crossover study comparing patient experience.

OBJECTIVES: To compare flexible distal-chip laryngoscopy (FDL) versus rigid telescopic laryngoscopy (RTL) in regard to examinees' pain level, comfort, satisfaction, and preference, and to evaluate the clinician's assessment of the examinees' experience with both exam types. STUDY DESIGN: Randomized crossover study. METHODS: Twenty-three normal adult subjects were recruited to undergo both FDL and RTL; the initial exam type was randomized. Subjects and clinicians completed corresponding questionnaires after each exam. Differences in participant characteristics and questionnaire scores between the two exam types were assessed via Pearson χ2 and paired t tests, respectively. RESULTS: Overall, participants reported that FDL was more uncomfortable than RTL (4.22 vs. 2.91, P = .003) and scored higher on the pain scale for FDL compared to RTL (2.91 vs. 1.70, P = .006). However, there was no significant difference in number of participants who preferred FDL versus RTL (10 [43%] vs. 13 [57%]). Poor correlation was seen between clinicians' assessment of participants' discomfort and actual reported discomfort for FDL (2.70 vs. 4.22, P = .001). CONCLUSIONS: Subjects undergoing FDL experience greater discomfort and pain compared to RTL, but do not demonstrate a differential preference of exam. Overall, clinicians underestimate the discomfort of patients undergoing FDL, but participants maintain high satisfaction with both exams nonetheless. LEVEL OF EVIDENCE: 1 Laryngoscope, 130:2663-2666, 2020.

Vocal Dose in Older Adults with Presbyphonia: An Analytic, Cross-Sectional Study.

PURPOSE: Older patients with age-related voice changes (presbyphonia) are considered vocal under-doers due to a reportedly low a amount and intensity of voice use (ie, low vocal dose). This low voice use may be consequential to negative effects of presbyphonia like throat discomfort, as well as anxiety and frustration from difficulty communicating. Causally speaking, vocal fold atrophy (presbylaryngis) may indicate inadequate intrinsic laryngeal muscle loading with low voice use, though research is lacking. As a first step, this study examined voice use objectively using vocal dosimetry in older adults with presbyphonia. We hypothesized participants, especially if retired, would exhibit low vocal doses, and lower than reported for other populations. METHOD: This research used an analytic, cross-sectional design with subgroup analyses to determine feasibility of vocal dosimetry in older adults with presbyphonia. Thirteen older adults with presbyphonia (7 males) completed vocal dose monitoring using an ambulatory phonation monitor (APM). The APM measured vocal parameters over a day of monitoring, from which time, cycle, and distance doses were calculated. Data also were gathered on demographics, vocal handicap, and vocal effort. RESULTS: Descriptively, the group showed a low mean time dose as compared to published vocal dose data from other populations. Females exhibited significantly higher mean values of time dose, cycle dose, and fundamental frequency than males. Time dose for males was negatively correlated with vocal effort. Subgroup analyses failed to detect an effect of age group, but found significantly a higher mean value for time dose in employed, compared to retired, participants. CONCLUSIONS: Consistent with self-report, we found older adults with presbyphonia exhibit low time doses, which were in contrast to high vocal doses published on teachers, patients with dysphonia, and even office workers. We found differences in vocal dose as a function of sex and employment status. Though a limited sample, findings suggest patients with presbyphonia may demonstrate low vocal dose, which may be a useful target in treatment.

Common practices in botulinum toxin injection for spasmodic dysphonia treatment: A national survey.

OBJECTIVES/HYPOTHESIS: Although no clear guidelines exist, protocols in the treatment of spasmodic dysphonia (SD) vary among physicians. Previously published work comes from relatively few centers. STUDY DESIGN: A descriptive survey among experts (laryngologists who practice Botulinum toxin injections for SD). METHODS: An online 58-item survey was sent to all otolaryngologists who self-identify as laryngologists on the American Academy of Otolaryngology-Head and Neck Surgery website. Items surveyed included botulinum toxin injection technique, laterality, and dosage. RESULTS: An 80% response rate was achieved (70 completed the survey). Participants collectively reported treating >4,000 SD patients in the past year (mean, 71 ± 68 patients/laryngologist). Eighty-seven percent perform injections exclusively in the office; the remainder both in the office and operating room. For adductor SD injections, 88% use electromyographic (EMG) guidance alone via cricothyroid approach. The remainder use anatomical landmarks alone (9%) or EMG with endoscopic guidance (3%). Sitting is the preferred patient position (70%; supine, 30%). A substantial majority (87%) begin with bilateral injections (starting dosage mode, 1.25 units/side). For abductor SD injections, 67% use EMG guidance alone and 31% use endoscopic guidance with or without EMG. Sitting is the preferred patient position (84%; supine, 16%). The preferred approach is anterior-translaryngeal (51%), followed by lateral-retrolaryngeal with rotation (34%). A considerable majority (79%) begin with unilateral injections (starting dosage mode, 5 units). When deciding on initial dosage, the most influential factor was balancing patients' desire/needs, followed by patients' frailty and risk of aspiration. The typical planned interval between injections is 3 to 4 months. CONCLUSIONS: Laryngologists follow fairly uniform protocols in the treatment of SD with some important and previously unpublished differences. This study documents areas of agreement and discordance among laryngologists in the United States for the treatment of SD. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1650-1656, 2019.

Airflow Patterns of Running Speech in Patients With Voice Disorders.

OBJECTIVE: Aerodynamic measures of voice have historically been acquired using sustained phonation tasks. This study seeks to determine whether there are differences in airflow during sustained phonation (MFs), in running speech (MFrs), or during phonation in running speech (MFvrs). We also seek to determine whether these patterns are diagnostically significant. METHODS: Data were collected on 40 subjects (15 men, 25 women), ages 20-79, with a mean age of 53 in this prospective study. All participants received a comprehensive videostroboscopic evaluation and were deemed appropriate for voice evaluation and trial therapy. The Phonatory Aerodynamic System 6600 was used for data collection. The Comfortable Sustained Phonation and Running Speech protocols were used for data acquisition. Patient diagnoses were divided into five subgroups: benign lesions, vocal fold paralysis or paresis, muscle tension dysphonia, edema or laryngitis, and chronic cough. Statistical methods such as analysis of variance and Tukey tests assessed pairwise differences in the airflow rate. Pairwise Tukey multiple comparisons of means testing using a 95% family-wise confidence level were completed to determine the interrelationships of the pairs. RESULTS: Differences were found among airflow measures (P value = 0.0152), pairwise comparisons of MFs-MFvrs pair (P value = 0.012), and diagnosis. No significance was found in MFs-MFrs (P = 0.051) or MFvrs-MFrs (P = 0.94) pairs. Mean flow rates were higher than the norms in MFs. The overall range of mean airflow was similar to those of published norms. CONCLUSION: Assumptions about mean airflow of connected speech should not be made based on sustained phonation tasks alone. No salient diagnostic characteristics were found by diagnosis.

Validation of the OMNI vocal effort scale in the treatment of adductor spasmodic dysphonia.

OBJECTIVES: To establish the validity of the OMNI Vocal Effort Scale (OMNI-VES) for resistance exercise, a single-question pictorial scale, in voice-related perceived exertion. Additionally, the study aimed to assess the role of the OMNI-VES as an outcome measurement in the treatment of adductor spasmodic dysphonia (ADSD). METHODS: A prospective validation study was conducted on 226 participants. The case group was comprised of 178 patients receiving botulinum toxin (BTX) injections for ADSD and 48 controls without a voice disorder. Prior to a planned injection, the participants were asked to complete the OMNI-VES and the Voice-Related Quality-of-Life (V-RQOL) questionnaires, and the clinician completed the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). A subgroup of 17 patients were administered a repeat assessment 1 month after injection. RESULTS: There was a weak correlation between the OMNI-VES and the V-RQOL score (Tau-b = -0.252, P < 0.001), and no significant correlation with the CAPE-V. Participants with ADSD had significantly higher OMNI-VES scores compared with normal controls, 5.07 ± 2.18 and 1.47 ± 2.28, respectively (P value < 0.0001). The average OMNI-VES score significantly improved 1 month following a BTX injection, from 6 ± 2.4 to 3.4 ± 2.8 (P value = 0.0003). Eighty-eight percent of the patients demonstrated a decrease in the OMNI-VES score following injection, whereas only 47% demonstrated an improvement in the V-RQOL score. CONCLUSION: The OMNI-VES is a validated tool for rating perceived voice-related exertion in people with ADSD and can be used for evaluating response to BTX injection treatment. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:448-453, 2019.

The Singer's and the Clinician's Perspective on Vitamin B12 Treatment for Vocal Benefits.

INTRODUCTION: There is a belief among vocalists that there are voice benefits from vitamin B12 treatment. Yet there are no previous reports regarding vitamin B12 effects on voice. OBJECTIVES: To assess the prevalence of vitamin B12 use among singers and their beliefs regarding vitamin B12 therapy. METHODS: Anonymous online survey administered to singers, singing-teachers, speech-language pathologists, and laryngologists. RESULTS: A total of 192 participants completed the surveys; 128 singers (68 singing-teachers, 30 speech-language pathologists) and 64 laryngologists. Among singers, 12% have perceived voice benefits from vitamin B12 treatment taken for any reason. Four percent used vitamin B12 for voice benefits; all perceived voice benefits as a result. The leading voice benefits were improved stamina, reduced effort, confidence, and control. Nineteen percent of the singers would recommend vitamin B12 treatment to a friend; 15% of the singing-teachers would recommend it to a student. Among laryngologists, 33% been asked by a singer to prescribe vitamin B12 for voice benefits; 9% have prescribed it in the past. Yet only 3% would you recommend it to a patient. When asked "Do you believe vitamin B12 therapy improves vocal performance?" 31% of the singers responded "Yes," compared with none in the laryngologists. When asked "Do you think the singing community believes vitamin B12 therapy improves vocal performance?" 26% of the singers responded "Yes," compared with 53% of the laryngologists (P = 0.0002). CONCLUSIONS: There is a discrepancy between the singers' and the laryngologists' beliefs regarding vocal benefits perceived by vitamin B12. Blinded randomized trials are required to verify or refute this belief.