Development of a New Self-Assessment Tool for Laryngopharyngeal Reflux Screening in Singers (SVHI-12-LPR).

INTRODUCTION: The present study aimed to develop a new tool for the evaluation of singers with self-reported symptoms suggestive of laryngopharyngeal reflux (LPR) (the SVHI-12-LPR), by correlating RSI with SVHI in a population sample of 163 subjects (both professional and amateur singers), evaluated also by videolaryngostroboscopy. This study was a cross-sectional, double-observational study. METHODS: RSI and SVHI were administered to 159 singers (amateurs, singing students, and professional singers). All subjects underwent videolaryngostroboscopy to objectively identify four subgroups: normal subjects (41.5%), subjects with organic lesions occupying the glottic space (17.6%), subjects with functional dysphonia (18.2%), and subjects presenting solely signs suggestive of LPR (22.6%). Using the validated RSI threshold, 33.9% of participants presented an RSI total score >13, suggestive of LPR. RESULTS: Subjects with a suspected diagnosis of LPR at videolaryngostroboscopy presented a mean RSI significantly higher than other subgroups (p < 0.001). Moreover, the SVHI-36 score did not statistically differ between pathological subgroups. A significant positive relationship was observed between RSI and SVHI total score (Spearman's rank correlation coefficient [ρ] = 0.474, p < 0.001). 12 SVHI items (items 1, 2, 4, 5, 6, 7, 12, 20, 24, 25, 26, 30) showed a significant association with RSI pathology classification. Statistical analysis demonstrated for the 12 selected items (SVHI-12-LPR) acceptable specificity (0.691) and sensibility (0.833) for the suspected diagnosis of LPR with a cut-off of 15. CONCLUSIONS: From the SVHI-36, 12 items were extracted that correlated with the specific impact that LPR has on the singer's voice (SVHI-12-LPR), as evaluated by RSI and videolaryngostroboscopy. Such questionnaire represents a new tool that could be applied to singers with symptoms suggestive of LPR to select which patients would benefit from a further phoniatric and videolaryngostroboscopic evaluation.

Psychopathological aspects of dysphagia: a systematic review on correlations with eating disorders and other psychiatric conditions.

BACKGROUND: The effect of psychopathology on swallowing ability tends to be an overlooked issue in the assessment of dysphagic patients, possibly overshadowed by the given prominence to organic pathologies and the difficulties on the management of these patients. In addition, it should also be kept in mind that a great number of psychotropic drugs can affect swallowing adding problematic clinical issues in this area. Despite this, assessment of dysphagia should be considered as an extremely important issue, due to its impact on basic symptomatology, course of illness and quality of life. OBJECTIVE: This review aims to be an overview of relevant data on psychopathology associated with dysphagia and impairment of swallowing function. MATERIALS AND METHODS: An extensive bibliographic search was carried out in different medical databases (PubMed and Psycharticles) to comprehensively identify the most relevant publications available on dysphagia in eating disorders published until December 2020, according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) method. Research articles, either theoretical or empirical-based, published in peer-reviewed journals and in English language, were included. Case reports were also considered in the analysis when it was appropriate for completeness purposes. Titles and abstracts were reviewed according to the eligibility criteria. RESULTS: In total, 260 published studies were identified and 40 were finally selected after removal of duplicates and relevance. Primarily we investigated the correlation between dysphagia and eating disorders, analysing the complex relationship between the two conditions. Then we provided an overview of the assessment of dysphagic symptoms in other psychiatric syndromes. LIMITS: No exclusion criteria or statistical methods were applied nor was an assessment of study-level or outcome-level bias applicable for our purpose. The topic is vast and research bias could not be excluded; moreover, data available are heterogeneous and lacking systematic approach. CONCLUSIONS: With this review, the authors want to provide an overview of the most considerable and clinically useful information about the topic, focusing on some key points to disentangle psychiatric components from the complexity of patient with dysphagia. It should be a relevant concern for all clinicians and should be always thoroughly assessed, considered its frequency in clinical practice and its implications in every kind of patients' morbidity, mortality and quality of life. Special attention should be paid to mentally ill patients, who might display complex and multiple comorbidities, as well as consequences of abnormal eating behaviours, occasionally exacerbated by psychotropic medications. More systematic studies are needed, while it seems clear that a multidisciplinary approach is pivotal in the assessment and management of dysphagic patients. LEVEL OF EVIDENCE: Level I (evidence obtained from at least one properly designed randomized controlled trials; systematic reviews and meta-analyses; experimental studies).

Complications during Fiberoptic Endoscopic Evaluation of Swallowing in 5,680 Examinations.

OBJECTIVE: To evaluate retrospectively the incidence of complications during fiberoptic endoscopic evaluation of swallowing (FEES) in 5,680 examinations. PATIENTS AND METHODS: 5,680 patients were evaluated at the Department of Otorhinolaryngology, Audiology and Phoniatrics of Pisa University Hospital between January 2014 and December 2018, involving both inpatients and outpatients. Most common comorbidities included neurological pathologies such as stroke (11.8%), neurodegenerative diseases (28.9%) and a history of previous head and neck surgery (24.6%). The evaluation was conducted by clinicians with experience in swallowing for a minimum of 10 years with the assistance of one or more speech-language pathologists. RESULTS: In all patients studied the endoscope insertion was tolerated, and it was possible to visualize the pharyngolaryngeal structures. Three subjects refused to undergo the procedure after being informed regarding the protocol and were therefore not included in this study. Most patients reported discomfort (70.1%) and gagging (20.8%). In a minority of patients complications were recorded, such as anterior epistaxis (0.1%), posterior epistaxis (0.02%), vasovagal crises (0.08%) and laryngospasm (0.04%). Especially laryngospasm was recorded in patients affected by amyotrophic lateral sclerosis. Multivariate binary logistic regression showed that discomfort (OR 9.944; CI 7.643-12.937), chronic gastrointestinal diseases (OR 2.003; CI 1.518-2.644), neurodegenerative diseases (OR 1.550; CI 1.302-1.846) and brain tumors (OR 1.577; CI 1.179-2.111) were risk factors associated with minor complications. CONCLUSIONS: FEES proved to be easy to perform, well tolerated by the patients and cost-effective. It can be performed at the patient's bedside, and it is characterized by a low rate of complications. As a matter of fact, normally only discomfort, gagging and/or vomiting are reported. Complications occurred only rarely, such as anterior or posterior epistaxis episodes or vasovagal crises, but these are still easily managed. Exceptionally, more severe complications are reported: adverse drug reactions to substances such as blue dye (methylene blue) and local anesthetics (not used in our protocol), and laryngospasm.

Pattern of dysphagia after swallowing-sparing intensity-modulated radiotherapy (IMRT) of head and neck cancers: results of a mono-institutional prospective study.

BACKGROUND AND PURPOSE: A prospective instrumental assessment of late dysphagia using swallowing organs at risk (SWOARs)-sparing IMRT for nasopharyngeal and oropharyngeal cancers. MATERIALS AND METHODS: Objective instrumental assessment included fiberoptic endoscopic evaluation of swallowing (FEES) and videofluoroscopy (VFS) at baseline, and at 6 and 12 months after treatment. FEES assessed the pharyngeal residue according to the Farneti pooling score (P-score) as follows: 4-5 no dysphagia; 6-7 mild dysphagia; 8-9 moderate dysphagia; 10-11 severe dysphagia. Three different consistencies were tested for the P­score: liquid (L), semisolid (SS), and solid (S). VFS assessed penetration-aspiration according to the Penetration-Aspiration Scale (PAS) and two different consistencies of the bolus were tested: thin liquid barium (L) and paste barium (S). RESULTS: 38 patients were evaluable. There was a significant worsening of the P­score at 6 months both for SS (p = 0.015) and S (p < 0.001), which persisted only for S at 12 months (p < 0.0001). Similarly, there was a significant worsening of the PAS score at 6 and 12 months (p = 0.065 and 0.039, respectively) for the S bolus. Overall, 3-7 and 10-14% aspiration after L and S was observed, respectively. CONCLUSIONS: Promising results using a SWOARs-sparing IMRT technique are reported. Therefore, treatment plans should be optimized for reducing doses to these structures.

HASHIMOTO THYROIDITIS AND VESTIBULAR DYSFUNCTION.

OBJECTIVE: The aim of this review was to analyze the existing literature concerning the relationship between Hashimoto thyroiditis (HT) and vestibular dysfunction. METHODS: We used electronic databases (PubMed, EMBASE, Cochrane Library) to search and collect all published articles about the association between HT and vestibular disorders. RESULTS: Several observational and retrospective studies have postulated a relationship between thyroid autoimmunity and vestibular disorders. In most cases, an appropriate control group was lacking, and the impact of thyroid functional status could not precisely be established. In recent years, two well-designed prospective studies have provided convincing evidence that the association is not random. One article reported that patients with Ménière disease (MD) had a significantly higher prevalence of positive anti-thyroid autoantibody as compared to healthy controls. Moreover, more than half of MD patients had either positive anti-thyroid or non-organ-specific autoantibody titers, compared to less than 30% of both patients with unilateral vestibular paresis without cochlear involvement and healthy controls. Another study found that patients with benign paroxysmal positional vertigo (BPPV) had significantly higher serum thyroid-stimulating hormone and antithyroid autoantibody levels than healthy controls. Additionally, almost one-fifth of euthyroid patients with HT had signs of BPPV. CONCLUSION: The published results indicate that patients with MD or BPPV are potential candidates to also develop HT. Thus, in HT patients, the presence of even slight symptoms or signs potentially related to vestibular lesions should be carefully investigated. ABBREVIATIONS: AITD = autoimmune thyroid disease; BPPV = benign paroxysmal positional vertigo; EH = endolymphatic hydrops; HT = Hashimoto thyroiditis; L-T4 = L-thyroxine; MD = Ménière disease; PS = Pendred syndrome; Tg = thyroglobulin; TPO = thyroid peroxidase; TSH = thyroid-stimulating hormone.

Complications with Fiberoptic Endoscopic Evaluation of Swallowing in 2,820 Examinations.

OBJECTIVE: To perform a retrospective evaluation of the incidence of complications and adverse events during fiberoptic endoscopic evaluation of swallowing (FEES) in 2,820 examinations. PATIENTS AND METHODS: Subjects included in- and outpatients at Pisa University Hospital referred for FEES by other physicians due to dysphagia symptoms. Neurologic diseases were the most commonly diagnosed conditions in the patients tested (48.3%). Informed consent was obtained from all subjects. RESULTS: Our study showed minor side effects (discomfort, occasional gagging and vomiting) and a few complications [three cases of anterior epistaxis (0.1%), one case of posterior epistaxis (0.04%), three cases of vasovagal syncope (0.1%) and two cases of laryngospasm (0.07%)]. These cases of laryngospasm occurred in patients with amyotrophic lateral sclerosis (ALS) and spontaneously resolved after some difficulty. CONCLUSIONS: Our study confirms the published data regarding the safety of FEES and the incidence of complications with this procedure, but also highlights that in neurologic patients with neurodegenerative diseases such as ALS, laryngospasm is more likely to occur as a severe complication. The overall risk of FEES is minimal, but it is recommended that clinicians be well trained in recognising the signs and symptoms of adverse reactions and be ready to take appropriate action if these occur.

Assessment of radiation-induced xerostomia: validation of the Italian version of the xerostomia questionnaire in head and neck cancer patients.

PURPOSE: Xerostomia is the most common acute and late side effect of radiation treatment for head and neck cancer. Affecting taste perception, chewing, swallowing and speech, xerostomia is also the major cause of decreased quality of life. The aims of this study were to validate the Italian translation of the self-reported eight-item xerostomia questionnaire (XQ) and determine its psychometric properties in patients treated with radiotherapy for head and neck cancer. METHODS: An observational cross-sectional study was conducted in the Radiotherapy Unit of the Veneto Institute of Oncology - IOV in Padua. The XQ was translated according to international guidelines and filled out by 102 patients. Construct validity was assessed using principal component analysis, internal consistency using Cronbach's α coefficient and test-retest reliability at 1-month interval using the intraclass correlation coefficient (ICC). Criterion-related validity was evaluated to compare the Italian version of XQ with the European Organization for Research and Treatment of Cancer (EORTC) Core Quality-of-Life Questionnaire (QLQ-C30) and its Head and Neck Cancer Module (QLQ-H&N35). RESULTS: Cronbach's α for the Italian version of XQ was strong at α = 0.93, test-retest reliability was also strong (0.79) and factor analysis confirmed that the questionnaire was one-dimensional. Criterion-related validity was excellent with high association with the EORTC QLQ-H&N35 xerostomia and sticky saliva scales. CONCLUSIONS: The Italian version of XQ has excellent psychometric properties and can be used to evaluate the impact of emerging radiation delivery techniques aiming at preventing xerostomia.

Vestibular disorders in euthyroid patients with Hashimoto's thyroiditis: role of thyroid autoimmunity.

INTRODUCTION: A relationship between vestibular disorders and thyroid autoimmunity independently from thyroid function has been postulated. AIM: To shed more light on the actual relationship between vestibular lesions and Hashimoto's thyroiditis (HT) regardless of thyroid function. METHODS: Forty-seven patients with HT (89·4% F; aged 48·3 ± 12·7 years), 21 with multinodular goitre (MNG; 57·1% F; 54·1 ± 9·8 years) and 30 healthy volunteers (56·7% F; 50·7 ± 13·9 years) were enrolled. Inclusion criteria were the presence of normal thyroid function tests and no clinical history of vestibular dysfunction. Each subject was submitted to complete vestibular evaluation [Caloric Test, Vestibular evoked myogenic potentials (VEMPs), Head Shaking Test (HST)]. RESULTS: 52·2% of HT patients showed an alteration of VEMPs and 44·7% of caloric test (P < 0·0001 for both). None of the MNG patients showed any vestibular alteration, while one healthy control showed an altered caloric test. A correlation was found between vestibular alterations of HT patients and the degree of serum TPOAb level, not affected by age and serum TSH value. By logistic regression analysis, the absence of thyroid autoimmunity significantly reduced the risk of vestibular alterations: HR 0.19 (95%CI: 0·003-0.25, P = 0·0004) for caloric test; HR 0·07 (95%CI: 0·02-0·425, P < 0·0001) for VEMPs; and HR 0·22 (95%CI: 0·06-0·7, P = 0·01) for HST. CONCLUSION: In euthyroid HT patients, a significant relationship between subclinical vestibular damage and the degree of TPOAb titre was documented. This finding suggests that circulating antithyroid autoantibodies may represent a risk factor for developing vestibular dysfunction. An accurate vestibular evaluation of HT patients with or without symptoms is therefore warranted.

Adaptation and validation of the Italian Singing Voice Handicap Index-10 (SVHI-10-IT).

Objective: The aim of this study was to adapt and validate the Italian version of the singing Voice Handicap Index-10 (SVHI-10-IT). Methods: 99 Italian singers were enrolled in the study. All subjects underwent videolaryngostroboscopic examination and were asked to fill out the self-reported 10-item SVHI-10-IT. Laryngostroboscopic examination was pathological in 56 subjects (study group) (56.6%), while it was normal in the remaining 43 singers (control group) (43.4%). Dimensionality, test retest and internal validity for SVHI-10-IT were performed. Videolaryngostroboscopy was used as gold-standard for external validity. Results: The items of SVHI-10-IT were uni-dimensional and Cronbach's α was 0.853 (95% CI = 0.805-0.892). High and comparable area under curve (AUC:0.93 95% CI = 0.88-0.98) values indicate a good ability of the scale to distinguish between the study and control groups. Based on balanced sensitivity (Se = 83.9%) and specificity (Sp = 86.0%), the optimal cut-off score for a singer's perceived voice handicap was 12. Conclusions: The SVHI-10-IT is a reliable and valid instrument to evaluate the self-reported singing voice handicap among singers. It can also be used as a quick screening tool since a score higher than 12 is indicative of a problematic voice as perceived by singers.

Dysphagia in Parkinson's disease: Pharyngeal manometry and fiberoptic endoscopic evaluation.

OBJECTIVE: Dysphagia is a common symptom in Parkinson's disease (PD) and it represents a negative prognostic factor because of its complications. This study is to evaluate pharyngeal dysphagia for boluses of various consistencies with Fiberoptic Endoscopic Evaluation of Swallowing (FEES) and Pharyngeal High-Resolution Manometry (PHRM) in a group of PD patients, making a comparison between the information provided by the two exams. METHODS: Group of 20 patients affected by PD was selected and initially subjected to a qualitative evaluation of the swallowing performing FEES. Subsequently, they were evaluated by PHRM to identify quantitative measures associated with pressures expressed by pharyngeal organs during swallowing. Values obtained in the study group were compared with those recorded in a group of 20 healthy subjects. RESULTS: Study showed that Pmax (the maximum pressure elicited by the single pharyngeal muscle structures involved in swallowing) was significantly lower than the control group (p<0.05) for all the boluses and consistency tested, in particular for the Tongue base and the Cricopharyngeal muscle. Pmean pre-swallowing pressure (represents the mean value of a contraction in which basal and maximal pressure where normally calculated) was significantly higher compared to normal subjects for the Tongue base and the Cricopharyngeal muscle (p<0.05). Mean intra-swallowing pressure was higher for the Velopharynx and the Cricopharyngeal muscle, but lower for the tongue base. Pmax and Pmean at PHRM were altered independently to the degree of dysphagia detected at FEES, and they did not correlate either with the location of the residue or with the type of bolus. Images displayed at the FEES, found the corresponding biomechanical explanations in the PHRM, which also allowed us to quantify the extent of the dysfunction, through the calculation of the pressures generated in the various structures studied. CONCLUSION: PHRM is particularly useful in the early detection of dysphagia, when FEES may still show no evidence of abnormal swallowing.

Reflux Symptom Index (RSI) and Singing Voice Handicap Index (SVHI) in Singing Students: A Pilot Study.

OBJECTIVE: To correlate, RSI with SVHI, in a group of singing students, by means of a specific anamnestic questionnaire which analyzes the physical, social, emotional, and economic impacts of voice problems on their lives. This study is a cross-sectional single-center observational study. METHODS: Forty-two modern singing students (26F/16M; average age: 24.9 ± 5.7; range: 16-46 years old) were recruited. A self-assessment of the singing-voice (SVHI) and of reflux symptom (RSI) was performed. RESULTS: Using the validated RSI threshold, 31% of participants were classified as RSI greater than 13 as an indication of suspected LPR. Classifying the SVHI score as proposed in the recent literature (cutoff of 20.35) our sample was a voice disorders prevalence of 71.4%. There was no significant positive or negative relationship between RSI and SVHI total score (rho = 0.238, P = 0.13). Instead, by considering the relationship between the individual items of the two questionnaires, it is highlighted that the item 1 of SVHI was significantly correlated with most of the RSI items (P = 0.0001-0.006). In the same vein, the item 5 of SVHI was correlated to hoarseness and coughing (P = 0.005-0.006). The item 20 of SVHI was significantly correlated with hoarseness, excess mucus in the throat or postnasal drip and with the pharyngeal Globus sensation (P = 0.001-0.005). By aggregating the SVHI item response as a positive response (2-4) versus a negative response (0 or 1) between "RSI pathology classification," a significant association was observed for SVHI item 1 (P < 0.021), item 5 (P < 0.006), item 20 (P < 0.042), item 24 (P < 0.044) item 25 (P < 0.047). These associations were confirmed by univariate binary logistic. Multivariate binary logistic regression confirms that SVHI Item 1, Item 5 were more associated with RSI positive. Based on results, we propose a questionnaire that combines the most relevant SVHI items correlated to LPRD (SVHI-10-LPRD questionnaire). Cronbach's alpha coefficient for the 10 items selected was 0.87; item-total correlation coefficients for each item were in the range of 0.461 to 0.670. CONCLUSIONS: This pilot study shows that, in case of significant RSI for LPR, it is possible to observe a significant association with some symptoms described in SVHI. These results underline that the association of the RSI and SVHI questionnaires administered to singers and singing students, can represent a simple screening to reveal possible alterations of the singing voice correlate to LPR. Moreover, we propose a Singing Voice Handicap Index correlated to LPR (SVHI-10-LPRD). It will be necessary to increase the sample of subjects in the study to confirm these preliminary data.

Evaluation of the Electroglottographic Signal Variability in Organic and Functional Dysphonia.

OBJECTIVES: To confirm the data reported in our previous studies on the analysis of the variability of the electroglottographic signal in the pathological voice; to evaluate possible differences in variability between organic and functional pathologies; to identify any distinctive/typical EGG patterns for these pathologies. METHODS: One hundred twenty-five subjects were enrolled (36 euphonic and 89 pathological: 24 functional dysphonia, 21 bilateral vocal nodules, 23 unilateral polyps and 21 unilateral cysts). All subjects were studied with videolaryngostroboscopy, spectrographic analysis of voice and electroglottography (EGG). The EGG signal variability was then investigated using amplitude-speed combined analysis, by means of a proprietary software algorithm. Amplitude and Speed variation were expressed as a new parameter, the Variability Index (VI), calculated both for the whole EGG signal recorded (VI-tot) and in each phase of the glottic cycle (VI-Q, absolute value; VI-Q%, percentage value). RESULTS: In the comparison of VI values between pathological and normal groups, VI-tot and VI-Q2% (which corresponds to the final phase of vocal fold contact) were significantly greater in pathological subjects (P= 0.002). The comparison of VI values among subgroups of the various pathologies showed a difference for VI-tot (P< 0.0001) and VI-Q2% (P= 0.001); this difference was more marked in the cysts than in the functional dysphonia. The cut-off values of VI-tot and VI-Q2% were 0.191 and 18.17%, respectively (sensitivity and specificity 65.2% and 66.7% for VI-tot and 84.3% and 77.8% for VI-Q2%). CONCLUSIONS: The variability of the EGG signal investigated through the combined analysis of the amplitude and the speed of vibration using a proprietary algorithm software has proved useful not only to distinguish the normal voice from the pathological voice, but also to characterize which phases are more altered in the various voice pathologies studied, both functional and organic. Furthermore, the analysis of the VI parameter allowed to propose cut-off values characterized by a good sensitivity and specificity to discriminate dysphonia from the euphonic voice. Larger groups of patients will be needed to confirm these results.

Respiratory retraining therapy in long-term treatment of paradoxical vocal fold dysfunction.

OBJECTIVES: Paradoxical vocal fold dysfunction (PVFD) is a disorder in the larynx featuring involuntary adduction of the vocal folds during the inspiratory phase of breathing. The symptoms include acute episodes of dyspnea and bouts of coughing. To date, there is no universally acknowledged treatment for PVFD, though respiratory retraining therapy is the treatment of choice. AIMS: The purpose of this work was to evaluate the results of long-term respiratory retraining therapy in cases of PVFD. PATIENTS AND METHODS: We treated 20 patients with PVFD for 2 years: 10 subjects were submitted to a cycle of respiratory retraining therapy every 12 months (receiving a total of 3 cycles) while 10 were given a cycle every 3 months (for a total of 9 cycles) no matter what their clinical conditions were. RESULTS: The results show that long-term respiratory retraining is particularly efficacious if the cycles of treatment are repeated, no matter what clinical conditions are present. In fact, when only one cycle of retraining treatment is given a year, there is initial improvement followed by progressive worsening. CONCLUSIONS: Long-term respiratory rehabilitation is effective, especially if the treatment is given at least once every 3 months.

Sex hormone receptors in vocal fold tissue: a theory about the influence of sex hormones in the larynx.

OBJECTIVE: The larynx is considered a secondary sexual organ. To demonstrate that sex hormones can directly influence laryngeal function, specific receptors in the vocal cord must be identified. MATERIALS AND METHODS: We searched for estrogen, progesterone and androgen receptors, using an immunohistochemical method, in normal human vocal cords (from 3 cadavers) and in samples of healthy vocal cords and of laryngeal carcinomas from 15 live subjects. Breast and prostate carcinoma were used as controls. RESULTS: In all the normal samples tested, the results were negative; there was only a nonspecific cytoplasmatic response in the subepithelial glands (false positives). In the neoplastic tissue, 2 samples had a weak nuclear focal positivity for estrogen and progesterone receptors; all 15 subjects studied were negative for androgen receptors. CONCLUSIONS: Since our data show that sex hormone receptors are absent in the vocal cords, other theories must be considered to explain the fact that hormones influence the quality of the voice. This study discusses the possibility that the changes of voice according to gender and throughout life might be linked with a different expression of some growth factors in the laryngeal tissue and that this expression might in turn be influenced by hormonal variations.

Elevated antithyroid peroxidase and antinuclear autoantibody titers in Ménière's disease patients: more than a chance association?

OBJECTIVE/HYPOTHESIS: The aim of this prospective study is to evaluate the possible association between Ménière's disease (MD) and autoantibodies. METHODS: Fifty-five patients with definite MD (51 unilateral and 4 bilateral) were matched with 55 patients with unilateral vestibular paresis without cochlear involvement and 55 healthy subjects. Blood samples were collected from all study subjects for the determination of serum TSH, free triiodothyronine, free thyroxine, anti-TSH receptor antibody, antithyroperoxidase antibody, antithyroglobulin antibody and of antibodies to non-organ-specific antigens, namely antinuclear antibodies, antibodies to extractable nuclear antigens and antineutrophilic cytoplasmic antibodies. RESULTS: Thirty-three subjects (60%) of the MD group had 1 or more elevated serum autoantibody levels, both organ and non-organ specific; 16 patients (29.1%) with unilateral vestibular paresis had 1 or more elevated serum autoantibody levels, while 13 healthy subjects (23.6%) had 1 or more elevated serum autoantibody levels. CONCLUSIONS: Based on our data we speculate that there is a more than a chance association between MD and 'autoimmunity', thus suggesting a hypothetical role of the immune system in MD pathogenesis. In other words, a pathogenetic role of an 'immune dysregulation' in MD patients can be hypothesized.

Expression of 3-nitrotyrosine, a marker for peroxynitrite, in nasal polyps of nonatopic patients.

BACKGROUND: Several works have reported that nitric oxide and free oxygen radicals are up-regulated in nasal polyposis. This study aimed to assess the distribution of peroxynitrite in nasal polyps from nonatopic patients. Occurrence of peroxynitrite also was analyzed in relation with eosinophil infiltration and epithelial alterations. MATERIAL/METHODS: Hematoxylin and eosin staining was used for histologic study. Peroxynitrite was assessed by 3-nitrotyrosine immunohistochemistry. Quantitative evaluation was done by measuring the total number of eosinophils, the number of 3-nitrotyrosine-positive eosinophils, and the extension of the various epithelial alterations. RESULTS: Hematoxylin and eosin staining showed that the nasal polyp epithelium is characterized by progressive disruption or squamous metaplasia. In both cases, infiltrating eosinophils were found in the epithelium and lamina propria. The regions featuring epithelial disruption exhibited 3-nitrotyrosine immunostaining in eosinophils and epithelial cells; hematoxylin-and-eosin - stained eosinophils and 3-nitrotyrosine - positive eosinophils showed conspicuous variations in number. Within the regions featuring squamous metaplasia, 3-nitrotyrosine-positive eosinophils were rarely found, and the epithelium exhibited 3-nitrotyrosine only in the superficial cells. In these regions, hematoxylin-eosin - stained eosinophils showed slight variations in number. CONCLUSIONS: Peroxynitrite plays a pivotal role in the pathophysiology of nasal polyps. In fact, strong expression of peroxynitrite is associated with epithelial disruption, while poor expression of peroxynitrite is associated with squamous metaplasia. Peroxynitrite could influence afflux of eosinophils in the nasal mucosa; moreover, the total number of eosinophils is not critical in generating alterations of nasal polyp mucosa.

Assessment and Diagnostic Accuracy Evaluation of the Reflux Symptom Index (RSI) Scale: Psychometric Properties using Optimal Scaling Techniques.

OBJECTIVES: To investigate the psychometric properties of the reflux symptom index (RSI) as short screening approach for the diagnostic of laryngopharyngeal reflux (LPR) in patients with confirmed diagnosed regarding the 24-hour multichannel intraluminal impedance-pH monitoring (MII-pH). METHODS: From January 2017 to December 2018, 56 patients with LPR symptoms and 71 healthy individuals (control group) were prospectively enrolled. The LPR diagnosis was confirmed through MII-pH results. All subjects (n = 127) fulfilled RSI and the Reflux Finding Score (RFS) was performed through flexible fiberoptic endoscopy. The sensitivity and the specificity of RSI was assessed by ROC (Receiver Operating Characteristic) analysis. RESULTS: A total of 15 LPR patients (26.8%) of the clinical group met MII-pH diagnostic criteria. Among subjects classified as positive for MII- pH diagnoses, RSI and RFS mean scores were respectively 20 (SD ± 10.5) and 7.1 (SD ± 2.5), values not significantly different compared to the negative MII-pH group. The metric analysis of the items led to the realization of a binary recoding of the score. Both versions had similar psychometric properties, α was 0.840 for RSI original version and 0.836 for RSI binary version. High and comparable area under curve (AUC) values indicate a good ability of both scales to discriminate between individuals with and without LPR pathology diagnosis. Based on balanced sensitivity and specificity, the optimal cut-off scores for LPR pathology were ≥ 5 for RSI binary version and ≥ 15 for RSI original version. Both version overestimated LPR prevalence. The original version had more sensitivity and the RSI Binary version had more specificity. CONCLUSIONS: It would be necessary to think about modifying the original RSI in order to improve its sensitivity and specificity (RSI binary version, adding or changing some items), or to introduce new scores in order to better frame the probably affected of LPR patient.

Endoscopic and Phoniatric Evaluation in Singing Students.

OBJECTIVES: In To analyze laryngostroboscopic findings and ENT/phoniatric examination results in a group of singing students and in a control group of non-singing subjects to emphasize the importance of ENT/phoniatric examination and of laryngostroboscopy before taking up singing. METHODS: 56 singing students and 60 healthy euphonic non-singer volunteers were recruited. In each subject a perceptual assessment and a self-assessment (VHI) of the voice were performed. The singing students filled out the Singing-VHI. All subjects underwent flexible fiberoptic endoscopy and laryngostroboscopy. All subjects were evaluated through the Reflux Symptom Index (RSI) and the Reflux Finding Score (RFS). RESULTS: At laryngostroboscopy, 60.7% of students presented pathological findings, versus 20% of controls (P < 0.0001). Incomplete glottic closure (35.7% vs. 13.3%), supraglottic hypertonus (16.1% vs. 5%), organic lesions (bilateral nodules, cysts, sulcus vergeture) (17.9% vs. 3.3%), posterior erythema (16.1% vs. 5%) and laryngeal edema (14.3% vs 3.3%) were more frequent in the students. The most common symptoms in singers were phonasthenia (37.5 % vs 6.7%; P = 0.0001) and mucus sensation (17.9% vs. 5%, P = 0.03). S-VHI showed higher values in students with pathological laryngostroboscopy (P < 0.0001). Finally, average RSI and RFS were higher in students. CONCLUSIONS: Due to the high percentage of organic and functional voice disorders in singing students, it would be desirable that every subject who is going to start singing underwent an ENT/phoniatric investigation with videostrobolaryngoscopy to ascertain vocal folds healthy condition.

Dysphagia in Amyotrophic Lateral Sclerosis: Relationships between disease progression and Fiberoptic Endoscopic Evaluation of Swallowing.

OBJECTIVE: Our aim was to evaluate the relationship between the disease severity of Amyotrophic Lateral Sclerosis (ALS) and the following parameters of Fiberoptic Endoscopic Evaluation of Swallowing (FEES): premature spillage, post-swallowing residue and aspiration. METHODS: We studied 202 patients (95 women and 107 men) with ALS; of these, 136 had spinal and 66 had bulbar onset. They were analyzed according to the Amyotrophic Lateral Sclerosis Functioning Rating Scale (ALSFRS) and the b-ALSFRS subscale (bulbar scale). All subjects underwent FEES. Post-swallowing residue was classified into four classes (0-3); premature spillage and aspiration were considered either present or absent. RESULTS: Spearman's correlation test showed a highly significant correlation (p<0.0001) between the value of ALSFRS and b-ALSFRS and the FEES parameters as the following: disease severity and dysphagia severity are closely related, both in spinal and bulbar onset, no matter what bolus texture was used. Spearman's Rho was more significant for post-swallowing residue, ≤-0.500 with all three consistencies (p<0.0001) in spinal onset and -0.520 only with liquid bolus (p<0.0001) in bulbar onset. Independent T-Test revealed a significant difference (p<0.0001) between the mean ALSFRS and b-ALSFRS scores and the presence/absence of aspiration. For the premature spillage in spinal onset (ALSFRS), we found a statistically significant difference for all three bolus textures (p<0.0001). Analysis of variance for the post-swallowing residue in spinal onset (ALSFRS) revealed a statistically significant difference (p<0.0001) for most of the comparisons between groups for all three textures. For the premature spillage in bulbar onset (b-ALSFRS), we found a statistically significant difference for all three textures (p<0.0001). Analysis of variance for the post-swallowing residue in bulbar onset (b-ALSFRS) showed a statistically significant difference (p<0.0001) for most of the comparisons between groups for all three textures. Kruskal-Wallis test showed a highly significant association between the classes of severity in bulbar forms and all the FEES parameters, no matter what type of bolus was administered (p<0.0001), whereas a significant correlation in spinal forms only for post-swallowing residue with solid (p=0.026) and semisolid (p=0.031) boluses. CONCLUSION: There is a highly significant relationship as the following between the FEES parameters and the disease severity assessed via ALSFRS and b-ALSFRS: classes of greater severity entail a greater deterioration of FEES parameters. FEES can be considered a good indicator of the dysphagia severity and a useful test for the follow-up of dysphagia in patients with ALS, whether of spinal or bulbar onset.

The role of 99mTc-tetrofosmin scintigraphy for staging patients with laryngeal cancer.

Diagnosis and staging of laryngeal cancer is currently based on physical examination, endoscopy, and imaging techniques such as computed tomography (CT) and/or magnetic resonance (MR) and histology. While imaging techniques have a pivotal role for defining the size of the primary tumor, they are less accurate for defining metastatic involvement of regional lymph nodes, especially if lymph nodes are smaller than 10-15 mm. The aim of this study was to comparatively assess the relevance of (99m)Tc-tetrofosmin scintigraphy for the staging of laryngeal tumors versus the CT scan. We evaluated the sensitivity of imaging with (99m)Tc-tetrofosmin in 28 consecutively enrolled patients with squamous cell laryngeal carcinoma. Total-body scintigraphy with 99mTc-tetrofosmin was performed preoperatively, and the results were compared to CT images of the neck and mediastinum. CT and (99m)Tc-tetrofosmin scintigraphy were equally sensitive (96%) in identifying the primary tumor. While CT was more sensitive for detecting metastatic lymph nodes (100% versus 50%), (99m)Tc-tetrofosmin scintigraphy was more specific (100% versus 56%; p < 0.04). The overall diagnostic capabilities of the two techniques for detecting lymph node metastases were comparable (Youden Index: J = 0.56 for CT and J = 0.50 for (99m)Tc-tetrofosmin scintigraphy). (99m)Tc-tetrofosmin scintigraphy is a useful complement to CT for staging laryngeal tumors, especially for detecting metastatic lymph nodes and distant metastases.