Cough in Children and Adults: Diagnosis, Assessment and Management (CICADA). Summary of an updated position statement on chronic cough in Australia.

INTRODUCTION: Cough is the most common symptom leading to medical consultation. Chronic cough results in significant health care costs, impairs quality of life, and may indicate the presence of a serious underlying condition. Here, we present a summary of an updated position statement on cough management in the clinical consultation. MAIN RECOMMENDATIONS: Assessment of children and adults requires a focused history of chronic cough to identify any red flag cough pointers that may indicate an underlying disease. Further assessment with examination should include a chest x-ray and spirometry (when age > 6 years). Separate paediatric and adult diagnostic management algorithms should be followed. Management of the underlying condition(s) should follow specific disease guidelines, as well as address adverse environmental exposures and patient/carer concerns. First Nations adults and children should be considered a high risk group. The full statement from the Thoracic Society of Australia and New Zealand and Lung Foundation Australia for managing chronic cough is available at https://lungfoundation.com.au/resources/cicada-full-position-statement. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: Algorithms for assessment and diagnosis of adult and paediatric chronic cough are recommended. High quality evidence supports the use of child-specific chronic cough management algorithms to improve clinical outcomes, but none exist in adults. Red flags that indicate serious underlying conditions requiring investigation or referral should be identified. Early and effective treatment of chronic wet/productive cough in children is critical. Culturally specific strategies for facilitating the management of chronic cough in First Nations populations should be adopted. If the chronic cough does not resolve or is unexplained, the patient should be referred to a respiratory specialist or cough clinic.

Instrument adaptation and preliminary validation study of the Laryngeal Hypersensitivity Questionnaire used for assessment of laryngeal symptoms in patients with artificial airways.

BACKGROUND: The Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ) was developed to measure abnormal laryngeal sensation and was originally validated in a patient sample from otolaryngologic and respiratory outpatient clinics. Modification is needed for patients who are mechanically ventilated via an endotracheal tube or a tracheostomy tube. OBJECTIVES: We sought to adapt and preliminarily validate a modified version of the LHQ appropriate for nurses and other clinicians to administer in acute hospital settings called the LHQ-Acute (LHQ-A). METHODS: Internal consistency and construct validity analyses using secondary data from patients at a tertiary teaching hospital who presented with symptoms of laryngeal irritability/hypersensitivity between September 2012 and October 2013 were performed. RESULTS: A total of 131 patients, most complaining of coughing and dysphonia, with a median age of 58 (interquartile range: 48, 66) years and 29 healthy participants with a median age of 62 (interquartile range: 50, 66) years were analysed. The original LHQ was reduced from 14 questions with responses on a 7-point scale to the LHQ-A containing 13 questions with responses on a 4-point scale. Correlations between items of the LHQ and LHQ-A were similar, and internal consistency was excellent and highly comparable, with Cronbach's alpha = 0.906 and 0.902, respectively. CONCLUSIONS: The LHQ-A, which has been adapted for nurses and other clinicians to administer to a critically ill patient population, demonstrated comparable reliability and validity to the original LHQ. Validation of the LHQ-A in independent patient populations from acute settings is necessary to better understand norms and changes during recovery from acute illness.

Interaction effect of chronic cough and ageing on increased risk of exacerbation in patients with asthma: a prospective cohort study in a real-world setting.

Background: Older adults with asthma have the greatest burden and worst outcomes, and there is increasing evidence that chronic cough (CC) is associated with asthma severity and poor prognosis. However, the clinical characteristics of older adult patients with both asthma and CC remain largely unknown. Methods: Participants with stable asthma underwent two cough assessments within 3 months to define the presence of CC. Patients were divided into four groups based on CC and age (cut-off ≥60 years). Multidimensional assessment was performed at baseline, followed by a 12-month follow-up to investigate asthma exacerbations. Logistic regression models were used to explore the interaction effect of CC and age on asthma control and exacerbations. Results: In total, 310 adult patients were prospectively recruited and divided into four groups: older CC group (n=46), older non-CC group (n=20), younger CC group (n=112) and younger non-CC group (n=132). Compared with the younger non-CC group, the older CC group had worse asthma control and quality of life and increased airflow obstruction. The older CC group showed an increase in moderate-to-severe exacerbations during the 12-month follow-up. There was a significant interaction effect of CC and ageing on the increased moderate-to-severe exacerbations (adjusted risk ratio 2.36, 95% CI 1.47-3.30). Conclusion: Older asthma patients with CC have worse clinical outcomes, including worse asthma control and quality of life, increased airway obstruction and more frequent moderate-to-severe exacerbations, which can be partly explained by the interaction between CC and ageing.

State of the Art for Refractory Cough: Multidisciplinary Approach.

Chronic cough is a common problem that can be refractory to medical treatment. Nonpharmaceutical management of chronic cough has an important role in well selected patients. This review article outlines the history of chronic cough management, current approaches to speech pathology management of the condition and new modalities of nonpharmaceutical treatment. There is a need for further research into nonpharmaceutical options with well described randomised control trials.

Impact of Landscape Fire Smoke Exposure on Patients With Asthma With or Without Laryngeal Hypersensitivity.

BACKGROUND: Individuals with asthma experienced severe and prolonged symptoms after the Australian 2019 to 2020 landscape fire. Many of these symptoms, such as throat irritation, occur in the upper airway. This suggests that laryngeal hypersensitivity contributes to persistent symptoms after smoke exposure. OBJECTIVE: This study examined the relationship between laryngeal hypersensitivity and symptoms, asthma control, and health impacts on individuals exposed to landscape fire smoke. METHOD: The study was a cross-sectional survey of 240 participants in asthma registries who were exposed to smoke during the 2019 to 2020 Australian fire. The survey, completed between March and May 2020, included questions about symptoms, asthma control, and health care use, as well as the Laryngeal Hypersensitivity Questionnaire. Daily concentration levels of particulate matter less than or equal to 2.5 µm in diameter were measured over the 152-day study period. RESULTS: The 49 participants with laryngeal hypersensitivity (20%) had significantly more asthma symptoms (96% vs 79%; P = .003), cough (78% vs 22%; P < .001), and throat irritation (71% vs 38%; P < .001) during the fire period compared with those without laryngeal hypersensitivity. Participants with laryngeal hypersensitivity had greater health care use (P ≤ .02), more time off work (P = .004), and a reduced capacity to participate in usual activities (P < .001) during the fire period, as well as poorer asthma control during the follow-up (P = .001). CONCLUSIONS: Laryngeal hypersensitivity is associated with persistent symptoms, reports of lower asthma control, and increased health care use in adults with asthma who were exposed to landscape fire smoke. Management of laryngeal hypersensitivity before, during, or immediately after landscape fire smoke exposure might reduce the symptom burden and health impact.

Diagnosis of vocal cord dysfunction/inducible laryngeal obstruction: An International Delphi Consensus Study.

BACKGROUND: Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is characterized by breathing difficulties in association with excessive supraglottic or glottic laryngeal narrowing. The condition is common and can occur independently; however, it may also be comorbid with other disorders or mimic them. Presentations span multiple specialties and misdiagnosis or delayed diagnosis is commonplace. Group-consensus methods can efficiently generate internationally accepted diagnostic criteria and descriptions to increase clinical recognition, enhance clinical service availability, and catalyze research. OBJECTIVES: We sought to establish consensus-based diagnostic criteria and methods for VCD/ILO. METHODS: We performed a modified 2-round Delphi study between December 7, 2021, and March 14, 2022. The study was registered at ANZCTR (Australian New Zealand Clinical Trials Registry; ACTRN12621001520820p). In round 1, experts provided open-ended statements that were categorized, deduplicated, and amended for clarity. These were presented to experts for agreement ranking in round 2, with consensus defined as ≥70% agreement. RESULTS: Both rounds were completed by 47 international experts. In round 1, 1102 qualitative responses were received. Of the 200 statements presented to experts across 2 rounds, 130 (65%) reached consensus. Results were discussed at 2 international subject-specific conferences in June 2022. Experts agreed on a diagnostic definition for VCD/ILO and endorsed the concept of VCD/ILO phenotypes and clinical descriptions. The panel agreed that laryngoscopy with provocation is the gold standard for diagnosis and that ≥50% laryngeal closure on inspiration or Maat grade ≥2 define abnormal laryngeal closure indicative of VCD/ILO. CONCLUSIONS: This Delphi study reached consensus on multiple aspects of VCD/ILO diagnosis and can inform clinical practice and facilitate research.

Vocal cord dysfunction/inducible laryngeal obstruction-2022 Melbourne Roundtable Report.

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO), is a common condition characterized by breathlessness associated with inappropriate laryngeal narrowing. Important questions remain unresolved, and to improve collaboration and harmonization in the field, we convened an international Roundtable conference on VCD/ILO in Melbourne, Australia. The aims were to delineate a consistent approach to VCD/ILO diagnosis, appraise disease pathogenesis, outline current management and model(s) of care and identify key research questions. This report summarizes discussions, frames key questions and details recommendations. Participants discussed clinical, research and conceptual advances in the context of recent evidence. The condition presents in a heterogenous manner, and diagnosis is often delayed. Definitive diagnosis of VCD/ILO conventionally utilizes laryngoscopy demonstrating inspiratory vocal fold narrowing >50%. Computed tomography of the larynx is a new technology with potential for swift diagnosis that requires validation in clinical pathways. Disease pathogenesis and multimorbidity interactions are complex reflecting a multi-factorial, complex condition, with no single overarching disease mechanism. Currently there is no evidence-based standard of care since randomized trials for treatment are non-existent. Recent multidisciplinary models of care need to be clearly articulated and prospectively investigated. Patient impact and healthcare utilization can be formidable but have largely escaped inquiry and patient perspectives have not been explored. Roundtable participants expressed optimism as collective understanding of this complex condition evolves. The Melbourne VCD/ILO Roundtable 2022 identified clear priorities and future directions for this impactful condition.

The impact of the 2019/2020 Australian landscape fires on infant feeding and contaminants in breast milk in women with asthma.

BACKGROUND: The 2019/2020 Australian landscape fires (bushfires) resulted in prolonged extreme air pollution; little is known about the effects on breastfeeding women and their infants. This study aimed to examine the impact of prolonged landscape fires on infant feeding methods and assess the concentration of polycyclic aromatic hydrocarbons (PAHs) and elements in breast milk samples. METHODS: From May - December 2020, women with asthma, who were feeding their infants during the fires, were recruited from an existing cohort. Data on infant feeding and maternal concern during the fires were retrospectively collected. Breast milk samples were collected from a sample of women during the fire period and compared with samples collected outside of the fire period for levels of 16 PAHs (gas chromatography coupled with mass spectrometry), and 20 elements (inductively coupled plasma-mass spectrometry). RESULTS: One-hundred-and-two women who were feeding infants completed the survey, and 77 provided 92 breast milk samples. Two women reported concern about the impact of fire events on their infant feeding method, while four reported the events influenced their decision. PAHs were detected in 34% of samples collected during, versus no samples collected outside, the fire period (cross-sectional analysis); specifically, fluoranthene (median concentration 0.015 mg/kg) and pyrene (median concentration 0.008 mg/kg) were detected. Women whose samples contained fluoranthene and pyrene were exposed to higher levels of fire-related fine particulate matter and more fire days, versus women whose samples had no detectable fluoranthene and pyrene. Calcium, potassium, magnesium, sodium, sulphur, and copper were detected in all samples. No samples contained chromium, lead, nickel, barium, or aluminium. No statistically significant difference was observed in the concentration of elements between samples collected during the fire period versus outside the fire period. CONCLUSIONS: Few women had concerns about the impact of fire events on infant feeding. Detection of fluoranthene and pyrene in breast milk samples was more likely during the 2019/2020 Australian fire period; however, levels detected were much lower than levels expected to be related to adverse health outcomes.

A Prospective, Longitudinal and Exploratory Study of Head and Neck Lymphoedema and Dysphagia Following Chemoradiotherapy for Head and Neck Cancer.

The aim of the study was to examine the following: (a) the trajectory of external and internal head and neck lymphoedema (HNL) in patients with head and neck cancer (HNC) up to 12 months post-chemoradiotherapy (CRT) and (b) the relationship between HNL and swallowing function. Using a prospective longitudinal cohort study, external/internal HNL and swallowing were examined in 33 participants at 3, 6 and 12 months post-CRT. External HNL was assessed using the Assessment of Lymphoedema of the Head and Neck and the MD Anderson Cancer Centre Lymphoedema Rating Scale. Internal HNL was rated using Patterson's Radiotherapy Oedema Rating Scale. Swallowing was assessed via clinical, instrumental and patient-reported measures. Associations between HNL and swallowing were examined using multivariable regression models. External HNL was prevalent at 3 months (71%), improved by 6 months (58%) and largely resolved by 12 months (10%). In contrast, moderate/severe internal HNL was prevalent at 3 months (96%), 6 months (84%) and at 12 months (65%). More severe penetration/aspiration and increased diet modification were associated with higher severities of external HNL (p=0.006 and p=0.031, respectively) and internal HNL (p<0.001 and p=0.007, respectively), and more diffuse internal HNL (p=0.043 and p=0.001, respectively). Worse patient-reported swallowing outcomes were associated with a higher severity of external HNL (p=0.001) and more diffuse internal HNL (p=0.002). External HNL largely resolves by 12 months post-CRT, but internal HNL persists. Patients with a higher severity of external and/or internal HNL and those with more diffuse internal HNL can be expected to have more severe dysphagia.

Diagnosis of vocal cord dysfunction / inducible laryngeal obstruction-A Delphi study protocol.

INTRODUCTION: Currently there is no consistent and widely accepted approach to the diagnosis of vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO). Harmonised diagnostic methods are vital to enable optimal diagnosis, advance management and enable research. We aim to obtain consensus on how expert clinicians recognise and diagnose VCD/ILO. METHODS AND ANALYSIS: Two-round modified Delphi, with workshop validation. ETHICS AND DISSEMINATION: Institutional Board Review was obtained from the Monash Health Human Research Ethics Committee. The dissemination plan is for presentation and publication. REGISTRATION DETAILS: Registered at Australia and New Zealand Clinical Trials Registry ACTRN12621001520820p.

The impact of prolonged landscape fire smoke exposure on women with asthma in Australia.

BACKGROUND: Little is known about the physical and mental health impact of exposure to landscape fire smoke in women with asthma. This study examined the health impacts and information-seeking behaviours of women with asthma exposed to the 2019/2020 Australian fires, including women who were pregnant. METHODS: Women with asthma were recruited from the Breathing for Life Trial in Australia. Following the landscape fire exposure period, self-reported data were collected regarding symptoms (respiratory and non-respiratory), asthma exacerbations, wellbeing, quality of life, information seeking, and landscape fire smoke exposure mitigation strategies. Participants' primary residential location and fixed site monitoring was used to geolocate and estimate exposure to landscape fire-related fine Particulate Matter (PM2.5). RESULTS: The survey was completed by 81 pregnant, 70 breastfeeding and 232 non-pregnant and non-breastfeeding women with asthma. Participants had a median daily average of 17 µg/m3 PM2.5 and 105 µg/m3 peak PM2.5 exposure over the fire period (October 2019 to February 2020). Over 80% of participants reported non-respiratory and respiratory symptoms during the fire period and 41% reported persistent symptoms. Over 82% reported asthma symptoms and exacerbations of asthma during the fire period. Half the participants sought advice from a health professional for their symptoms. Most (97%) kept windows/doors shut when inside and 94% stayed indoors to minimise exposure to landscape fire smoke. Over two in five (43%) participants reported that their capacity to participate in usual activities was reduced due to prolonged smoke exposure during the fire period. Participants reported greater anxiety during the fire period than after the fire period (mean (SD) = 53(13) versus 39 (13); p < 0.001). Two in five (38%) pregnant participants reported having concerns about the effect of fire events on their pregnancy. CONCLUSION: Prolonged landscape fire smoke exposure during the 2019/2020 Australian fire period had a significant impact on the health and wellbeing of women with asthma, including pregnant women with asthma. This was despite most women taking actions to minimise exposure to landscape fire smoke. Effective and consistent public health messaging is needed during landscape fire events to guard the health of women with asthma.

Myofunctional device use in oral care and swallowing: a protocol for a feasibility study in an aged care population.

BACKGROUND: Poor oral health is a known predictor of aspiration pneumonia in vulnerable populations such as the elderly and chronically ill and has been linked to systemic disease, morbidity, and mortality. Reduced oral health not only places individuals at a greater risk of aspiration pneumonia but may result in pain or poorer dentition which can impact on mastication and swallowing. Consequences of this may include reduced oral intake, malnutrition, poorer health outcomes, and reduced quality of life. Few evidence-based protocols exist to manage oral care in aged care populations, and maintenance of good oral hygiene is difficult for nursing and care staff to facilitate. However, a recent literature review found that improvements in oral hygiene, oral behaviors, and swallowing, along with breathing and speech have been found to be associated with the use of myofunctional devices due to positive changes in orofacial functions such as lip seal, mastication, swallowing, and nasal breathing patterns. The primary aim of this study is to assess the feasibility of using a myofunctional device to improve oral care and swallowing function in an aged care population. METHODS/DESIGN: This project is a feasibility study that involves a 5-week intervention for oral hygiene and dysphagia for residents >65 years old in an aged care setting. Feasibility will be determined by the acceptability of the intervention, study recruitment and retention, and adherence to the intervention. Feasibility testing will also include an evaluation of clinical outcome measures, and sensitivity to detect changes in oral health and swallowing in an aged care population. DISCUSSION: The results of this trial will provide important information regarding the feasibility of utilizing a myofunctional device to improve oral care and dysphagia in elderly patients in an aged care facility. This knowledge will further guide and inform design of a larger trial or future research. TRIAL REGISTRATION: This trial was registered August 10, 2021, with the Australian New Zealand Clinical Trials Registry and allocated the ACTRN: ACTRN12621001359820.

'Breathing Fire': Impact of Prolonged Bushfire Smoke Exposure in People with Severe Asthma.

Wildfires are increasing and cause health effects. The immediate and ongoing health impacts of prolonged wildfire smoke exposure in severe asthma are unknown. This longitudinal study examined the experiences and health impacts of prolonged wildfire (bushfire) smoke exposure in adults with severe asthma during the 2019/2020 Australian bushfire period. Participants from Eastern/Southern Australia who had previously enrolled in an asthma registry completed a questionnaire survey regarding symptoms, asthma attacks, quality of life and smoke exposure mitigation during the bushfires and in the months following exposure. Daily individualized exposure to bushfire particulate matter (PM2.5) was estimated by geolocation and validated modelling. Respondents (n = 240) had a median age of 63 years, 60% were female and 92% had severe asthma. They experienced prolonged intense PM2.5 exposure (mean PM2.5 32.5 µg/m3 on 55 bushfire days). Most (83%) of the participants experienced symptoms during the bushfire period, including: breathlessness (57%); wheeze/whistling chest (53%); and cough (50%). A total of 44% required oral corticosteroid treatment for an asthma attack and 65% reported reduced capacity to participate in usual activities. About half of the participants received information/advice regarding asthma management (45%) and smoke exposure minimization strategies (52%). Most of the participants stayed indoors (88%) and kept the windows/doors shut when inside (93%), but this did not clearly mitigate the symptoms. Following the bushfire period, 65% of the participants reported persistent asthma symptoms. Monoclonal antibody use for asthma was associated with a reduced risk of persistent symptoms. Intense and prolonged PM2.5 exposure during the 2019/2020 bushfires was associated with acute and persistent symptoms among people with severe asthma. There are opportunities to improve the exposure mitigation strategies and communicate these to people with severe asthma.

Chronic cough in asthma is associated with increased airway inflammation, more comorbidities, and worse clinical outcomes.

Background: Cough is often the most prominent and intractable symptom reported by patients with asthma, but few studies have explored the characteristics of patients with asthma and with chronic cough (CC) in a real-world setting. Methods: In a prospective cohort study, patients ages ≥ 18 years with stable asthma were consecutively recruited at the West China Hospital, Sichuan University. The patients were classified as having asthma with CC (the CC group) or asthma with non-CC (the non-CC group) after 3 months of optimized asthma therapy according to standard guidelines. Multidimensional assessment was performed at baseline, followed by a 12-month follow-up to assess asthma exacerbations. Results: Of 323 patients with asthma, 127 patients were assigned to the CC group and 196 patients were assigned to the non-CC group. The participants with CC were older and had more airflow obstruction; worse asthma control and quality of life; increased airway inflammation; upper respiratory tract infection as a trigger; and more comorbidities, such as psychological dysfunction, rhinitis, chronic obstructive pulmonary disease, and bronchiectasis. They reported greater work productivity loss and daily activity impairment, and increased moderate-to-severe exacerbations. Conclusion: The participants with asthma and with CC had a significant disease burden, with increased exacerbations, health-care utilization, and impaired work productivity and daily activity. These observations indicated potential clinical implications in patients with asthma and with CC, and call for more attention to this aspect of asthma.

The Impact of Functional Laryngoscopy on the Diagnosis of Laryngeal Hypersensitivity Syndromes.

BACKGROUND: Chronic cough and vocal cord dysfunction are manifestations of laryngeal hypersensitivity syndrome. OBJECTIVE: The aim of the study was to determine the clinical utility of functional transnasal laryngoscopy in patients with laryngeal hypersensitivity syndromes. METHODS: This study was a prospective observational cross-sectional study design of 71 participants with laryngeal hypersensitivity syndrome referred for functional transnasal laryngoscopy. Participants had a clinical assessment with a speech pathologist after which a provisional diagnosis of chronic cough, suspected vocal cord dysfunction, suspected muscle tension dysphonia, or a combination was made. A laryngoscopy with provocation was performed and the diagnosis revised after which the provisional and revised diagnoses were compared. RESULTS: The diagnosis changed in 67% of participants after laryngoscopy. Vocal cord dysfunction was diagnosed in an additional 17 cases when not expected clinically but discounted when suspected clinically in 12 participants. Muscle tension dysphonia was diagnosed in an additional 31 cases when not suspected clinically and not confirmed when suspected in 2. CONCLUSION: This study demonstrated that conditions such as muscle tension dysphonia and vocal cord dysfunction cannot be diagnosed based on symptoms alone. In addition to diagnostic accuracy, functional laryngoscopy enhances treatment planning and provides immediate feedback regarding laryngeal movement during respiration and phonation.

Feasibility and clinical utility of ambulatory cough monitoring in an outpatient clinical setting: a real-world retrospective evaluation.

RESEARCH QUESTION: Objective quantification of cough is rarely utilised outside of research settings and the role of cough frequency monitoring in clinical practice has not been established. This study examined the clinical utility of cough frequency monitoring in an outpatient clinical setting. METHODS: The study involved a retrospective review of cough monitor data. Participants included 174 patients referred for treatment of cough and upper airway symptoms (103 chronic cough; 50 inducible laryngeal obstruction; 21 severe asthma) and 15 controls. Measures, taken prior to treatment, included 24-h ambulatory cough frequency using the Leicester Cough Monitor, the Leicester Cough Questionnaire and Laryngeal Hypersensitivity Questionnaire. Post-treatment data were available for 50 participants. Feasibility and clinical utility were also reported. RESULTS: Analysis time per recording was up to 10 min. 75% of participants could use the monitors correctly, and most (93%) recordings were interpretable. The geometric mean cough frequency in patients was 10.1±2.9 (mean±sd) compared to 2.4±2.0 for healthy controls (p=0.003). There was no significant difference in cough frequency between clinical groups (p=0.080). Cough frequency decreased significantly following treatment (p<0.001). There was a moderate correlation between cough frequency and both cough quality of life and laryngeal hypersensitivity. Cough frequency monitoring was responsive to therapy and able to discriminate differences in cough frequency between diseases. CONCLUSION: While ambulatory cough frequency monitoring remains a research tool, it provides useful clinical data that can assist in patient management. Logistical issues may preclude use in some clinical settings, and additional time needs to be allocated to the process.

Lymphoedema after head and neck cancer treatment: an overview for clinical practice.

Lymphoedema is a disorder of the lymphatic system that presents as an atypical swelling and accumulation of protein-rich fluid within the interstitial spaces. Head and neck lymphoedema (HNL) is highly prevalent in patients who have been treated for head and neck cancer (HNC) and may manifest externally on the face and neck; internally within the oral cavity, pharynx or larynx; or as a combination of both. HNL is known to contribute to a wide range of physical, functional and psychological issues, and presents several unique challenges in terms of its management. This review article provides an overview of HNL for clinicians and aims to improve awareness of this condition and the impact it has on patients.

Laryngeal Dysfunction in Severe Asthma: A Cross-Sectional Observational Study.

BACKGROUND: Laryngeal disorders can contribute to disease burden in severe asthma yet the nature of laryngeal disorders in severe asthma is poorly understood. OBJECTIVE: The aim of this study was to examine laryngeal function in patients with severe asthma. METHOD: A cross-sectional observational study involving 97 participants compared laryngeal function in patients with severe asthma (n = 53) with patients with laryngeal disorders of vocal cord dysfunction/inducible laryngeal obstruction (n = 16) and muscle tension dysphonia (n = 14), and with healthy controls (n = 13). A pre-post pilot study of speech pathology intervention for laryngeal symptoms was then provided to 11 participants with severe asthma and laryngeal dysfunction. RESULTS: Laryngeal dysfunction was common in severe asthma. The majority of participants with severe asthma (87%) had laryngeal dysfunction, which affected respiration, phonation, or both. Three distinct patterns of laryngeal dysfunction in severe asthma were identified: (1) phonatory laryngeal dysfunction, (2) respiratory laryngeal dysfunction, and (3) combined laryngeal dysfunction. Laryngeal hypersensitivity and impaired voice measures were common in severe asthma. Patient-reported outcome measures improved after therapy, and laryngeal dysfunction improved in 7 (64%) participants. CONCLUSION: Laryngeal dysfunction affects respiration and phonation in severe asthma. It requires identification and treatment to minimize its impact on asthma symptoms.

Association between external and internal lymphedema and chronic dysphagia following head and neck cancer treatment.

BACKGROUND: To examine the relationship between chronic external and internal head and neck lymphedema (HNL) and swallowing function in patients following head and neck cancer (HNC) treatment. METHODS: Seventy-nine participants, 1-3 years post treatment were assessed for external HNL using the MD Anderson Cancer Centre Lymphedema Rating Scale, and internal HNL using Patterson's Radiotherapy Edema Rating Scale. Swallowing was assessed via instrumental, clinical and patient-reported outcome measures. RESULTS: HNL presented as internal only (68%), combined external/internal (29%), and external only (1%). Laryngeal penetration/aspiration was confirmed in 20%. Stepwise multivariable regression models, that accounted for primary site, revealed that a higher severity of external HNL and internal HNL was associated with more severe penetration/aspiration (P < .004 and P = .006, respectively), diet modification (P < .001 both), and poorer patient-reported outcomes (P = .037 and P = .014, respectively). CONCLUSION: Increased swallowing issues can be expected in patients presenting with more severe external HNL and/or internal HNL following HNC treatment.

Comparing the prevalence, location, and severity of head and neck lymphedema after postoperative radiotherapy for oral cavity cancers and definitive chemoradiotherapy for oropharyngeal, laryngeal, and hypopharyngeal cancers.

BACKGROUND: This study aimed to examine the prevalence, location, and severity of chronic internal, external, and combined head and neck lymphedema (HNL) in patients with head and neck (HNC) who were treated with definitive chemoradiotherapy (CRT) or postoperative radiotherapy (PORT). METHODS: Sixty-two participants between 1 and 3 years post-treatment were recruited. Internal HNL was rated with Patterson's Scale. External HNL was graded with the MD Anderson Cancer Center Lymphedema Rating Scale. RESULTS: Ninety-eight percent of participants presented with some form of chronic HNL. Sixty-one percent had internal HNL only, 35% had combined HNL, and 2% had external HNL only. Participants treated with PORT were more likely to experience combined HNL (69% vs 24%, P = .001), whereas those treated with CRT were more likely to have internal HNL only (74% vs 25%, P = .001). CONCLUSIONS: Chronic HNL is highly prevalent following multimodal treatment, and differences in HNL presentations exist between treatment modalities.