Medicare Restriction of Telehealth Speech Services Negatively Impacts Patient Care.

OBJECTIVE: Ample literature shows voice and swallowing therapy, in-person or virtual, to be essential for Otolaryngology and Speech-Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital-based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy. STUDY DESIGN: Prospective cohort. SETTING: Tertiary laryngology center. METHODS: Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in-person, teletherapy with cash self-payment ($165-282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test. RESULTS: Fifty-three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in-person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self-pay. 67% of patients that canceled telehealth care cited distance from in-person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P = .034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P = .007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P = .12). CONCLUSION: Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk.

Predictors of Voice Therapy Attendance in an Interdisciplinary Care Model.

OBJECTIVES/HYPOTHESIS: The purpose of this study is to elucidate factors associated with voice therapy attendance within the interdisciplinary care model. STUDY DESIGN: This was a retrospective review. METHODS: Patients referred for voice therapy following interdisciplinary evaluation involving speech language pathology and laryngology were included. Independent variables were (1) duration between interdisciplinary voice evaluation and first voice therapy session, (2) plan of care determined at the time of evaluation, (3) mode of voice therapy delivery, and (4) stimulability for improvement during evaluation. Voice therapy attendance was measured as (1) attendance to the first voice therapy session and (2) overall voice therapy attendance. RESULTS: Of 272 patients referred for voice therapy, 69.12% attended the first session, 17.28% canceled/no-showed (C/NS), and 13.6% did not schedule the first session. Of 235 patients who scheduled voice therapy, 48.94% attended all their scheduled sessions, and 51.06% C/NS at least one session. Patients with a plan of care including voice therapy + surgery were 86% less likely (risk ratio [RR] = 0.14, P = 0.0014) to C/NS any of their voice therapy sessions. In contrast, patients with plan of care including voice therapy + medication were more likely to C/NS at least one voice therapy session (RR = 1.27, P = 0.1419), although this finding was not significant. No other covariates had a significant impact on voice therapy initiation or overall attendance. CONCLUSIONS: This study provides further support for the positive impact of interdisciplinary evaluation on voice therapy initiation. However, once voice therapy is initiated, overall C/NS rates are persistently high, consistent with previous investigations of voice therapy dropout. Our findings suggest that plan of care determined at the time of evaluation may have an impact on voice therapy attendance.

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

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

Gender-Affirming Voice Surgery: Considerations for Surgical Intervention.

The purpose of this article is to provide an overview of the current state and available evidence surrounding surgical voice care for the transgender and/or gender expansive population. The term "gender expansive" has been proposed as an inclusive term to classify those who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience. We aim to review indications and candidacy for surgery, surgical procedure options for altering vocal pitch, and typical postoperative expectations. The role of voice therapy and considerations for perioperative care will also be discussed.

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

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

Longitudinal Analysis of Swallowing Displacement Kinematics After Oropharyngeal Cancer Treatment.

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

Using Item-Response Theory to Improve Interpretation of the Trans Woman Voice Questionnaire.

OBJECTIVE: The Trans Woman Voice Questionnaire (TWVQ) is commonly used to quantify self-perceptions of voice for trans women seeking gender-affirming voice care, but the interpretation of TWVQ scores remains challenging. The objective of this study was to use item-response theory (IRT) to evaluate the relationship between TWVQ items and persons on a common scale and identify improvements to increase the meaningfulness of TWVQ scores. METHODS: A retrospective review of TWVQ scores from trans women patients between 2018-2020 was performed. Rasch-family models were used to generate item-person maps positioning respondent location and item difficulty estimates on a logit scale, which was then converted into a scaled score using linear transformations. RESULTS: TWVQ responses from 86 patients were analyzed. Initial item-person maps demonstrated that the middle response categories ("sometimes" and "often") performed inconsistently across items (poor threshold banding); interpretability improved when these ratings were scored as one category. The models were rerun using revised scoring, which retained high reliability (0.93) and supported a unidimensional construct. Updated item-person maps revealed four scaled score zones (≤54, >54 to ≤101, >101 to ≤140, and >140) that each corresponded to an increasing pattern of item thresholds (probability of selecting one response category vs. others). These ranges can be interpreted as minimal, low, moderate, and high, respectively. CONCLUSIONS: Empiric data from Rasch analysis supports new interval scoring for the TWVQ that advances the clinical and research utility of the instrument and lays the foundation for future improvements in clinical care and outcomes assessment. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1197-1204, 2023.

An investigation of the cutoff point of the English version of speech handicap index in the American total laryngectomees.

OBJECTIVES: The present article aims to identify the optimal cutoff score and the diagnostic accuracy for the English version of Speech Handicap Index (SHI) to screen out individuals with and without speech disorders in daily life. MATERIALS AND METHODS: In this cross-sectional cohort study, a volunteer sample of 104 adult patients after total laryngectomy and 99 healthy controls in the United States completed the English version of SHI online questionnaire. Sensitivity and specificity were computed for a range of cut-off values using the Receiving Operating Characteristics (ROC) analysis to establish an optimal cutoff point for the SHI. Other measures of diagnostic accuracy, such as likelihood ratios (LR), positive predictive values (PPV), and negative predictive values (NPV) were also computed. RESULTS: Patients after total laryngectomy obtained a higher score than the healthy controls on the mean scores of SHI. According to the ROC analysis, an optimal cutoff score of 17 points determined by Youden index was identified on the head and neck cancer population with a sensitivity of 92.31%, specificity of 92.31%, PPV of 90.60%, NPV of 91.75%, LR + of 9.14, and LR- of 0.09. CONCLUSIONS: The cutoff score of the English version of SHI applied on the English-speaking population in the United States demonstrated promising diagnostic accuracy.

Creation and Implementation of the UCSF Laryngeal Symptom Diary for Trial Vocal Fold Injection.

OBJECTIVES: Patient recollection of their trial vocal fold injection outcomes is crucial in determining future treatment. This study aims to assess a new clinical tool, the UCSF Laryngeal Symptom Diary, for its ease of use, clinical value in patient symptom tracking, and utility for long-term decision-making following trial vocal fold injection. MATERIALS AND METHODS: In this prospective cohort study, consecutive patients undergoing trial vocal fold injection between June 2019 and January 2020 completed the UCSF Laryngeal Symptom Diary. Patients rated standardized and customized laryngeal symptoms weekly. Upon follow-up, a survey pertaining to the diary was completed by both the patient and treating laryngologist. RESULTS: A total of 29 patients opted to participate and were provided with the UCSF Laryngeal Symptom Diary. The diary was returned by 82.3% (n = 24/29) of patients. Mean time to follow up was 5.98 weeks. Survey participation rate was 93.1% (n = 27/29). From the patients' perspective, 66.7% (n = 18/27) found the diary useful in following their symptom evolution. Treating laryngeal surgeon noted excellent concordance between diary entries and patient's overall injection benefit (91.7%, n = 22/24). The diary was useful in clinician-recommendation of subsequent treatment options in 70.8% (n = 17/24) of patients. CONCLUSION: The UCSF Laryngeal Symptom Diary is a patient friendly clinical tool for trial vocal fold injection that facilitates patient tracking of symptom evolution and helps guide treating clinicians in subsequent treatment planning.

Implementation of Telemedicine in a Laryngology Practice During the COVID-19 Pandemic: Lessons Learned, Experiences Shared.

OBJECTIVES: The novel coronavirus disease 2019 has posed significant limitations and barriers to providing in-person healthcare. We aim to provide a summary of learned experiences and important considerations for implementing and offering telehealth to provide laryngology subspecialty care during the COVID-19 pandemic and thereafter. MATERIALS AND METHODS: Four laryngologists and a voice-specialized speech-language pathologist from a tertiary-care academic Voice and Swallowing Center were engaged in a structured group consensus conference. Participants shared input, experiences, and practice patterns employed via telemedicine (via telephone or video-communication) during the early COVID-19 era. RESULTS: Key identified areas of consideration when offering telemedicine included (1) how to set up and structure a telemedicine visit and maintain patient confidentiality, (2) patient examination and treatment initiation, (3) optimization of the tele-visit, (4) limitations and recognition of when a tele-visit is insufficient for patient care needs, (5) billing/reimbursement considerations. Group consensus for the aforementioned topics is summarized and discussed. CONCLUSION: During the COVID-19 pandemic, a telemedicine model can be effectively employed to improve patient access to subspecialty laryngology care, including a multidisciplinary care approach, with initiation of various therapeutic interventions. A major limitation given the preclusion of in-person assessment is the lack of access to laryngoscopy, which can likely be delayed safely in the majority of individuals.

Observations and Considerations for Implementing Remote Acoustic Voice Recording and Analysis in Clinical Practice.

OBJECTIVES/HYPOTHESIS: Remote voice recording and acoustic analysis allow for comprehensive voice assessment and outcome tracking without the requirements of travel to the clinic, in-person visit, or expensive equipment. This paper delineates the process and considerations for implementing remote voice recording and acoustic analysis in a high-volume university voice clinic. STUDY DESIGN: Clinical Focus. METHODS: Acoustic voice recordings were attempted on 108 unique patients over a 6-month period using a remote voice recording phone application. Development of the clinical process including determining normative data in which to compare acoustic results, clinician training, and clinical application is described. The treating Speech Language Pathologists (SLPs) were surveyed 2 months after implementation to assess ease of application, identify challenges and assess implementation of potential solutions. RESULTS: Of 108 unique patients, 83 patients were successful in completing the process of synchronous remote acoustic voice recording in conjunction with their SLP clinician. The process of downloading the application, setting up, and obtaining voice recordings was most commonly 10-20 minutes according to the 8 SLPs surveyed. Challenges and helpful techniques were identified. CONCLUSIONS: Remote acoustic voice recordings have allowed SLPs to continue to complete a comprehensive voice evaluation in a telepractice model. Given emerging knowledge about the viability of remote voice recordings, the success in obtaining acoustic data remotely, and the accessibility of a low-cost app for SLPs makes remote voice recordings a viable option to facilitate remote clinical care and research investigation.

Cultural Adaptation and Validation of Speech Handicap Index: A Scoping Review.

Objectives The Speech Handicap Index (SHI) is a self-reported speech-related quality of life assessment originally developed for measuring the psychosocial speech impact in patients with oral or pharyngeal cancer. This review article provides a scoping review of the literature on the validated SHI, with the purpose of identifying and documenting available studies and procedures for the cultural adaption and validation of SHI. Method Prime databases including PubMed, EMBASE, and Google Scholar were searched for journal publications reporting validation of the SHI. Reviews and reference cross-checking were performed using a priori selection criteria. A body of literature related to SHI was scoped and publication quality was categorized independently by two investigators. After applying all the screening criteria, articles that met the eligibility criteria were included in the review. Results The scoping review yielded 10 articles that met the inclusion criteria presenting the SHI in eight different languages, including Dutch, U.K. English, French, Korean, Simplified Chinese (Mandarin), Lithuanian, Italian, and European Portuguese. All of them reported validity, reliability, and translation method. Discussion and Conclusions High reliability and validity between various language versions of the SHI were identified. The current scoping review provides a useful summary and could be a helpful precursor to a systematic review on SHI in the future. Supplemental Material https://doi.org/10.23641/asha.14082704.

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.

Examining the Relationships Between Lingual Strength, Perihyoid Strength, and Swallowing Kinematics in Dysphagic Adults: A Retrospective Cross-Sectional Analysis.

Purpose The aim of this study was to examine the relationships of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics and swallowing safety in a heterogenous group of dysphagic adults. Method A retrospective analysis was completed of videofluoroscopic swallow studies of consecutive dysphagic outpatient adults presenting to a tertiary swallowing center from January 1, 2015, to December 31, 2017. Videofluoroscopic swallow study records were included if containing displacement swallowing kinematics of a 20-ml single liquid swallow and clinical measures of anterior (L-MIPA) or posterior (L-MIPP) lingual maximal isometric press, saliva mean swallowing pressures (S-MSP), and/or open mouth-maximal isometric press (OM-MIP). Regression analyses were used to examine the relationships between clinical measures of lingual (L-MIPA, L-MIPP, S-MSP) and perihyoid (OM-MIP) strength and displacement swallowing kinematics, and binomial logistic regressions were used to examine the relationships between clinical measures of lingual and perihyoid strength and swallowing safety (Penetration-Aspiration Scale [PAS]). Results Multivariate regressions revealed significant relationships of L-MIPA, L-MIPP, S-MSP, and OM-MIP with group-level changes to the displacement swallowing kinematics. Univariate analyses revealed significant relationships of L-MIPA and L-MIPP with pharyngeal constriction ratio, maximal extent of upper esophageal segment opening, and PAS. Conclusions Weak relationships were identified of clinical measures of lingual and perihyoid strength with displacement swallowing kinematics. These findings suggest that clinical measures of lingual and perihyoid strength do not fully explain impairments in swallowing kinematics across a heterogenous group of dysphagic patients. Weak-to-moderate relationships were identified between clinical measures of lingual strength and PAS, suggesting that they may have value in predicting functional measures of swallowing safety. Further research is needed to examine how findings may differ between specific patient populations.

Laryngology Quality of Life Questionnaire Associations: Towards Reducing Survey Burden.

OBJECTIVES: Outcomes in laryngology focus primarily on patient reported outcome measures (PROMs). The increasing number of questionnaires may lead to survey fatigue. We sought to determine the relationship between the newest questionnaire, Laryngopharyngeal Universal Measure of Perceived Sensation (LUMP), and other laryngology PROMs. STUDY DESIGN: Cross-sectional study. METHODS: Patients undergoing laryngology multidisciplinary evaluation prospectively completed laryngology questionnaires. Average summed scores between standard laryngology PROMs (ie, VHI-10, RSI, DI, CSI, EAT-10) and LUMP were compared. Expert consensus panel identified the most clinically relevant statements which were then compared to LUMP summed scores, in increasingly additive fashion. RESULTS: Four hundred eighty patients (259 female) were assessed. Average age was 57.1 ± 17.7 years. Intraclass correlation coefficient (ICC) for each PROM in comparison to LUMP ranged from moderate to poor correlation: 0.64 (RSI), 0.55 (EAT-10), 0.50 (DI), 0.48 (CSI), and 0.34 (VHI-10). ICC for combinations of the five most clinically relevant individual items ranged from 0.29-0.53. CONCLUSIONS: Patients with self-reported globus had statistically significantly higher scores across all PROMs. RSI had moderate correlation with LUMP, and the five selected expert consensus items demonstrated weaker correlation. While RSI may serve as a moderately selective clinical proxy for the LUMP questionnaire, LUMP remains a validated tool with increased specificity for quantification of globus which may be especially important in the research setting. There is continued question about the need for multiple laryngologic PROMs to evaluate patient complaints, and survey reduction remains an area of interest to decrease respondent fatigue, optimize patient care, and quantify interventional success. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1561-1565, 2021.

Voice and Stroboscopic Characteristics in Transgender Patients Seeking Gender-Affirming Voice Care.

OBJECTIVE: Understanding transgender voice is in nascent stages. This study describes voice characteristics in treatment-seeking trans women by comparing two validated questionnaires-Voice Handicap Index-10 (VHI-10) and Transsexual Voice Questionnaire (TVQMtF )-and reports incidence of abnormal stroboscopy findings and acoustic characteristics. METHODS: Retrospective review of transgender patients presenting to tertiary-care laryngology center between February 2018-February 2019. Mean VHI-10, TVQ, and Singing VHI-10 (SVHI-10) scores; audio-perceptual grade; acoustic measures; and stroboscopy findings were analyzed. VHI-10 and SVHI-10 vs TVQMtF were compared. RESULTS: Sixty-one trans female patients (mean age: 32 ± 11 years) were analyzed. Mean duration since start of transition was 41.5 ± 61 months. Sixty-nine percent presented full-time female in all contexts. Pathologic stroboscopy findings were found in 5%. Mean questionnaire scores were 16 ± 10 (VHI-10), 19 ± 13 (SVHI-10), and 81 ± 22 (TVQMtF ). Correlation between VHI-10 and SVHI-10 versus TVQMtF was weak, R = 0.47 (P = .053) and R = 0.35 (P = .17), respectively. Mean audio-perceptual grade was 0.27 ± 0.15. Mean Cepstral Spectral Index of Dysphonia (CSID, sustained vowel) was 8.5 ± 21.9. Mean Cepstral Peak Prominence (CPP) Fo and CPP Fo SD in rainbow passage were 157.3 ± 16 and 59.4 ± 15.9, respectively. CONCLUSION: Trans women report perceived voice handicap in speaking and singing, which appears separate from gender-related voice/communication concerns. This study is the first to report stroboscopy findings in transgender individuals, with 5% being abnormal. Stroboscopy is encouraged before initiating voice intervention in transgender patients. Preliminary evaluation suggests weak correlation between VHI-10 or SVHI-10 and TVQMtF but requires further investigation. TVQMtF may provide information which more specifically reflects voice concerns of trans women as compared to VHI-10 and SVHI-10. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1071-1077, 2021.

Cortical-Basal Ganglia-Cerebellar Networks in Unilateral Vocal Fold Paralysis: A Pilot Study.

OBJECTIVES/HYPOTHESIS: To evaluate differences in cortical-basal ganglia-cerebellar functional connectivity between treated unilateral vocal fold paralysis (UVFP) and healthy control cohorts using resting-state functional magnetic resonance imaging (RS-fMRI). STUDY DESIGN: Cross-sectional. METHODS: Ten UVFP study patients treated by type I thyroplasty and 12 control subjects underwent RS-fMRI on a 3-Tesla scanner to evaluate differences in functional connectivity of whole-brain networks. Spontaneous RS-fMRI data were collected using a gradient echo planar pulse sequence, preprocessed, and analyzed to compare seed-to-voxel maps between the two cohorts. Seeds were placed in the caudate, putamen, and globus pallidus divisions of the basal ganglia in both hemispheres. Group contrasts were tested for statistical significance using two-tailed unpaired t tests corrected for multiple comparisons with a cluster false discovery rate threshold of P < .05. RESULTS: UVFP patients demonstrated increased connectivity between both caudate nuclei and the precuneus, a node of the default mode network, compared to healthy controls. Both caudate nuclei also showed decreased connectivity with the left cerebellar hemisphere. The putamen and globus pallidus divisions of the basal ganglia were not abnormally connected to other brain structures. CONCLUSIONS: UVFP patients treated by type I thyroplasty exhibited long-term alterations of cortical-basal ganglia-cerebellar networks thought to be important for self-referential voice quality awareness and learning processes that compensate for changes to the paralyzed hemilarynx. This pilot study on relatively small cohorts adds to growing evidence for persistent central nervous system changes in treated UVFP. Replication studies with larger numbers of subjects will be essential to validate and extend findings. LEVEL OF EVIDENCE: 3b Laryngoscope, 130:460-464, 2020.

Open Mouth-Maximal Isometric Press: Development and Norms for Clinical Swallowing Evaluations and Treatment.

Purpose The aims of this study were to (a) describe the development and utility of the Open Mouth-Maximal Isometric Press (OM-MIP), a tool designed for the quantitative assessment of suprahyoid-infrahyoid muscle strength; (b) examine the effects of age and sex on the OM-MIP; and (c) establish age- and sex-based OM-MIP norms. Method Two hundred sixteen healthy male and female volunteers were recruited. Participants performed the OM-MIP, and the maximum of 3 trials that were within 10% of each other was recorded. Rest between each trial was allowed to avoid fatigue. Multiple regression examined the influence of age and sex on the OM-MIP. Descriptive statistics outlined normative OM-MIP values for young adult (aged 18-39 years), middle-aged adult (aged 40-59 years), old adult (aged 60-79 years), and very old adult (aged ≥ 80 years) men and women. Two-way analysis of variance determined if normative data differed significantly between the age and sex groups. Results Age and sex significantly influenced the OM-MIP, although no significant interaction effect was identified. Women had lower mean OM-MIPs when compared with men ( p < .0005), and very old adults had lower mean OM-MIPs when compared with young ( p = .001), middle-aged ( p < .0005), and old ( p = .013) adults. Conclusions This study establishes age- and sex-based OM-MIP norms and outlines its potential utility during clinical swallowing evaluations and treatment. By providing these norms, clinicians can begin to quantitatively measure suprahyoid and infrahyoid strength, individualize resistance training programs to patients' OM-MIP 1 repetition maximum, and track strength changes over time in response to therapeutic interventions.

Vocal motor control and central auditory impairments in unilateral vocal fold paralysis.

OBJECTIVES: To evaluate differences in vocal motor control and central auditory processing between treated unilateral vocal fold paralysis (UVFP) and healthy control cohorts. STUDY DESIGN: Cross-sectional. METHODS: Ten UVFP study patients treated by type I thyroplasty with stable voices were compared to 12 control subjects for vocal motor control using a pitch perturbation response task and central auditory processing performance using a battery of complex sound intelligibility assays that included adverse temporal and noise conditions. Standard clinical evaluations of voice production and peripheral audiometric sensitivity were performed. RESULTS: Vocal motor control was impaired in treated UVFP. The UVFP cohort exhibited a 32.5% reduction in the instantaneous, subconscious compensatory response to pitch feedback perturbation in the interval between 150 ms and 550 ms following onset (P < 0.0001, linear mixed effects model). This impairment cannot simply be ascribed to vocal motor capacity insufficiency in the UVFP cohort because both cohorts demonstrated comparable functional capacity to perform the vocal motor task. The UVFP cohort also showed greater propensity for central auditory processing impairment (P < 0.05), notably for temporal compression and added noise challenges. CONCLUSION: Combined central vocal motor control and auditory processing impairments in treated UVFP highlight reciprocal interdependency of sensory and motor systems. This pilot study suggests that peripheral motor impairment of the larynx can degrade central auditory processing, which in turn may contribute to vocal motor control impairment. A more complete restoration communicative function in UVFP will require deeper understanding of sensory, motor, and sensorimotor aspects of the human communication loop. LEVEL OF EVIDENCE: 3b Laryngoscope, 129:2112-2117, 2019.

Voice therapy associated with a decrease in the reflux symptoms index in patients with voice complaints.

OBJECTIVES/HYPOTHESIS: Patients with muscle tension dysphonia often demonstrate an elevation in Reflux Symptom Index (RSI) and 10-item Voice Handicap Index (VHI-10) scores, and may be erroneously diagnosed with laryngopharyngeal reflux disease. In this study we assessed the effects of voice therapy on RSI and VHI-10 scores in patients with voice complaints not responsive to antireflux medications. STUDY DESIGN: Retrospective cohort study. METHODS: A study of patients was conducted at a single tertiary-care center over 1 year (January 2012-January 2013). Patients were included if they had dysphonia not responsive to proton pump inhibition, did not have neurologic or neoplastic disease, and participated in at least three voice-therapy sessions in the absence of antireflux therapy. Primary analysis assessed change in RSI scores between the initial and follow-up visits with a laryngologist. RESULTS: A total of 18 patients were included (mean age = 49.9 ± 14.5 years, 89% female, 83% with a primary complaint of dysphonia). From initial to follow-up visit, the median RSI score (18.5 [interquartile range {IQR}, 9.5-22.8] vs. 10.5 [IQR, 4.5-14]; P = .02) and median VHI-10 score (25.5 [IQR, 11.3-30.0] vs. 13.5 [IQR, 9.5-20.8]; P = .03) significantly decreased. A significant inverse correlation was found between the number of voice therapy sessions/month and change in RSI score (r = -0.4; P = .05). CONCLUSIONS: In this study of patients with muscle tension dysphonia or vocal hyperfunction not responsive to antireflux therapy, RSI and VHI-10 scores improved following voice therapy. Results suggest that self-reported symptoms typically attributed to laryngopharyngeal reflux disease may actually be secondary to inefficient voice use patterns or anxiety about dysphonia that are responsive to voice therapy. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1169-1173, 2019.