The mechanism of action for laryngeal manual therapies: the need for an update.

PURPOSE OF REVIEW: To propose a pathway for expanding the understanding of potential mechanisms of action with laryngeal-based manual therapy (LMT) for muscle tension dysphonia (MTD). This review may help determine if current LMT literature has kept up with advances in the more general manual therapy (MT) findings. RECENT FINDINGS: Studies over the past thirty years, including recently published articles, have confirmed the efficacy of various manual therapy interventions in treating MTD. However, gaps exist between current LMT literature and that being presented in the more general MT field. Instead of viewing peripheral manipulation's influences as a local cause/effect process, the MT literature paints a richer tapestry of centrally mediated impacts. SUMMARY: Evidence from outside the LMT field has introduced a broad tapestry of factors that may contribute to the efficacy of MT, extending beyond the local effects reported in LMT literature. To better understand the effect and mechanism of action touch-based interventions have on a patient's voice and to potentially improve outcomes, it is necessary to broaden investigations to include a broader range of perspectives.

The Minimal Important Difference of Acoustic Voice Quality Index in the Treatment of Voice Disorders.

OBJECTIVES: The acoustic voice quality index (AVQI) is a reliable tool that objectively assesses dysphonia levels using six acoustic parameters. Despite its high criterion-related concurrent validity, diagnostic accuracy, and minimal detectable change derived from test-retest reliability, the minimal important difference (MID) of the AVQI has not been tested before. This study aimed to estimate the MIDs of AVQI for improvement audibly perceived by clinicians and self-reported improvement by patients. METHODS: A retrospective study was conducted on 110 patients who received treatment for voice disorders. Patients completed AVQI and Voice Handicap Index-10 (VHI-10) questionnaires before and after the therapy. The MIDs of the AVQI were estimated using the anchor of either auditory-perceptual judgment of total dysphonia levels by clinicians or the VHI-10 questionnaire by patients. A distribution-based approach was also used to complement the results. RESULTS: First, using the auditory-perceptual anchor, a decrease of 0.95 in the AVQI was estimated as the MID for clinicians' perception, as a result of the receiver operating curve. Then, using the patient-reported anchor, an improvement of 1.36 in the AVQI was estimated as the MID for patients' voice-related disability. The distribution-based approach also ensured the anchor-based results of both the MIDs. CONCLUSIONS: The AVQI is a reliable and valid tool for evaluating voice quality, and a 0.95 decrease in the AVQI represents a meaningful improvement for clinicians' perception, whereas a 1.36 decrease in the AVQI influences patients' self-reported disability. This study contributes to understanding the minimal change necessary for clinicians to make informed decisions and ensure patient satisfaction. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:2805-2811, 2024.

Objective Analysis Of Voice Quality In Patients With Thyroid Pathology.

OBJECTIVE: The goal of this study is to analyze the voice in patients with thyroid pathology through two objective indexes with great diagnostic accuracy. Overall vocal quality was evaluated with the Acoustic Voice Quality Index (AVQI v.03.01) and the breathy voice with the Acoustic Breathiness Index (ABI). DESIGN: Observational case-control study. SETTING: Hospital Universitario Nuestra Señora de Candelaria. PARTICIPANTS: Fifty-eight subjects, 29 controls and 29 thyroidectomy candidates. MAIN OUTCOME MEASURES: All participants with thyroid pathology completed the Spanish version of Voice Handicap Index-10. Also, patient complaints relating to possible laryngeal dysfunction were assessed through closed questions. A sustained vowel and three phonetically balanced sentences were recorded for each subject (118 samples). AVQI v.03.01 and ABI were assessed using the Praat program. Two raters perceptually evaluated each voice sample by using the Grade parameter of GRABS scale. RESULTS: Acoustic analysis shows that 55.17% of subjects present values above the pathological threshold of the AVQI, and 58.62% above that of the ABI. Results of the Student's test comparisons of the AVQI and ABI values between the control group and the thyroid group show significantly higher values of AVQI (t[56]  = -3.85, p < .001) and ABI (t[54.39]  = -4.82, p < .001) in thyroidectomy candidates. CONCLUSION: A mild decrease in vocal quality is part of the symptomatology presented by thyroidectomy candidates.

Non-motor symptoms in spasmodic dysphonia: A case control-study.

OBJECTIVE: Non-motor symptoms (NMS) have been identified in some focal adult-onset dystonia. In the present study we aimed to evaluate the presence of NMS in patients with spasmodic dysphonia (SD), a focal action-induced dystonia that affects intrinsic laryngeal muscle control. METHODS: Seventeen SD patients and 17 control subjects not significantly different in age and sex were evaluated for the presence of NMS. Additionally, voice handicap index (VHI-10), reflux symptom index, neuropsychiatric symptoms and QoL were assessed by validated scales and questionnaires. RESULTS: Patients' group significantly differed from control group in mild depressive symptoms (4.35 ± 3.9 vs. 1.47 ± 2; p=0.01), insomnia (35.3% vs. 14.7%; p=0.016), smell and taste loss (11.8% vs. 0%; p=0.033), swallowing difficulties (17.6% vs. 0%; p=0.007) and throat pain (17.6% vs. 0%; p=0.007). In the group of SD, there was no correlation between voice perception evaluated by VHI-10, number of NMS or QoL. CONCLUSION: Patients with SD have a greater burden of depressive, smell, taste, and sleep NMS than control subjects.

Impaired auditory discrimination and auditory-motor integration in hyperfunctional voice disorders.

Hyperfunctional voice disorders (HVDs) are the most common class of voice disorders, consisting of diagnoses such as vocal fold nodules and muscle tension dysphonia. These speech production disorders result in effort, fatigue, pain, and even complete loss of voice. The mechanisms underlying HVDs are largely unknown. Here, the auditory-motor control of voice fundamental frequency (fo) was examined in 62 speakers with and 62 speakers without HVDs. Due to the high prevalence of HVDs in singers, and the known impacts of singing experience on auditory-motor function, groups were matched for singing experience. Speakers completed three tasks, yielding: (1) auditory discrimination of voice fo; (2) reflexive responses to sudden fo shifts; and (3) adaptive responses to sustained fo shifts. Compared to controls, and regardless of singing experience, individuals with HVDs showed: (1) worse auditory discrimination; (2) comparable reflexive responses; and (3) a greater frequency of atypical adaptive responses. Atypical adaptive responses were associated with poorer auditory discrimination, directly implicating auditory function in this motor disorder. These findings motivate a paradigm shift for understanding development and treatment of HVDs.

Perceptual Evaluation of Vocal Fold Vibratory Asymmetry.

OBJECTIVES: Laryngeal vibratory asymmetry occurring with paresis may result in a perceptually normal or abnormal voice. The present study aims to determine the relationships between the degree of vibratory asymmetry, acoustic measures, and perception of sound stimuli. STUDY DESIGN: Animal Model of Voice Production, Perceptual Analysis of Voice. METHODS: In an in vivo canine model of phonation, symmetric and asymmetric laryngeal vibration were obtained via graded unilateral recurrent laryngeal nerve (RLN) stimulation simulating near paralysis to full activation. Phonation was performed at various contralateral RLN and bilateral superior laryngeal nerve stimulation levels. Naïve listeners rated the perceptual quality of 182 unique phonatory samples using a visual sort-and-rate task. Cepstral peak prominence (CPP) was calculated for each phonatory condition. The relationships among vibratory symmetry, CPP, and perceptual ratings were evaluated. RESULTS: A significant relationship emerged between RLN stimulation and perceptual rating, such that sound samples from low RLN levels were preferred to those from high RLN levels. When symmetric vibration was achieved at mid-RLN stimulation, listeners preferred samples from symmetric vibration over those from asymmetric vibration. However, when symmetry was achieved at high RLN levels, a strained voice quality resulted that listeners dispreferred over asymmetric conditions at lower RLN levels. CPP did not have a linear relationship with perceptual ratings. CONCLUSIONS: Laryngeal vibratory asymmetry produces variable perceptual differences in phonatory sound quality. Though CPP has been correlated with dysphonia in previous research, its complex relationship with quality limits its usefulness as clinical marker of voice quality perception. LEVEL OF EVIDENCE: NA, basic science Laryngoscope, 131:2740-2746, 2021.

Disfonía en la edad pediátrica. Análisis descriptivo de los factores implicados, parámetros clínicos y repercusión en la calidad de vida / Dysphonia in children. Descriptive analysis of the factors involved, clinical parameters and impact on quality of life

INTRODUCCIÓN: La prevalencia de la disfonía en la edad pediátrica se estima en torno a un 6%. La disfonía en este grupo de edad suele deberse a un uso incorrecto de la voz, que lleva al desarrollo de lesiones en las cuerdas vocales. Esta alteración puede afectar negativamente a la autoestima del niño. El objetivo del estudio es describir la epidemiología de los trastornos de la voz en la edad pediátrica en nuestra área, realizar un examen detallado de la voz, así como identificar el impacto de esta afección sobre la calidad de vida. MATERIAL Y MÉTODO: Presentamos un estudio descriptivo sobre 87 pacientes diagnosticados de disfonía con edades comprendidas entre los 5 y los 14 años. La recogida de datos se realizó en nuestro centro entre enero del año 2016 y abril del 2019. Analizamos factores epidemiológicos y clínicos. Se estudia el impacto en la calidad de vida mediante el cuestionario Pediatric Voice Handicap Index. RESULTADOS: Se incluyen 87 pacientes, 57 varones (65,5%) y 30 mujeres (34,5%). La edad media fue de 8,5 años (DE 2,08; rango 4-13). Los parámetros más constantes fueron tener un hermano o más (89,6%) y la práctica de deporte en equipo (58,6%). La alteración fonatoria más frecuente fue la tensión muscular global (88,5%). En el examen laringoscópico, el hallazgo más frecuente fue la presencia de nódulos vocales (45,9%). La puntuación media en el Pediatric Voice Handicap Index fue de 24,3 puntos en total: 4,9 en la escala funcional, 17,6 en la física y 1,8 en la emocional. CONCLUSIONES: Es fundamental una correcta anamnesis que incluya datos sobre el entorno familiar o la práctica de deporte en equipo. La exploración física debe incluir el examen laringoscópico. Existe un impacto en la calidad de vida de los pacientes con disfonía, percibido por ellos y por sus familiares, siendo el físico el principal componente percibido como afectado. Consideramos necesario el abordaje multidisciplinar de esta afección

INTRODUCTION: The prevalence of dysphonia in children is estimated at around 6%. Dysphonia in this age group is usually due to misuse of the voice that leads to the development of vocal fold injuries. This condition can negatively affect the child's self-esteem. The aim of the study is to describe the epidemiology of voice disorders in children in our area, perform an examination of the voice, as well as identify the impact of this pathology on quality of life. MATERIAL AND METHOD: We present a descriptive study with 87 patients aged between 5 and 14 years old, diagnosed with dysphonia. Data collection was carried out in our centre between January 2016 and April 2019. We analysed epidemiological and clinical factors. The impact on quality of life was studied using the Pediatric Voice Handicap Index questionnaire. RESULTS: 87 patients, 57 men (65.5%) and 30 women (34.5%) were included. Mean age 8.5 years (SD: 2.08; range 4-13). The most frequent phonatory disturbance was global muscle tension (88.5%). In the laryngoscopic examination, the most frequent finding was the presence of vocal nodules (45.9%). The average score on the Pediatric Voice Handicap Index was 24.3 points in total; 4.9 on the functional scale; 17.6 on the physical scale and 1.8 on the emotional scale. CONCLUSION: A correct anamnesis that includes the family environment and practice of team sport is essential. The physical examination should include a laryngoscopic examination. There is an impact on the quality of life of patients with dysphonia perceived by them and their families; the physical component is perceived to be most affected. We consider a multidisciplinary approach to this condition necessary

COVID-19 associated central nervous system manifestations, mental and neurological symptoms: a systematic review and meta-analysis.

The ongoing pandemic of Coronavirus disease 2019 (COVID-19) has infected more than 27 million confirmed cases and 8,90,000 deaths all around the world. Verity of viral infections can infect the nervous system; these viral infections can present a wide range of manifestation. The aim of the current study was to systematically review the COVID-19 associated central nervous system manifestations, mental and neurological symptoms. For that we conducted a comprehensive systematic literature review of four online databases, including Web of Science, PubMed, Scopus and Embase. All relevant articles that reported psychiatric/psychological symptoms or disorders in COVID-19 without considering time and language restrictions were assessed. All the study procedures were performed based on the PRISMA criteria. Due to the screening, 14 studies were included. The current study result indicated that, the pooled prevalence of CNS or mental associated disorders with 95% CI was 50.68% (6.68-93.88). The most prevalence symptoms were hyposmia/anosmia/olfactory dysfunction (number of study: 10) with 36.20% (14.99-60.51). Only one study reported numbness/paresthesia and dysphonia. Pooled prevalence of numbness/paresthesia and dysphonia was 5.83% (2.17-12.25) and 2.39% (10.75-14.22). The pooled prevalence of depression and anxiety was 3.52% (2.62-4.54) and 13.92% (9.44-19.08). Our findings demonstrate that COVID-19 has a certain relation with neurological symptoms. The hypsomia, anosmia or olfactory dysfunction was most frequent symptom. Other symptoms were headache or dizziness, dysgeusia or ageusia, dysphonia and fatigue. Depression, anxiety, and confusion were less frequent symptoms.

Interdependencies between acoustic and high-speed videoendoscopy parameters.

In voice research, uncovering relations between the oscillating vocal folds, being the sound source of phonation, and the resulting perceived acoustic signal are of great interest. This is especially the case in the context of voice disorders, such as functional dysphonia (FD). We investigated 250 high-speed videoendoscopy (HSV) recordings with simultaneously recorded acoustic signals (124 healthy females, 60 FD females, 44 healthy males, 22 FD males). 35 glottal area waveform (GAW) parameters and 14 acoustic parameters were calculated for each recording. Linear and non-linear relations between GAW and acoustic parameters were investigated using Pearson correlation coefficients (PCC) and distance correlation coefficients (DCC). Further, norm values for parameters obtained from 250 ms long sustained phonation data (vowel /i/) were provided. 26 PCCs in females (5.3%) and 8 in males (1.6%) were found to be statistically significant (|corr.| ≥ 0.3). Only minor differences were found between PCCs and DCCs, indicating presence of weak non-linear dependencies between parameters. Fundamental frequency was involved in the majority of all relevant PCCs between GAW and acoustic parameters (19 in females and 7 in males). The most distinct difference between correlations in females and males was found for the parameter Period Variability Index. The study shows only weak relations between investigated acoustic and GAW-parameters. This indicates that the reduction of the complex 3D glottal dynamics to the 1D-GAW may erase laryngeal dynamic characteristics that are reflected within the acoustic signal. Hence, other GAW parameters, 2D-, 3D-laryngeal dynamics and vocal tract parameters should be further investigated towards potential correlations to the acoustic signal.

Localised laryngotracheal amyloidosis: a differential diagnosis not to forget.

We present a case of multifocal laryngotracheal amyloidosis (LTA) in a 43-year-old man with persistent and progressive dysphonia and dyspnoea, and a first inconclusive histology. Although laryngeal amyloidosis accounts for fewer than 1% of all benign laryngeal tumours, it is in fact the most common site of amyloid deposition in the head, neck and respiratory tract. The clinical scenario is non-specific and diagnosis depends on a high degree of suspicion and on histology. Imaging is useful in mapping lesions, which are often more extensive than they appear during laryngoscopy. Despite being a benign entity, the prognosis is variable with a high-rate and long-latency recurrences, requiring long-term follow-up.

Sulcus vocalis in spasmodic dysphonia-A retrospective study.

BACKGROUND: Spasmodic dysphonia (SD) is a neurological condition of the larynx characterised by task specific, involuntary spasms of the intrinsic laryngeal muscles causing frequent voice breaks during speech. The current treatment modality involves Botulinum Toxin injections into the affected group of muscles. This has yielded satisfactory results in Adductor SD (ADSD) and mixed SD but not in Abductor SD (ABSD). Sulcus vocalis is a morphological condition of the vocal folds with invagination of the superficial epithelium into the lamina propria or deeper layers. It is characterised by breathiness in voice and hypophonia. In our voice clinic, patients diagnosed with SD were occasionally found to have a sulcus on flexible stroboscopy. Studies have revealed an asymmetric stimulation of both the adductor and abductor group of muscles in ABSD and a predominant possibly symmetric stimulation of the adductor group of muscles in ADSD. Our objective was to study any significant association between vocal fold sulcus and two groups within SD; group one being ADSD and group two being both ABSD and Mixed SD. A literature review did not reveal any studies suggesting an association between SD and vocal fold sulcus to date. METHODS: A retrospective review of the stroboscopic video recordings as well as file records of all patients diagnosed with SD between January 2016 and September 2019 was conducted at our voice clinic. The first author was the laryngologist who had diagnosed SD and its type on the basis of hearing the voice and making the patient perform various vocal tasks with and without flexible videostroboscopy. The SD patients were divided into two groups with the first group consisting of ADSD patients and the second group consisting of ABSD as well as Mixed SD patients. The presence or absence of vocal fold sulcus was noted in all the SD patients. Odds ratio was used to establish statistical significance of the presence of vocal fold sulcus in the two SD groups. RESULTS: Among the 106 patients of SD, 62 patients were males and 44 were females. A total of 84 patients were diagnosed as ADSD, 10 as ABSD and 12 as Mixed SD patients. Vocal fold sulcus was noted in 5 out of 84 patients of ADSD, 4 out of 10 patients of ABSD, and in 3 out of 12 patients of mixed SD. Odds Ratio of 7.37 (C.I. = 2.063-26.35) was obtained for the second group of patients i.e. ABSD and Mixed SD. CONCLUSION: Our study revealed a significant association between patients of SD having an abductor component (ABSD and mixed SD) and vocal fold sulcus. The two hypothesis proposed for this are the possibility of asymmetrical adductor and abductor muscle stimulation in SD being responsible for the development of a vocal fold sulcus or the primary presence of a vocal fold sulcus contributing to altered sensory feedback resulting in SD. Further study to evaluate this, as well as a study of the vocal response to medialisation procedures for patients of ABSD with sulcus is recommended.

Structure and Function of the Vocal Cords after Airway Reconstruction on Magnetic Resonance Imaging.

OBJECTIVES/HYPOTHESIS: Dysphonia is a common problem at long-term follow-up after airway surgery for laryngotracheal stenosis (LTS) with major impact on quality of life. Dysphonia after LTS can be caused by scar tissue from initial stenosis along with anatomical alterations after surgery. There is need for a modality to noninvasively image structure and function of the reconstructed upper airways including the vocal cords to assess voice outcome and possible treatment after LTS. Our objective was to correlate vocal cord structure and function of patients after airway reconstruction for LTS on static and dynamic magnetic resonance imaging (MRI) to voice outcome. STUDY DESIGN: Prospective cohort study. METHODS: Voice outcome was assessed by voice questionnaires ((pediatric) Voice Handicap Index (p)VHI)) and the Dysphonia Severity Index (DSI). Postsurgical anatomy, airway lumen, and vocal cord thickness and movement on multiplanar static high-resolution MRI and dynamic acquisitions during phonation was correlated to voice outcome. RESULTS: Forty-eight patients (age 14.4 (range 7.5-30.7) years) and 11 healthy volunteers (15.9 (8.2-28.8) years) were included. Static MRI demonstrated vocal cord thickening in 80.9% of patients, correlated to a decrease in DSI (expected odds 0.75 [C.I. 0.58-0.96] P = .02). Dynamic MRI showed impaired vocal cord adduction during phonation in 61.7% of patients, associated with a lower DSI score (0.65 [C.I. 0.48-0.88] P = .006). CONCLUSIONS: In LTS patients, after airway reconstruction MRI can safely provide excellent structural and functional detail of the vocal cords correlating to DSI, with further usefulness expected from technical refinements. We therefore suggest MRI as a tool for extensive imaging during LTS follow-up. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:E2402-E2408, 2021.

Correlation of Glottic Gap and Voice Impairment in Presbyphonia.

OBJECTIVE/HYPOTHESIS: The objective of this study was to investigate the glottic gap area as a significant marker for the severity of presbyphonia as it relates to patient-reported outcome measures (Voice Handicap Index-10 [VHI-10]) and stroboscopic findings. STUDY DESIGN: Retrospective case-control study conducted in an academic tertiary voice center. METHODS: Patients seen at a tertiary voice clinic who were diagnosed with presbyphonia without other organic laryngeal pathology from January 2014 to December 2017 were included. Clinical data and laryngeal videostroboscopy videos were collected. Still images at the point of vocal process approximation during adduction were captured, and the glottic gap area was measured using ImageJ. These were compared to a control cohort. Correlations were made using Wilcoxon rank sum test, Mann-Whitney U test, and Pearson correlation coefficients. RESULTS: Thirty-three patients were included. Inter-rater reliability of glottic area measurement was strong (intraclass correlation coefficient = 0.73, P < .001). Compared to controls, presbyphonia patients had a larger glottic gap area (P < .001) and greater open-phase quotient on laryngeal videostroboscopy (P < .001). Larger glottic gap area did not correlate with patient-reported vocal function as measured by VHI-10 (P = .79) and did not correlate with presence of secondary muscle tension dysphonia (P = .99). In the presbyphonia cohort, the glottic gap area did not correlate with age (P = .29). CONCLUSIONS: Glottic gap area at the point of vocal process approximation during phonation can be reliably measured. Patients with presbyphonia have a larger glottic gap area and greater open-phase quotient on stroboscopy, but these do not correlate with patient-reported voice impairment or the presence of secondary muscle tension dysphonia (MTD). These data suggest that dysphonia severity in presbyphonia is not fully explained by a glottic gap or secondary MTD alone. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1594-1598, 2021.

Validation of the Communicative Participation Item Bank as an Outcome Measure for Spasmodic Dysphonia.

OBJECTIVES: Current patient-reported outcome measures do not adequately capture the impact of spasmodic dysphonia (SD) on communication in daily life situations. The aim of this study was to validate the Communicative Participation Item Bank (CPIB), which specifically measures a disease's impact on daily conversational situations, as an outcome measure for SD. STUDY DESIGN: Multi-institutional prospective cohort study. METHODS: A prospective study was conducted with administration of the 46-question CPIB and the Voice Handicap Index-10 (VHI-10) to 190 participants with SD before (time 1) and 6 weeks after (time 2) botulinum toxin injection. Differential item function (DIF) analyses were performed to examine potential item bias. Paired t-tests were used to assess change in each of the CPIB and VHI-10 scores after treatment. Pearson correlations were calculated between the CPIB and VHI-10. RESULTS: DIF analyses revealed no clinically meaningful difference between the item parameters generated for this SD sample and the original CPIB calibration sample. There were statistically significant changes between the pre-treatment and post-treatment time points for both the CPIB and VHI-10. Correlations between the CPIB and VHI were moderate-high. CONCLUSIONS: The CPIB item bank, General Short Form, and scoring parameters can be used with people with SD for valid and reliable measurement of the impact of communication disorders on communication in everyday life. The CPIB is sensitive to changes with intervention, proving useful for clinical and research purposes to assess the efficacy and effectiveness of interventions. LEVEL OF EVIDENCE: Level 2, prospective observational research with an experimental design (ie, cohort study). Laryngoscope, 131:859-864, 2021.

Does Voice Therapy Improve Vocal Outcomes in Vocal Fold Atrophy?

OBJECTIVES: Vocal fold atrophy is increasingly identified in the geriatric population. Current literature shows varying outcomes with voice therapy. Our goal was to analyze multidimensional vocal outcomes of these patients who underwent voice therapy. Secondary aims included determining compliance and analyzing differences in patients who undergo surgery. METHODS: 197 patients with vocal fold atrophy were included and reviewed. Patients were categorized by treatment received. Patient-reported, perceptual, aerodynamic, and acoustic voice outcomes were analyzed before and after therapeutic intervention. Changes were calculated and significance determined using Wilcoxon signed-rank and rank-sum tests. RESULTS: 89(45%) received no therapy, 43(22%) incomplete therapy, 51(26%) complete therapy, 8(4%) surgery only, and 6(3%) therapy followed by surgery. Those who completed voice therapy showed significant improvement in voice related quality of life (VRQOL) (P = .0225), glottal function index (GFI) (P < .001), grade, roughness, breathiness, asthenia, strain (GRBAS) (P < .001), maximum phonation time (MPT) (P = .0081), and fundamental frequency in women (P = .0024). No significant changes were found in mean airflow. When comparing patients who underwent surgery versus voice therapy, statistically significant differences were present between pre-treatment VRQOL (P = .0269) and GFI (P = .0166). CONCLUSIONS: Only 29% of patients with vocal atrophy completed voice therapy when recommended. Within this patient cohort, voice therapy results in significant improvement in multidimensional voice outcomes. Patients with vocal atrophy that undergo surgical treatment differ from those treated with voice therapy alone in their pre-treatment patient-reported measures.

Dysphagia and Dysphonia, a Pairing of Symptoms Caused by an Unusual Pair of Diseases: Castleman's Disease and Myasthenia Gravis.

OBJECTIVES: To describe a case of coincident Castleman's disease and myasthenia gravis that initially presented as rapidly progressive dysphagia and dysphonia and to review the unique pathophysiology of these two uncommon diagnoses. METHODS: Case report and literature review. RESULTS: Castleman's disease, angiofollicular or giant lymph node hyperplasia, is a rare benign lymphoid proliferation. Traditionally, the disease is classified based on histologic and clinical characteristics. Fewer than 10 cases with concurrent myasthenia gravis have been reported. Myasthenia gravis and thymic epithelial tumors are both associated with acetylcholine receptor antibody. While patients with isolated Castleman's disease are usually asymptomatic, those who have concurrent myasthenia gravis and undergo surgical treatment are at increased risk of postoperative myasthenic crisis. Both pre- and postoperative plasmapheresis are suggested to improve muscle strength and prevent severe postoperative complications. CONCLUSIONS: In the setting of multiple cranial neuropathies including velopalatal insufficiency and bilateral ptosis it is important to consider myasthenia gravis. Castleman's disease occurs rarely in conjunction with myasthenia gravis but may increase the risk of myasthenic crisis.

Voice Component Relationships with High Reflux Symptom Index Scores in Muscle Tension Dysphonia.

OBJECTIVE: To analyze the Reflux Symptom Index (RSI) and the Voice-Related Quality of Life (V-RQOL) scores based on the perceptual and analytical parameters in primary MTD patients with no reflux. STUDY DESIGN: Cross-sectional study. METHODS: One hundred and eighteen participants, that is, sixty patients with normal voices and fifty-eight patients with primary MTD were recruited in this study. The diagnosis of primary MTD was made by perceptual voice analysis, neck palpation, video-laryngoscopic examination, and exclusion of other etiologies. Acoustic analysis and the GRBAS (Grade, Roughness, Breathiness, Asthenia, and Strain) scale were evaluated for all participants. The V-RQOL and RSI questionnaires were then given to all participants. RESULTS: This study included 118 participants of 29 males (48.3%) and 31 females (51.7%) in the normal group. MTD group also included 27 males (46.6%) and 31 (53.4%) female patients. Mean (SD) RSI and V-RQOL scores were 12.35 (3.84) and 11.09 (2.20) for the normal group, and 22.87 (6.97) and 22.89 (7.94) for the MTD group (P = .000). In the MTD group, V-RQOL had a positive correlation with jitter for /i/ and /u/, Noise to Harmonic Ratio (NHR) for /i/, /a/, and /u/, and Grade, Roughness, and Strain of GRBAS scale (P < .05). In addition, RSI had a positive correlation with Strain in the MTD group (P < .05). CONCLUSION: MTD patients in the absence of laryngopharyngeal reflux findings may have high RSI scores. Hence, patients with high RSI scores and disproportionate acoustic and perceptual analysis would require a thorough evaluation of MTD. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1573-E1579, 2021.

Listening to a Dysphonic Speaker in Noise May Impede Children's Spoken Language Processing in a Realistic Classroom Setting.

Purpose The aim of this study was to investigate children's processing of dysphonic speech in a realistic classroom setting, under the influence of added classroom noise. Method Typically developing 6-year-old primary school children performed two listening tasks in their regular classrooms: a phoneme discrimination task to assess speech perception and a sentence-picture matching task to assess listening comprehension. Speech stimuli were played back in either a typical or an impaired voice quality. Children performed the tasks in the presence of induced classroom noise at signal-to-noise ratios between +2 and +9 dB. Results Children's performance in the phoneme discrimination task decreased significantly when the speaker's voice was impaired. The effect of voice quality on sentence-picture matching depended on task demands: Easy sentences were processed more accurately in the impaired-voice condition than in the typical-voice condition. Signal-to-noise ratio effects are discussed in light of methodological constraints. Conclusions Listening to a dysphonic teacher in a noisy classroom may impede children's perception of speech, particularly when phonological discrimination is needed to disambiguate the speech input. Future research regarding the interaction of voice quality and task demands is necessary.

Characterization of Functional Dysphonia: Pre- and Post-Treatment Findings.

OBJECTIVES: Functional dysphonia (FD) is one of the possible presentations of chronic dysphonia. Defined as dysphonia without gross abnormality of the larynx, FD manifests as aberrant muscle contractions resulting in mild-to-severe dysphonia. Despite increasing clinical awareness, diagnosis, and treatment strategies for FD remain challenging. STUDY DESIGN: Institutional review board. METHODS: A retrospective review of videostroboscopic examinations and EMR data from 109 patients treated for FD was performed. Videostroboscopy was analyzed by two independent reviewers and classified by laryngeal posturing and observer-rated quality of voice. Medical records were reviewed and patient characteristics, history of disease, and survey responses were collected. Statistics were calculated using JMP and SAS packages. RESULTS: A total of 85.1% of subjects were female and the average voice handicap index (VHI30) score was 71.0/120. Average time to diagnosis of FD was 688 days and average time from diagnosis to treatment was 3.7 days. 44.0% of patients exhibited hyperadducted laryngeal posturing, 31.9% hypoadducted, and 24.2% showed a mixed posture. 98% of patient voices improved after treatment. 85% returned to normal voice and 10% maintained a mild residual dysphonia. CONCLUSION: We describe here a large cohort of patients affected by FD, including clinical presentation and videostroboscopic findings. Our data show that most individuals with FD improve after specialized voice therapy once correctly diagnosed but that correct diagnosis and proper treatment was often significantly delayed. LEVEL OF EVIDENCE: 4-Case-series Laryngoscope, 131:E1957-E1964, 2021.