Descriptive Epidemiology of Voice Disorders in Rheumatoid Arthritis: Prevalence, Risk Factors, and Quality of Life Burden.

OBJECTIVES: Rheumatoid arthritis (RA) is an autoimmune inflammatory disease which may adversely affect phonatory function. This study aimed to establish the prevalence, risks, and quality of life effects of voice disorders in RA. STUDY DESIGN: This is a cross-sectional, descriptive epidemiology study. METHODS: One hundred individuals with RA underwent a telephone interview to determine the frequency, severity, risks associated with, and quality of life burden of voice disorders. The results were analyzed using summary statistics, frequencies, chi-square tests, regression analysis, and risk ratios (P < 0.05). RESULTS: Thirty-five percent of participants with RA reported a current voice disorder which was chronic and long-standing in most cases. The prevalence of a current voice disorder did not significantly differ across age, sex, medication use, voice use patterns, medical history, or RA severity. These chronic voice disorders produced significant adverse effects on both voice-related quality of life and short form 36 health-related quality of life scales. Specific voice symptoms such as "voice-related discomfort" and "chronic throat dryness" contributed disproportionately to the quality of life burden. Of those participants with a voice disorder, only 37% had ever sought professional help to improve their voice. CONCLUSIONS: These results indicate that voice disorders are common in RA and produce significant adverse effects on quality of life. Further research is necessary to better understand the origin of these disorders and their potential response to treatment.

The Quality of Life Burden Associated With Voice Disorders in Sjögren's Syndrome.

OBJECTIVES: This study examined quality of life burden of voice disorders in Sjögren's syndrome (SS). METHODS: Patients with SS (n = 101) completed interviews involving patient-reported histories of voice disorders, specific voice symptoms, SS disease severity, the Voice-Related Quality of Life (V-RQOL), and the general health-related quality of life Short Form 36 (SF-36) questionnaires. Relationships among voice symptoms, disease severity, and quality-of-life measures were examined and compared with patient-reported voice disorders. RESULTS: Significant correlations were observed among voice symptoms, disease severity, V-RQOL, SF-36, and patient-reported voice disorders (P < .05). Patients with SS who reported a voice disorder experienced a greater burden on general quality of life as compared with those without voice disorders. Specific voice symptoms significantly correlated with reduced SF-36 scores included frequent throat-clearing, throat soreness, difficulty projecting, and vocal discomfort. Despite the added burden of a voice disorder on quality of life in SS, voice-related treatment seeking was low (15.8%). However, the majority of patients who received voice treatment reported voice improvement. CONCLUSIONS: Individuals with SS frequently experience voice disorders and specific voice-related symptoms that are associated with reduced quality of life. These findings have important implications for voice referral practices and voice disorder symptom management in this population.

Delayed otolaryngology referral for voice disorders increases health care costs.

BACKGROUND: Despite the accepted role of laryngoscopy in assessing patients with laryngeal/voice disorders, controversy surrounds its timing. This study sought to determine how increased time from first primary care to first otolaryngology outpatient visit affected the health care costs of patients with laryngeal/voice disorders. METHODS: Retrospective analysis of a large, national administrative claims database was performed. Patients had an International Classification of Diseases, 9(th) Revision-coded diagnosis of a laryngeal/voice disorder; initially saw a primary care physician and, subsequently, an otolaryngologist as outpatients; and provided 6 months of follow-up data after the first otolaryngology evaluation. The outpatient health care costs accrued from the first primary care outpatient visit through the 6 months after the first otolaryngology outpatient visit were determined. RESULTS: There were 260,095 unique patients who saw a primary care physician as an outpatient for a laryngeal/voice disorder, with 8999 (3.5%) subsequently seeing an otolaryngologist and with 6 months postotolaryngology follow-up data. A generalized linear regression model revealed that, compared with patients who saw an otolaryngologist ≤1 month after the first primary care visit, patients in the >1-month and ≤3-months and >3-months time periods had relative mean cost increases of $271.34 (95% confidence interval $115.95-$426.73) and $711.38 (95% confidence interval $428.43-$993.34), respectively. CONCLUSIONS: Increased time from first primary care to first otolaryngology evaluation is associated with increased outpatient health care costs. Earlier otolaryngology examination may reduce health care expenditures in the evaluation and management of patients with laryngeal/voice disorders.

Frequency and factors associated with use of videolaryngostroboscopy in voice disorder assessment.

OBJECTIVES/HYPOTHESIS: Videolaryngostroboscopy (VLS) is considered an important diagnostic tool in the evaluation of patients with laryngeal/voice disorders. We evaluated the frequency of, diagnoses associated with, and factors related to VLS use in the evaluation of outpatients with laryngeal/voice disorders. STUDY DESIGN: Retrospective analysis of a large, national administrative U.S. claims database. METHODS: Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes from January 1, 2004, to December 31, 2008, seen by an otolaryngologist were included. Patient age, gender, geographic region, laryngeal diagnosis, comorbid conditions, and whether laryngoscopy or VLS was performed during the outpatient otolaryngology visit were collected. RESULTS: A total of 168,444 unique patients saw an otolaryngologist for 272,112 outpatient visits. Of those, 6.2% of outpatient otolaryngology visits had a VLS performed. Patient age was related to VLS use, with lower odds in the elderly (≥ 65 years of age) and those 0 to 17 years of age. Geographic variation was noted, with higher odds of VLS use in urban versus rural areas and greater odds in the Northeast versus the South. Laryngeal diagnosis was associated with VLS use with greatest odds for patients with multiple diagnoses, vocal fold paralysis, and paresis-followed by nonspecific dysphonia and benign vocal fold/laryngeal pathology and followed by acute and chronic laryngitis and laryngeal cancer. Patients with gastro-esophageal reflux (GER) had greater odds of VLS use than patients without GER. CONCLUSIONS: VLS was used in 6.2% of outpatient otolaryngology outpatient visits; and its use was influenced by multiple factors.

Voice-related symptoms and their effects on quality of life.

OBJECTIVES: The purpose of this study was to identify the extent to which selected voice symptoms formed underlying constructs called factors, and the degree to which these factors influenced specific quality-of-life domains among a group of relatively healthy older adults. METHODS: A cross-sectional survey was completed in October 2010 by 461 individuals 50 years of age and older. The questionnaire items included demographics, medical history, health, voice use, and voice symptoms. Quality-of-life indicators were used from the Short Form 36 Health Survey, an 8-scale measure of functional health and well-being. RESULTS: Two clusters of symptoms were identified in the factor analysis. One cluster, consisting of 5 voice-related symptoms and labeled "phonatory effort," shared all significant negative correlations with health outcomes, whereas the other cluster, consisting of 2 voice-related symptoms and labeled "chronic throat condition," had a pattern of sharing significant negative correlations with only 3 health outcomes. All voice symptoms had significant negative correlations with general health, bodily pain, and energy/fatigue. CONCLUSIONS: Voice-related symptoms share complex relationships with and have negative effects on health outcomes. The specific mechanisms of impact need further research in order for us to better understand these effects on quality of life and how to prevent and treat the symptoms.

Evidence-based clinical voice assessment: a systematic review.

PURPOSE: To determine what research evidence exists to support the use of voice measures in the clinical assessment of patients with voice disorders. METHOD: The American Speech-Language-Hearing Association (ASHA) National Center for Evidence-Based Practice in Communication Disorders staff searched 29 databases for peer-reviewed English-language articles between January 1930 and April 2009 that included key words pertaining to objective and subjective voice measures, voice disorders, and diagnostic accuracy. The identified articles were systematically assessed by an ASHA-appointed committee employing a modification of the critical appraisal of diagnostic evidence rating system. RESULTS: One hundred articles met the search criteria. The majority of studies investigated acoustic measures (60%) and focused on how well a test method identified the presence or absence of a voice disorder (78%). Only 17 of the 100 articles were judged to contain adequate evidence for the measures studied to be formally considered for inclusion in clinical voice assessment. CONCLUSION: Results provide evidence for selected acoustic, laryngeal imaging-based, auditory-perceptual, functional, and aerodynamic measures to be used as effective components in a clinical voice evaluation. However, there is clearly a pressing need for further high-quality research to produce sufficient evidence on which to recommend a comprehensive set of methods for a standard clinical voice evaluation.

Factors influencing the health care expenditures of patients with laryngeal disorders.

OBJECTIVE: To identify factors related to the health care spending of patients with laryngeal disorders. STUDY DESIGN AND SETTING: Retrospective analysis of data from a large, nationally representative administrative US claims database. SUBJECTS AND METHODS: Patients with a laryngeal disorder based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004, to December 31, 2008, and who were continuously enrolled for 12 months were included. Age, sex, comorbidity, geography, provider type, visit type, and type of laryngeal pathology were collected. To identify which factors were related to the direct costs, a generalized linear regression with gamma distribution was used. RESULTS: Of almost 55 million individuals in the database, 309,300 patients with a laryngeal disorder and 12 months of follow-up data were identified (mean [SD] age, 47.3 [21.3] years; 63.5% female). Age, sex, geographic region, number of comorbid conditions, type of provider, visit type, and laryngeal pathology were significantly associated with the health care expenditures (all P values <.05). Costs increased with increasing age and were greater for male patients, higher in the South and Northeast compared with the West and North-central regions, greater in 2008 compared with 2004, higher for inpatient compared with outpatient care, higher with increasing number of comorbid conditions, and lower if a patient was treated by a primary care physician only. Among the various laryngeal pathologies, the greatest direct costs were for laryngeal cancer and patients with multiple diagnoses. CONCLUSION: This study identified multiple factors associated with the health care expenditures of patients with laryngeal disorders.

Direct health care costs of laryngeal diseases and disorders.

OBJECTIVES/HYPOTHESIS: To estimate the annual direct costs associated with the diagnosis and management of laryngeal disorders. STUDY DESIGN: Retrospective analysis of data from a large, nationally representative, administrative US claims database. METHODS: Patients with a laryngeal disorder based on International Classification of Diseases,Ninth Revision-Clinical Modification codes from January 1, 2004 to December 31, 2008 and who were continuously enrolled for 12 months were included. Data regarding age, gender, geographic location, and type of physician providing the diagnosis were collected. Medical encounter, medication, and procedure costs were determined. Total and mean costs per person for 12 months were determined. RESULTS: Of almost 55 million individuals in the database, 309,300 patients with 12 months follow-up, mean age of 47.3 years (standard deviation: 21.3), and 63.5% female were identified. Acute and chronic laryngitis, nonspecific causes of dysphonia, and benign vocal fold lesions were the most common etiologies. The total annual direct costs ranged between $178,524,552 to $294,827,671, with mean costs per person between $577.18 and $953.21. Pharmacy claims accounted for 20.1% to 33.3%, procedure claims 50.4% to 69.9%, and medical encounter claims 16.3% to 8.6% of overall direct costs. Antireflux medication accounted for roughly 10% and antibiotics 6% of annual direct costs. CONCLUSIONS: This study establishes the economic impact of the assessment and management of patients with laryngeal disorders and permits cost comparisons with other diseases.

Prevalence and causes of dysphonia in a large treatment-seeking population.

OBJECTIVES/HYPOTHESIS: To determine the prevalence and common causes of dysphonia as diagnosed by primary care physicians (PCPs) and otolaryngologists and to evaluate differences in etiologies offered by these providers. STUDY DESIGN: Retrospective analysis of data from a large, nationally representative administrative U.S. claims database. METHODS: Patients were identified as dysphonic based on International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2004, to December 31, 2008. Data regarding age, sex, geographic location, and type of physician providing the dysphonia diagnosis were collected. Overall and age-related prevalence rates, as well as frequency of specific etiologies by provider type, were calculated. RESULTS: Of the almost 55 million individuals in the database, 536,943 patients (ages 0 to >65 years) were given a dysphonia diagnosis (point prevalence rate of 0.98%). The prevalence rate was higher among females as compared to males (1.2% vs. 0.7%) and among those >70 years of age (2.5%). The most frequent diagnoses overall were acute laryngitis, nonspecific dysphonia, benign vocal fold lesions, and chronic laryngitis. PCPs more commonly diagnosed acute laryngitis, whereas otolaryngologists more commonly diagnosed nonspecific dysphonia and laryngeal pathology. Gastroesophageal reflux was more commonly diagnosed as a comorbid condition by otolaryngologists than by PCPs. Overall laryngeal cancer prevalence in this treatment-seeking population was 2.2% and was greatest among males >70 years of age. CONCLUSIONS: This analysis of insurance claims data from a nationally representative database represents the largest study of its kind. Important differences in dysphonia prevalence related to age, sex, diagnosis, and physician type were identified.

Spasmodic dysphonia: onset, course, socioemotional effects, and treatment response.

OBJECTIVES: This investigation explored the onset, progression, socioemotional effects, and treatment outcomes of spasmodic dysphonia (SD). METHODS: A cross-sectional epidemiological approach was used to examine questionnaire responses from 150 individuals with SD. RESULTS: Symptoms of SD (mean age at onset, 46 years) began gradually in 76% of cases and were progressive (ie, failed to plateau) in 34% of cases. Botulinum toxin A (Botox) helped to attenuate voice symptoms in 91% of cases; however, the scores on the Voice-Related Quality of Life questionnaire (V-RQOL) were not associated with this effect. The V-RQOL scores improved with time since symptom onset, independent of age and treatment. The patients with only SD experienced onset, course, and progression of symptoms similar to those of the patients with SD and coexisting vocal tremor. CONCLUSIONS: The symptoms of SD begin gradually and worsen over time. New evidence indicates that SD symptoms may continue to progress without plateau in at least a subset of patients. Individuals with SD and coexisting vocal tremor experience symptom trajectories similar to those of patients with SD only. Although Botox may attenuate voice symptoms, these effects do not appear to be strongly related to the V-RQOL scores. These results provide new and valuable insights regarding the onset, course, progression, and treatment of SD.

Vocal function exercises for presbylaryngis: a multidimensional assessment of treatment outcomes.

OBJECTIVES: Presbylaryngis, or aging of the larynx, can adversely affect vocal function and quality of life in the elderly. This preliminary investigation examined the effects of vocal function exercises, a physiologic voice therapy approach, as a primary treatment for presbylaryngis. METHODS: Nine consecutive elderly patients with presbylaryngis (2 female, 7 male) underwent a 6-week course of voice therapy employing vocal function exercises. Pretherapy-versus-posttherapy comparisons were made of self-ratings of voice handicap and phonatory effort level, as well as auditory-perceptual voice assessments, acoustic analyses, and visual-perceptual evaluations of laryngeal images. RESULTS: After treatment, patients reported significant reductions on Voice Handicap Index scores, phonatory effort levels, and voice disorder severity. Blinded listeners rated the posttreatment voices as significantly less breathy and strained. However, comparison of pretreatment and posttreatment maximum phonation times, acoustic measures, and laryngeal images did not reveal significant changes. CONCLUSIONS: These preliminary data suggest that vocal function exercises produce significant functional and perceptual improvements in voice, and deserve further attention as a treatment for elderly patients with presbylaryngis.

The Acoustic Voice Quality Index: toward improved treatment outcomes assessment in voice disorders.

UNLABELLED: Voice practitioners require an objective index of dysphonia severity as a means to reliably track treatment outcomes. To ensure ecological validity however, such a measure should survey both sustained vowels and continuous speech. In an earlier study, a multivariate acoustic model referred to as the Acoustic Voice Quality Index (AVQI), consisting of a weighted combination of 6 time-, frequency- and quefrency-domain metrics, was developed to measure dysphonia severity in both speaking tasks. In the current investigation, the generalizability and clinical utility of the AVQI are evaluated by first assessing its external cross-validity and then determining its sensitivity to change in dysphonia severity following surgical and/or behavioral voice treatment. The results, based upon a new set of normal and disordered voices compared favorably with outcomes reported earlier, indicating acceptable external validity. Furthermore, the AVQI was sensitive to treatment-related changes, validating its role as a potentially robust and objective voice treatment outcomes measure. LEARNING OUTCOMES: Readers will be able to: (1) explain methodological issues surrounding the development of voice treatment outcomes measures (such as external cross-validity and responsiveness to change), (2) appreciate the relevance of measuring dysphonia severity in both sustained vowels and connected speech, (3) describe the method of obtaining the Acoustic Voice Quality Index (AVQI), (4) appreciate differences among a variety of estimates of diagnostic accuracy, and (5) discuss the AVQI as a clinically valid treatment outcomes measure.

Assessment and treatment of musculoskeletal tension in hyperfunctional voice disorders.

Poorly regulated activity of the perilaryngeal muscles affects phonatory function and contributes to a class of disorders known as hyperfunctional or musculoskeletal tension voice disorders. Recognizing the signs and symptoms of excess or dysregulated laryngeal muscle activity is critical to proper diagnosis and selection of appropriate treatment(s). Although numerous approaches exist to manage such hyperfunctional syndromes, manual circumlaryngeal techniques have recently received attention as valuable tools in both assessment and treatment. Therefore, the purpose of this article is to: (1) describe common phenomenological features of dysregulated laryngeal muscle tension, thereby facilitating its recognition, (2) highlight the role of manual circumlaryngeal techniques in assessment and management, (3) survey additional treatment approaches for laryngeal hyperfunction, and explore the evidence to support their effectiveness, and (4) identify unresolved issues and controversies surrounding tension-based voice disorders. A series of pre- and post-treatment audio examples are provided on the journal website at www.informaworld.com/ijslp .

Lidocaine block of the recurrent laryngeal nerve in adductor spasmodic dysphonia: a multidimensional assessment.

OBJECTIVES/HYPOTHESIS: Lidocaine block of the recurrent laryngeal nerve (RLN) has been reported as a procedure for surgical selection of patients with adductor spasmodic dysphonia (ADSD). However, its effects on phonation have not been rigorously assessed in a prospective fashion using strict entry criteria and multiple measures of phonatory function. This investigation assessed the phonatory effects of RLN lidocaine block in ADSD to explore its potential as a diagnostic tool. STUDY DESIGN: Single group, pre/postexperimental trial. METHODS: Twenty-one consecutive patients with suspected ADSD underwent unilateral RLN block, causing temporary ipsilateral vocal fold paralysis. Voices were recorded before and during the block. Patients completed self-ratings of overall level of dysphonia severity, vocal effort, and laryngeal tightness. Blinded listeners completed auditory-perceptual ratings, and the frequency of phonatory breaks was acoustically analyzed. RESULTS: During the block, patients reported significant reductions on overall severity (P = .045), vocal effort (P < .001), and laryngeal tightness (P = .002). Listeners rated the voices during the block as significantly more breathy (P < .001), less strained (P < .001), and less severe (P = .059). Acoustic analysis confirmed significantly fewer phonatory breaks during the block (P < .001). Patient-based ratings of improvement were more consistent than listener ratings, and reduction in overall severity correlated with perceived breathiness. CONCLUSIONS: Although individuals varied in their outcomes, group results suggest that response to RLN lidocaine block warrants further study as a possible diagnostic tool in ADSD.

Intensive stuttering modification therapy: a multidimensional assessment of treatment outcomes.

Nineteen adults who stutter participated in a 3-week intensive stuttering modification treatment program (the Successful Stuttering Management Program [SSMP]). A series of 14 fluency and affective-based measures were assessed before treatment, immediately after treatment, and 6 months after treatment. Measures included stuttering frequency; the Stuttering Severity Instrument for Children and Adults, Third Edition (SSI-3); a self-rating of stuttering severity; the Perceptions of Stuttering Inventory (PSI); the Locus of Control of Behavior Scale; the Beck Depression Inventory; the Multicomponent Anxiety Inventory IV (MCAI-IV); and the State-Trait Anxiety Inventory. Statistically significant improvements were observed on 4 of the total 14 measures immediately following treatment and on 4 measures at 6 months posttreatment. Statistically significant improvements observed immediately posttreatment included scores on the SSI and the Struggle, Avoidance, and Expectancy subscales of the PSI. Sustained statistically significant improvements at 6 months posttreatment were observed only on client-reported perceptions of stuttering (the Avoidance and Expectancy subscales of the PSI) and 2 specific affective functioning measures (the Psychic and Somatic Anxiety subscales of the MCAI-IV). The SSMP generated some anxiolytic effects but was ineffective in producing durable reductions of core stuttering behaviors, such as stuttering frequency and severity. The discussion focuses on the strengths, weaknesses, and durability of the SSMP treatment approach.