A summary of the Clinical Practice Guideline for the Diagnosis and Management of Voice Disorders, 2018 in Japan.

OBJECTIVE: To develop a summary of the first version of the Clinical Practice Guideline of Voice Disorders for Diagnosis, Management, and Treatment in Japan by the Clinical Practice Guideline Committee of the Japan Society of Logopedics and Phoniatrics and The Japan Laryngological Association. The 2018 recommendations, based on a review of the scientific literature, are intended to serve as clinical practice guidelines for the diagnosis, management, and treatment of voice disorders in Japan. METHODS: A summary of the original version of the Clinical Practice Guideline of Voice Disorders for Diagnosis, Management, and Treatment in Japan was described. Recommendations for the diagnosis, management, and treatment of voice disorders were prepared. Twelve clinical questions (CQs) regarding the diagnosis, management, treatment, and effectiveness of therapy for voice disorders were also prepared. RESULTS: A summary of the first version of the clinical practice guidelines for the diagnosis, management, and therapy of voice disorders was prepared and is presented. Additionally, answers to the 12 CQs on the diagnosis, management, treatment, and effectiveness of voice disorder therapy were prepared, and include evidence-based recommendations. CONCLUSION: These guidelines present a summary of the standard approaches for the diagnosis and treatment of voice disorders and relevant CQs that consider the medical environments in Japan. We hope that the guidelines will assist physicians in clinical settings for patients with voice disorders.

Diagnosis and management of unilateral thyroarytenoid muscle palsy.

The objective of this study is to assess and propose a method of diagnosis and management of patients with unilateral thyroarytenoid muscle palsy (TAMP). This is a retrospective review of clinical records. The records of seven patients diagnosed as having idiopathic TAMP were reviewed. Despite the adductive and abductive functions of the vocal folds being within normal range, apparent palsy was seen in the unilateral thyroarytenoid muscle of these patients. TAMP was confirmed by laryngeal electromyography, and the adductive and abductive movements of the vocal folds were evaluated as the mobility of the arytenoid cartilages by three-dimensional computed tomography and endoscopy. Most of patients with TAMP had been diagnosed as having other diseases or normal, and in one patient, it took over 6 years to establish a correct diagnosis. Two patients recovered by conservative treatment; however, in five patients, TAMP remained even after 6 months. In 4 of those 5 patients, treatment with hyaluronic acid injections was performed. In the remaining patient, surgical treatment, namely, nerve-muscle pedicle flap implantation was performed, which resulted in a favorable recovery of phonation. The average maximum phonation time (MPT) of all patients was extended from 11.4 (±4.4) s before treatment to 19.9 (±4.3) s after treatment, and the pitch range was also increased from 25.1 (±7.2) to 34.6 (±5.8) semitones following our management course. Our results indicate that there is a possibility that TAMP can be diagnosed and treated sufficiently. Therefore, further research toward establishing the concept of and treatment for TAMP is anticipated.

[Botulinum toxin injection into the cricopharyngeal muscle for dysphagia: report of 2 successful cases].

Dysphagia is frequently observed in patients with sequelae after multiple cerebral infarctions and those with neuromyopathy. Dysphagia in these patients can be successfully treated by laryngeal suspension and cricopharyngeal myotomy. Surgery is not indicated in senile patients with serious complications, where conservative treatment is performed. We injected botulinum toxin into the right cricopharyngeal muscle with excellent results in two dysphagic patients with multiple cerebral infarction who refused surgery. There two cases developed dysphasia after multiple cerebral infarction, where surgical therapy was not indicated. Dysphagia is successfully treated by 5 units of botulinum toxin injected into the cricopharyngeal muscle. Botulinum toxin injection is considered useful for dysphagia in patients in whom surgery is not indicated. The effect of botulinum toxin lasts for 3 to 4 months. Injection of botulinum toxin is useful for patients with temporary dysphasia after cerebral infarction and soon improves swallowing with the assistance of rehabilitation.

Hoarseness caused by unilateral vocal fold paralysis: how long should one delay phonosurgery?

We present a case of idiopathic right vocal fold paralysis which resolved completely 18 months after onset. Instead of using surgery to improve the hoarseness of our patient, our experience suggested that speech therapy might be effective. Although the voice can be improved by overadduction of the healthy vocal fold, as surgery is irreversible it is better to wait for 18 months after onset in case spontaneous recovery occurs. During this period, one should of course continue to investigate the origin of the paralysis.

Involuntary expiratory phonation as a dose-related consequence of L-dopa therapy in a patient with Parkinson's disease.

We report a case of involuntary phonation caused by abnormal vocal cord movements during expiration in a patient with Parkinson's disease. A 60-year-old woman had been treated for parkinsonism at the outpatient clinic of the Department of Neurology since August 1999. She began to groan involuntarily in the daytime in September 2001. She could not eat well while groaning. Stridor was not noted during sleep at night. Endoscopic examination of the larynx revealed insufficient abduction of the bilateral vocal cords, although the glottis was not so small as to cause stridor during inspiration. During expiration, however, the vocal cords adducted, resulting in the involuntary production of voice. Electromyography showed an increase in the activity of the thyroarytenoid and lateral cricoarytenoid muscles. This muscle activity was further enhanced during inspiration. The involuntary phonation disappeared when the patient's dose of L-dopa was decreased, although she had a decrease in her systemic mobility as well. When the dose of L-dopa was increased to the therapeutic level, involuntary phonation recurred, and her voluntary systemic activity improved. In the present case, it was considered that excessive dopaminergic denervation occurred in the nerve innervating the laryngeal adductors. Involuntary voice appeared to be produced by hypertonus of the laryngeal adductors because of a lowering in the threshold level for L-dopa, even though the drug was administered at the usual dose.