Physiologic and Acoustic Effects of Opera Performance.

INTRODUCTION/HYPOTHESIS: Opera performance is physiological and emotional, and singing performers utilize their larynges in often strenuous ways. Historically, the training of a classical voice has been considered the paragon of healthy singing. However, the natural history of a performing larynx has not been studied systematically. There is paucity of scientific studies to guide practice patterns, particularly with regard to the course and extent of post-performance physiologic and acoustic changes. STUDY DESIGN: A prospective case series was carried out. METHODS: Principal singers in the Houston Grand Opera's 2012-2013 repertory were enlisted, for a total of seven singers. Stroboscopy was performed prior to the start of rehearsals, and at the completion of the opera's run. Data points included erythema, edema, masses or lesions, mucosal waveform, supraglottic posture; acoustic measurements were also performed. RESULTS: There were statistically significant differences (P < 0.05) in the mucosal wave on pre- and postperformance stroboscopic examinations. Acoustical measures did not achieve statistical significance, but there was a trend toward increased harmonic-to-noise ratio in postperformance measures, as well as decreased frequency range and reading F0. Measures of intra- and inter-rater reliability indicated varying levels of intra-rater reliability, and generally poor inter-rater reliability. CONCLUSIONS: This pilot study describes physiologic and acoustic changes that may occur over the course of a series of rehearsals and performances in the operatic larynx. In so doing, it highlights a need for larger studies with increased frequency of serial examinations to study in a systematized way what may be natural reactive changes that occur during performance.

Knowledge, experience, and anxieties of young classical singers in training.

OBJECTIVE/HYPOTHESIS: Young classical singers in training have a wide variety of knowledge about the anatomy and physiology of the voice and vocal pathology and harbor anxiety about treatment of vocal fold disorders. This study aimed to examine differences in knowledge, experience, and anxiety across levels of training at elite conservatories and young artist programs in the United States. STUDY DESIGN: Prospective cohort questionnaire. METHODS: Undergraduate (50), master's (35), and doctoral/young artist (25) singers (n = 110) were given an 80-point questionnaire assessing experience with vocal pathology, otolaryngologists, speech pathologists, and participation in choir or teaching. Participants were asked questions to test their medical knowledge in vocal anatomy, physiology, and care. They were also asked questions about their anxiety about medical visits and vocal pathology and about their habits in the care of their own voices. RESULTS: There was no statistically significant difference in test scores for vocal knowledge across the three levels of training (P = 0.47). Mean scores were just above 50% with standard deviations around 12-13 points. The lowest score was 26% and the highest score was 84%. Doctoral/young artist-level participants were more anxious regarding general office visits to an otolaryngologist compared with undergraduate and master's level participants. There were no other significant differences by level of training regarding anxiety about vocal pathology, scope examinations, or visits to a speech pathologist. There were no significant differences in self-reported levels of knowledge. All groups of young singers expressed marked interest in expanding their knowledge of anatomy and physiology, speech pathology, care of the vocal mechanism, and vocal disorders. CONCLUSIONS: More advanced singers do not have significantly greater knowledge of vocal form and function and are more anxious about visits to otolaryngologists and vocal pathology; a clear majority of singers indicate interest in knowing more. There is thus ample opportunity for innovation in the development of medical curricula in the instruction of young singers and clear interest in more knowledge on their part.

Simple carotid-sparing intensity-modulated radiotherapy technique and preliminary experience for T1-2 glottic cancer.

PURPOSE: To investigate the dosimetry and feasibility of carotid-sparing intensity-modulated radiotherapy (IMRT) for early glottic cancer and to report preliminary clinical experience. METHODS AND MATERIALS: Digital Imaging and Communications in Medicine radiotherapy (DICOM-RT) datasets from 6 T1-2 conventionally treated glottic cancer patients were used to create both conventional IMRT plans. We developed a simplified IMRT planning algorithm with three fields and limited segments. Conventional and IMRT plans were compared using generalized equivalent uniform dose and dose-volume parameters for in-field carotid arteries, target volumes, and organs at risk. We have treated 11 patients with this simplified IMRT technique. RESULTS: Intensity-modulated radiotherapy consistently reduced radiation dose to the carotid arteries (p < 0.05) while maintaining the clinical target volume coverage. With conventional planning, median carotid V35, V50, and V63 were 100%, 100%, and 69.0%, respectively. With IMRT planning these decreased to 2%, 0%, and 0%, respectively (p < 0.01). Radiation planning and treatment times were similar for conventional radiotherapy and IMRT. Treatment results have been excellent thus far. CONCLUSIONS: Intensity-modulated radiotherapy significantly reduced unnecessary radiation dose to the carotid arteries compared with conventional lateral fields while maintaining clinical target volume coverage. Further experience and longer follow-up will be required to demonstrate outcomes for cancer control and carotid artery effects.

Treatment of chronic posterior laryngitis with esomeprazole.

OBJECTIVE: To evaluate the efficacy of acid-suppressive therapy with the proton pump inhibitor esomeprazole on the signs and symptoms of chronic posterior laryngitis (CPL) in patients with suspected reflux laryngitis. STUDY DESIGN: Prospective, multicenter, randomized, parallel-group trial that compared twice-daily esomeprazole 40 mg with placebo for 16 weeks. METHODS: Eligible patients had a history of one or more CPL symptoms (throat clearing, cough, globus, sore throat, or hoarseness) and laryngoscopic signs indicating reflux laryngitis based on CPL index (CPLI) scores measured during a screening laryngoscopy. Patients were randomized to treatment if their 7-day screening diary-card recordings showed a cumulative primary symptom score of 9 or higher and they had 3 or more days with moderately severe symptoms based on a 7-point scale. Efficacy was assessed by changes in symptoms as recorded by patients and investigators and by changes in CPLI scores based on laryngoscopic examinations. RESULTS: The patients' primary CPL symptom at final visit (primary efficacy end point) was resolved in 14.7% (14/95) and 16.0% (8/50) of patients in the esomeprazole and placebo groups, respectively (P=.799). Esomeprazole and placebo were not significantly different for change from baseline to the final visit in mean total CPLI (-1.66+/-2.13 vs. -2.0+/-2.55, respectively; P=.446) or any other secondary efficacy end points based on patient diary card or investigator assessments. CONCLUSION: This study provides no evidence of a therapeutic benefit of treatment with esomeprazole 40 mg twice daily for 16 weeks compared with placebo for signs and symptoms associated with CPL.

Diagnosis of laryngopharyngeal reflux disease with digital imaging.

OBJECTIVE: The study goal was to assess the use of digital laryngeal videostroboscopy (LVS) in the detection of objective improvement of the larynx after 6 weeks of proton pump inhibitor (PPI) therapy and to evaluate a clinical grading scale for findings of laryngopharyngeal reflux disease (LPRD). STUDY DESIGN AND SETTING: We conducted a prospective analysis of digital LVS examinations from a tertiary referral center for laryngology by 3 independent blinded examiners. RESULTS: The mean score on the Laryngopharyngeal Reflux Disease Index for experimental patients was significantly higher than that for control patients (9.50 versus 2.92, P < 0.001), and posttreatment scores were significantly lower than pretreatment scores (7.35 versus 9.50, P < 0.001). Useful items on the grading scale for assessing the presence of LPRD and improvement in LPRD included supraglottic edema and erythema, glottic edema and erythema, and subglottic edema and erythema. Nonuseful items included the presence of pachydermia, granulomas, nodules, leukoplakia, and polyps. CONCLUSION: Objective improvement of signs of LPRD can be detected after 6 weeks of PPI therapy using digital LVS. The Laryngopharyngeal Reflux Disease Index is a useful valid clinical tool for following treatment response to PPI therapy.