Platelet Rich Plasma (PRP) Treatment in Recalcitrant, Bilateral Phono-traumatic Lesions.

OBJECTIVE: Mature vocal fold nodules and fibrous phono-traumatic lesions that have failed standard voice therapy can be challenging. Autologous platelet-rich plasma (PRP) is rich in growth factors and easily obtained from a simple blood draw. Growth factor injection into the vocal folds may reverse the scar and inflammation in recalcitrant, bilateral phono-traumatic lesions such as mature vocal fold nodules. This study reports the short-term (3months) voice results after PRP injection in 11 subjects with recalcitrant, bilateral phono-traumatic lesions that have failed voice therapy. MATERIALS AND METHODS: Serial autologous PRP injections were used to treat 11 patients with recalcitrant, bilateral phono-traumatic lesions in an office setting. All had prior conservative voice therapy or surgery and were deemed failures. Pre and post-treatment video stroboscopy, Voice Handicap Index (VHI-10), and Cepstral Spectral Index of Dysphonia (CSID) before and after treatment (3months) were tabulated and compared. An expert rater blinded to the treatment condition rated the stroboscopy and voice results. RESULTS: At 3months postinjection, 9 of the 11 patients reported improved VHI-10 and noted sustained voice improvement after PRP injections. Median VHI-10 changed from 20 to 13 (P < 0.05 paired t test). The CSID scores changed from 17 to 5 (NS P > 0.05, paired t test). Nine of 11 patients reported improved vocal effort and stamina. Stroboscopy ratings were better after treatment than before treatment in 7 of the 11 subjects. CONCLUSION: Short-term improvements in voice may occur in patients with recalcitrant, bilateral phono-traumatic lesions following PRP injection. PRP injections into the vocal folds may be a new treatment for nonsurgical intervention in patients with recalcitrant, bilateral phono-traumatic lesions. LEVEL OF EVIDENCE: II.

Chronic Refractory Cough: Long-Term Outcomes Following Cough Suppression Therapy.

OBJECTIVE: This study aimed to determine the long-term outcomes of patients with chronic refractory cough (CRC) following treatment for cough suppression therapy (CST). Currently, there is a lack of objective data regarding the long-term outcome of behavioral treatment for CRC. METHODS: From the charts of 106 adult patients diagnosed with CRC, 24 patients were identified as having long-term data at least 3 months post-CST in the form of otolaryngologic examination, Voice Handicap Index-10 (VHI-10), and Cough Severity Index (CSI) scores. Patients underwent otolaryngologic evaluation and completed the VHI-10 and CSI assessments during pretreatment, posttreatment, and long-term follow-up visits. Patients were also divided into two groups based on their number of comorbidities. RESULTS: Twenty of the 24 patients had significant reduction in cough severity after completing CST (P < 0.001). A significant difference was also found in CSI scores from pretherapy to the long-term follow-up visits (P = 0.001). No significant difference was found in CSI scores from posttherapy to long-term follow-up visits (P = 0.93). No significant difference was found in VHI-10 scores over time (P = 0.83). No correlation was found between changes in cough and voice severity and number of comorbidities at the tested level. CONCLUSIONS: Findings of no significant change in CRC over the long term compared to posttherapy measures suggest that patients were able to maintain improvement in cough over the long term despite various comorbidities. The current results suggest that CST represents a satisfactory approach to treating CRC and provides patients with an ongoing tool to maintain reduced cough severity. No significant correlations between number of comorbidities and mean CSI or VHI-10 scores were found over the long term.

Semi-supervised mixture multi-source exchangeability model for leveraging real-world data in clinical trials.

The traditional trial paradigm is often criticized as being slow, inefficient, and costly. Statistical approaches that leverage external trial data have emerged to make trials more efficient by augmenting the sample size. However, these approaches assume that external data are from previously conducted trials, leaving a rich source of untapped real-world data (RWD) that cannot yet be effectively leveraged. We propose a semi-supervised mixture (SS-MIX) multisource exchangeability model (MEM); a flexible, two-step Bayesian approach for incorporating RWD into randomized controlled trial analyses. The first step is a SS-MIX model on a modified propensity score and the second step is a MEM. The first step targets a representative subgroup of individuals from the trial population and the second step avoids borrowing when there are substantial differences in outcomes among the trial sample and the representative observational sample. When comparing the proposed approach to competing borrowing approaches in a simulation study, we find that our approach borrows efficiently when the trial and RWD are consistent, while mitigating bias when the trial and external data differ on either measured or unmeasured covariates. We illustrate the proposed approach with an application to a randomized controlled trial investigating intravenous hyperimmune immunoglobulin in hospitalized patients with influenza, while leveraging data from an external observational study to supplement a subgroup analysis by influenza subtype.

Targeting Tumor Microenvironment Akt Signaling Represents a Potential Therapeutic Strategy for Aggressive Thyroid Cancer.

Effects of the tumor microenvironment (TME) stromal cells on progression in thyroid cancer are largely unexplored. Elucidating the effects and underlying mechanisms may facilitate the development of targeting therapy for aggressive cases of this disease. In this study, we investigated the impact of TME stromal cells on cancer stem-like cells (CSCs) in patient-relevant contexts where applying in vitro assays and xenograft models uncovered contributions of TME stromal cells to thyroid cancer progression. We found that TME stromal cells can enhance CSC self-renewal and invasiveness mainly via the phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) pathway. The disruption of Akt signaling could diminish the impact of TME stromal cells on CSC aggressiveness in vitro and reduce CSC tumorigenesis and metastasis in xenografts. Notably, disrupting Akt signaling did not cause detectable alterations in tumor histology and gene expression of major stromal components while it produced therapeutic benefits. In addition, using a clinical cohort, we discovered that papillary thyroid carcinomas with lymph node metastasis are more likely to have elevated Akt signaling compared with the ones without metastasis, suggesting the relevance of Akt-targeting. Overall, our results identify PI3K/Akt pathway-engaged contributions of TME stromal cells to thyroid tumor disease progression, illuminating TME Akt signaling as a therapeutic target in aggressive thyroid cancer.

Incidence of Dysphonia and Dysphagia Exceeds Recurrent Laryngeal Nerve Injury During Thyroid Surgery.

OBJECTIVES: To determine the prevalence of separate and combined voice and swallowing impairments before and after total thyroidectomy and to delineate risk factors for these symptoms. METHODS: Retrospective review of 592 consecutive patients who underwent total thyroidectomy from July 2003 to August 2015. RESULTS: Combined voice and swallowing problems occurred preoperatively in 4.7% (11/234), 3.3% (3/92), and 6.0% (16/266) of patients with malignancy, hyperthyroidism, and benign euthyroid disease, respectively. Postoperatively, prevalence was 5.1%, 2.2%, and 1.9%, respectively. Benign euthyroid disease (20.7%) had the greatest risk of preoperative dysphagia (P = 0.003) and the largest glands (P < 0.001). Comparing before and after surgery, the cancer and benign euthyroid groups had decreased dysphagia (cancer: 11.5% vs. 6.0%, P = 0.034; benign: 20.7% vs. 3.8%, P < 0.001) but increased dysphonia (cancer: 19.2% vs. 28.6%, P = 0.017; benign: 15.8% vs. 27.1%, P = 0.002). Overall, 23/592 (3.9%) developed new dysphagia and 122/592 (20.6%) developed new dysphonia after surgery. Intraoperative recurrent laryngeal nerve transection occurred in 12 cases (2.0%). CONCLUSIONS: Total thyroidectomy resolved dysphagia but increased dysphonia in benign and malignant euthyroid patients. Voice and swallowing problems following thyroidectomy occurred more frequently than intraoperative recurrent laryngeal nerve transection, confirming symptoms often occur in the absence of suspected nerve injury.

Short-Term Voice Improvement after Repeated Office-Based Platelet-Rich Plasma PRP Injection in Patients with Vocal Fold Scar, Sulcus, and Atrophy.

INTRODUCTION: Improving the voice of patients with vocal atrophy, scar, and sulcus vocalis remains challenging. Platelet-rich plasma (PRP) is an autologous biological suitable for regenerative medicine. Office-based injections of PRP may serve as a source of improved wound healing. MATERIALS AND METHODS: Thirty two office based injections of PRP were performed in 14 patients with scar, sulcus, and vocal atrophy (12 scars, 1 sulcus, and 1 atrophy). PRP was prepared using 20 cc blood draw and double centrifugation method. Injection laryngoplasty was performed using trans cervical or indirect trans oral technique (10 trans cervical, 22 trans-oral). Volume of PRP use was 0.5-0.7 cc per side. Injections varied from 1 to 3 injections at monthly intervals. Videostroboscopy, Voice Handicap Index (VHI-10), and an objective analysis of the voice using Cepstral Peak Prominence (Cepstral Spectral Index of Dysphonia) were recorded. An expert rater speech pathologist rated the audio and stroboscopy results. RESULTS: Median follow-up was 15 months. No patients were made worse. The mean VHI-10 before the injection was 23. VHI-10 after the injection was 12.5 (P < 0.01). The mean Cepstral Spectral Index of Dysphonia score for CAPE-V sentence was 42.5 before the injection and 23.5 (P < 0.01) after the injection. The expert rater thought the post treatment was better (9/14 acoustic, 10/14 stroboscopy). Eleven of the 14 patients thought the intervention was worthwhile to repeat. The other 3 patients thought the improvement was transient. CONCLUSION: Office PRP injection into the vocal fold of patients with scar, sulcus, and atrophy may result in short term voice improvements. It is a biological worth considering.

The Diagnosis and Time of Onset of Voice Disorders in Patients with Chronic Cough.

OBJECTIVES: Chronic cough is a complaint of up to 46% of patients referred to specialist clinics. Patients with cough often report hoarseness at the time of the cough diagnosis. When the cough fails to resolve with standard medications, referrals to other specialists including otolaryngologists are made. This is the first study to report the specific diagnosis and length of time it took to obtain a specific voice disorder diagnosis in patients with chronic cough. STUDY DESIGN: Case Series METHODS: The charts of 105 patients referred to the Loma Linda Voice and Swallowing Center were reviewed. The first complaint of cough and/or hoarseness and the specific voice disorder diagnosis following otolaryngologic evaluation were identified. Voice disorders were divided into neurogenic or other/functional disorders and common comorbidities were identified. Statistical analysis between diagnostic groups, gender, and age were obtained. RESULTS: The specific voice disorders in the cohort were identified. There was a high prevalence of neurogenic voice disorders (n = 85, 81%). There were significant relationships between chronic cough and the two most common neurogenic voice disorders, vocal fold paresis and vocal fold atrophy. The average length of time between complaint of hoarseness and the specific voice disorder diagnosis was 32.3 months. Most patients (86%) complained of voice problems after diagnosis of chronic cough. A significant association was found in prevalence of asthma (OR = 4.52, P = 0.02) and dyspnea (OR = 4.24, P = 0.02) in the cohort who presented first with voice complaints and later developed chronic cough. CONCLUSIONS: There is a high incidence of neurogenic voice disorders accompanying patients with chronic cough. Understanding the relationship between chronic cough and hoarseness provides the clinician with specific diagnostic information in the treatment of both disorders.

Voice and Airway Outcomes of Montgomery T-tube Placement in Laryngotracheal Stenosis.

OBJECTIVES: To describe voice and airway outcomes and complications experienced by patients with laryngotracheal stenosis following Montgomery T-tube placement. METHODS: Retrospective chart review of all patients with laryngotracheal stenosis and Montgomery T-tube placement treated at a tertiary referral center from 2012 to 2021. RESULTS: Eighteen patients met criteria with laryngotracheal stenosis, seven including the level of the glottis and 11 without glottal involvement. Eleven were completely aphonic before T-tube placement and the remainder had severe dysphonia. There was improvement of Voice Handicap Index-10, Reflux Symptom Index, and GRBAS grade following T-tube placement in patients compared to their preoperative values. Improvement of grade was greater in patients without glottal involvement. Complications of chronic indwelling T-tube included granulation in 14 patients (78%), tracheitis in two patients (11%), and mucus plugging in three patients (17%) with one T-tube related mortality. Five patients were eventually decannulated, six returned to tracheostomy tube, and seven retained the T-tube at last follow-up (average: 30 months, range: 4-80 months). CONCLUSIONS: Montgomery T-tube placement improves voice in patients with severe dysphonia secondary to laryngotracheal stenosis with and without glottal involvement though the degree of improvement is greater in patients without glottal involvement. T-tube can help reestablish long-term laryngotracheal continuity in patients with no other surgical options. The potential benefits in phonation should be weighed against the possibility of rare but serious adverse events.

Expiratory Muscle Strength Treatment for Refractory Chronic Cough: A Short-term Single Exercise Program.

OBJECTIVES: Patients with chronic cough are some of the most challenging to treat. This preliminary study is the first to examine the effects of a single exercise muscle strength training program to reduce cough severity in patients who failed other treatments. METHODS: A total of 19 females were included in this study, ranging from age 24 to 80. The maximum phonation time (MPT), laryngeal airway resistance (LAR), maximum inspiratory pressure (MIP) and maximum expiratory pressure (MEP), Voice Handicap Index-10, (VHI-10) and the Cough Severity Index (CSI) values were obtained pre- and post-treatment. ANOVA two-factor without replication was used to compare values pre- and post-treatment. RESULTS: MIP (Mean of 62.00 to a mean of 78.53) and MEP (Mean of 90.00 to a mean of 112.16) showed significant increase post-treatment. In addition, LAR (Mean of 73.30 to a mean of 60.67) and CSI (Mean of 19.37 to a mean of 15.00) significantly decreased post-treatment. General changes in pre- and post-treatment values were identified with MPT (Mean of 14.89 to a mean of 16.17) and VHI-10 (Mean of 8.00 to a mean of 6.76). A follow-up questionnaire indicated that the majority of patients felt their cough was better after 4 weeks. CONCLUSIONS: Muscle strength training provides a tool to aid in the control of cough for patients who are refractory to medical and other behavioral treatments. Improvement in cough may be associated with a reduction in subglottic pressure and increased air flow resulting in lower laryngeal airway resistance.

Recent Laryngology Fellowship Graduates: Where Are They Now?

OBJECTIVES: Over the past 30 years laryngology fellowships have grown in number and diversity. This study investigated the career trajectories of recent laryngology fellowship graduates with the purpose of informing residents considering fellowship. STUDY DESIGN: Cross-sectional survey. SETTING: Academic medical center. METHODS: The directors of all 27 US laryngology fellowships that graduated/recruited fellows from 2010 to 2019 were contacted, and a list of former fellows was compiled. A short survey was administered in person or via email or phone. Additional data was gathered through internet searches. RESULTS: One hundred eighty-three fellows were identified having completed American laryngology fellowships between 2010 and 2019 (100M:83F). Fifteen percent now practice internationally and 68% are in academic practice. A higher proportion of women than men enter laryngology fellowship after otolaryngology residency. One hundred twenty-nine fellows responded to our survey. Two-thirds of former fellows report current participation in laryngology research. Seventy-two percent of former fellows are still in their first job after fellowship and 53% believe they have their ideal practice. Women were more likely to enter academics than men after laryngology fellowship. Responders were overwhelmingly satisfied with their fellowship experience, with 95% saying they would choose to pursue fellowship training again. CONCLUSIONS: Most former laryngology fellows enter academia, contribute to laryngology research, practice away from their training institution, and believe they have found their ideal practice. The results of this study may be useful to residents considering fellowship training, centers considering establishing laryngology fellowships, and practices recruiting fellowship graduates.

High Speed Video Observations of Vocal Fold Kinematics While Playing a Clarinet.

INTRODUCTION: In this pilot study, flexible high-speed video (HSV) technology with synchronized audio is used to visualize vocal fold behavior in a wind instrumentalist. Specifically, this study aims to contribute to describing the vocal fold behavior of a professional clarinet musician playing varying tones and melodies. METHOD: Vocal folds of a healthy 26-year-old professional clarinet musician were recorded utilizing a HSV camera coupled to a flexible endoscope, which allowed the synchronous recording of audio with vocal fold movement at the onset, playing, and offset of playing. Two raters experienced with analyzing vocal folds described vocal fold motion of each sample. Samples were processed through a software model to determine the vocal fold movement relative to their position at rest. Digital kymograms (DKGs) were additionally obtained to visualize vocal fold micromovements throughout each sample. RESULTS: At the onset of playing, the raters observed the vocal folds moving to a paramedian position. Vocal fold adduction varied according to the task performed and ranged from 58% to 77% of the original resting glottis width. The calculated changes in glottis width and DKGs were consistent with the descriptions by the raters. CONCLUSION: This study demonstrates the utility of flexible HSV in observing vocal fold motion before, during, and after events other than sustained phonation. The incomplete adducted vocal fold postures observed while playing the clarinet not only differ from phonation but also differ depending on task. These various postures may contribute to voice fatigue in wind instrumentalists or to various disorders experienced during their careers.

Voice assessment of fat injection vs medialization laryngoplasty in nonparalytic dysphonia.

OBJECTIVE: Compare long-term voice outcomes in patients treated with FIM or BML for nonparalytic dysphonia. There is controversy whether fat injection medialization (FIM) is a durable alternative to bilateral medialization laryngoplasty (BML) for nonparalytic dysphonia (atrophy, sulcus, scar, paresis). Both interventions yield improved voice quality, yet comparison of patients' long-term perceptions of their voice after these procedures has not been performed. METHODS: Retrospective review of patients who underwent FIM or BML for nonparalytic dysphonia was performed from 2008-2018. Charts were reviewed for demographic information, preoperative diagnosis, intervention, Voice Handicap Index-10 (VHI-10), and follow-up time. RESULTS: Forty-nine patients met our criteria. Fifty procedures were performed (25 FIM, 25 BML). One patient underwent BML with subsequent FIM. There was no significant difference in pre-treatment or post-treatment VHI-10 scores between both groups (Pre-FIM 21 Post-FIM 10.28; Pre-BML 22.48, Post-BML 10.88). Total median follow-up time was 11.3 months (FIM 14.8 months, BML 9.5 months). Using VHI-10 scores recorded at each patient's latest follow-up visit, both groups demonstrated significant decrease (P < .05) compared to preoperative scores: VHI-10 decreased by a mean delta of 10.72 in the FIM group and 11.6 in the BML group. There was no significant difference in pre, post and change in VHI between groups. CONCLUSIONS: In patients with nonparalytic dysphonia, FIM is a durable alternative to BML. Patients treated in both groups gained substantial improvement in vocal function. For both treatment groups, we should anticipate less than complete satisfaction with surgery and revision procedures in a minority of patients. LEVEL OF EVIDENCE: IV.

Effects of Cough Suppression Therapy on Voice Disorder Severity.

OBJECTIVES//HYPOTHESIS: To determine changes in voice severity when treating chronic cough refractory to medical treatment with cough suppression therapy (CST) in patients with chronic cough and voice complaints. Chronic cough has been reported to be refractory to medical treatment and frequently co-occurs with voice disorders. The possible effects of CST on self-assessed changes in chronic cough and voice disorders have not been demonstrated. STUDY DESIGN: Retrospective analysis of the effects of cough suppression therapy (CST) on self-assessed changes in chronic cough and voice disorder severity in patients with both chronic cough and voice disorders. METHODS: Forty-three adult patients with the primary complaint of chronic refractory cough underwent pre- and post-treatment diagnostic examinations, completed pre- and post-treatment Voice Handicap Index-10 (VHI-10) and Cough Severity Index assessments, and were treated by a licensed speech-language pathologist using CST. Twenty-seven subjects were assigned to the cough (C) group and 16 to the cough-voice (CV) group based on the severity of their VHI-10 scores. RESULTS: Post-test analysis showed significant improvement in cough severity for both groups and significant improvement in voice severity for the CV group. The VHI-10 scores for the C group did not change significantly. The median number of treatment sessions was 3, with a range of 1-13 sessions. Correlation between changes in severity and number of treatment sessions was not found to be significant at the tested level. CONCLUSIONS: CST represents a unifying approach for treatment of patients with CRC and comorbid voice disorders. CST offered cross-over effects to the voice when subjects were treated for their primary complaint of chronic cough. This treatment of the primary complaint improves function in systems that share a common pathway. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2747-2751, 2021.

Chronic Refractory Cough: Objective Improvement With Aerodynamic-Focused.

OBJECTIVE: Previous investigations have reported that a chronic cough that is refractory to medical therapies improves with behavioral therapies. However, the treatment parameters that may account for improvement in cough symptoms have not yet been objectively documented. The purpose of this study was to document changes in chronic refractory cough using a breath training protocol. METHODS: The charts of 27 patients with a long-term chronic cough (>6 months) refractory to various medical treatments were reviewed. These patients received 2-4 sessions of breath training therapy over a 6-month period. Treatment sessions consisted of breathing modification exercises such as those reported in the literature. Aerodynamic parameters including mean estimated subglottal air pressure, mean airflow rate, laryngeal airway resistance, and maximum phonation time were obtained before treatment and 6 months after therapy. Patients also completed the Cough Severity Index at the first visit and 6 months after treatment. RESULTS: Twenty four of the 27 patients (M:F = 6:21), with a mean age of 62.4 (range = 28-78, median = 66) had significant Cough Severity Index improvement from 16.74 to 10.04 (P< 0.001) after therapy. Maximum phonation time increased significantly from 12.00 to 16.38 seconds (P= 0.006); mean estimated subglottic air pressure decreased significantly from 7.58 to 6.36 cm H2O (P= 0.004); laryngeal airway resistance decreased significantly from 52.97 to 40.64 ppm (P= 0.013). CONCLUSION: This investigation provides evidence that patients who followed a protocol that focused on a breath training program reduced their chronic cough. Significant relationships between patient self-assessment of chronic cough and aerodynamic measures of subglottic pressure and glottal airway resistance were found in this group.

Vibratory Onset of Adductor Spasmodic Dysphonia and Muscle Tension Dysphonia: A High-Speed Video Study✰.

OBJECTIVE: Adductor spasmodic dysphonia (AdSD) is a challenging voice disorder to diagnose, often erroneously diagnosed as muscle tension dysphonia (MTD) or vocal tremor, due to its similarity in auditory and perceptual presentation. Assessments using laryngoscopy or strobolaryngoscopy procedures have demonstrated limited utility in the diagnosis of spasmodic dysphonia. High-speed videoendoscopy (HSV) provides visualization of the precise vibratory pattern of phonatory onset and thus, offers an alternative to previous diagnostic strategies for visual diagnosis of AdSD. The purpose of this study was to examine vibratory onset of patients with AdSD and patients with MTD using HSV methodology. METHODS: HSV of six adults with AdSD and five adults with MTD were captured during sustained phonation. Digital kymography was used to obtain precise vibrogram data at the mid-membranous region of the vocal fold prior to and at the onset of phonation. Voice onset delay was examined by (1) quantifying timing of prephonatory delay and steady state delay and (2) describing vocal fold onset movements qualitatively in each diagnosis. RESULTS: HSV adequately captured the phonatory onset of the vocal folds. Voice onset delay was not significantly different between AdSD and MTD. However, there were distinct differences in voice onset gestures. Both AdSD and MTD patients presented with vocal hyperfunction during the onset of phonation. In a subset of AdSD patients, a rapid sustained adduction occurred following the initial vibratory motion. Vocal fold vibration then continued until steady phonation was achieved. This oscillatory break pattern was not observed in patients with MTD. Therefore, there appears to be differences in vocal fold vibratory onset motion between MTD and AdSD. CONCLUSION: HSV captures the precise vibratory onset in patients with MTD and AdSD. Differences were most notable after vibratory onset as opposed to vibratory delay measurements. Examination of voice onset gesture may offer an additional laryngeal parameter to assist in the differential diagnosis of spasmodic dysphonia.

Checking for voice disorders without clinical intervention: The Greek and global VHI thresholds for voice disordered patients.

Voice disorders often remain undiagnosed. Many self-perceived questionnaires exist for various medical conditions. Here, we used the Greek Voice Handicap Index (VHI) to address the aforementioned problem. Everyone can fill in the VHI questionnaire and rate their symptoms easily. The innovative feature of this research is the global cut-off score calculated for the VHI. Therefore, the VHI is now capable of helping clinicians establish a more customizable treatment plan with the cut-off point identifying patients without normal phonation. For the purpose of finding the global cut-off point, a group of 180 participants was recruited in Greece (90 non-dysphonic participants and 90 with different types of dysphonia). The voice disordered group had higher VHI scores than those of the control group. In contrast to previous studies, we provided and validated for the first time the cut-off points for all VHI domains and, finally, a global cut-off point through ROC and precision-recall analysis in a voice disordered population. In practice, a score higher than the well-estimated global score indicates (without intervention) a possible voice disorder. Nevertheless, if the score is near the threshold, then the patient should definitely follow preventive measures.

Quality of Life and Voice Changes After a Single Injection in Patients With ADSD Over Time.

INTRODUCTION: Adductor spasmodic dysphonia (ADSD) is one of the most disabling voice disorders with no permanent cure. Patients with ADSD suffer from poor voice quality and repeated interruption of phonation that leads to limitations in daily communication. Botox (BT) injection, considered the gold standard treatment for ADSD, reduces the amount of voice breaks and improves voice quality for a limited period. In this study, patients with ADSD were followed after a single BT injection to track the changes in QOL and perceptual voice quality over a 6-month period. METHOD: This is a prospective and longitudinal study. Fifteen patients with ADSD were evaluated preinjection and 1, 3, and 6 months postinjection. They completed the Voice Activity and Participation Profile-Persian Version (VAPPP) and read a passage at each recording period. Perceptual assessment was done by three expert speech-language pathologists with knowledge of ADSD using the grade, roughness, breathiness, asthenia, strain (GRBAS) scale. The data were analyzed using Friedman, Wilcoxon, and McNemar tests. The significance level was set at P < 0.05. RESULTS: The VAPPP total score and each of the domain scores reached their peak scores at 3 months postinjection. At 6 months postinjection, the VAPPP scores increased significantly in comparison with the 3-month scores and but were lower than preinjection scores. GRBAS results also indicated that patients' voices at 1 and 3 months postinjection were significantly less severe in terms of strain and roughness (P = 0.01; P < 0.001, respectively). CONCLUSION: BT injection resulted in improvement of subjects' QOL. The improvement was greatest at 3 months postinjection but remained above the preinjection values at 6 months after injection. The voice quality also improved but was not judged as normal.

Aerodynamic Characteristics of Syllable and Sentence Productions in Normal Speakers.

BACKGROUND: Aerodynamic measures of subglottic air pressure (Ps) and airflow rate (AFR) are used to select behavioral voice therapy versus surgical treatment for voice disorders. However, these measures are usually taken during a series of syllables, which differs from conversational speech. Repeated syllables do not share the variation found in even simple sentences, and patients may use their best rather than typical voice unless specifically instructed otherwise. This study examined the potential differences in estimated Ps and AFR in syllable and sentence production and their effects on a measure of vocal efficiency in normal speakers. METHODS: Prospective study. Measures of estimated Ps, AFR, and aerodynamic vocal efficiency (AVE) were obtained from 19 female and four male speakers ages 22-44 years with no history of voice disorders. Subjects repeated a series of /pa/ syllables and a sentence at comfortable effort level into a face mask with a pressure-sensing tube between the lips. RESULTS: AVE varies as a function of the speech material in normal subjects. Ps measures were significantly higher for the sentence-production samples than for the syllable-production samples. AFR was higher during sentence production than syllable production, but the difference was not statistically significant. AVE values were significantly higher for syllable versus sentence productions. CONCLUSIONS: The results suggest that subjects increase Ps and AFR in sentence compared with syllable production. Speaking task is a critical factor when considering measures of AVE, and this preliminary study provides a basis for further aerodynamic studies of patient populations.

Assessment of Clinical and Social Characteristics That Distinguish Presbylaryngis From Pathologic Presbyphonia in Elderly Individuals.

Importance: An aging population experiences an increase in age-related problems, such as presbyphonia. The causes of pathologic presbyphonia are incompletely understood. Objective: To determine what distinguishes pathologic presbyphonia from presbylaryngis. Design, Setting, and Participants: This was a cohort study at an outpatient otolaryngology subspecialty clinic of a tertiary academic referral center. Participants were consecutive consenting adults older than 74 years without laryngeal pathologic abnormalities who visited the clinic as participants or companions. Patient questionnaires, otolaryngologic, video stroboscopic, and voice examinations were compiled. Patients were divided into groups based on whether they endorsed a voice complaint. Three blinded authors graded stroboscopic examinations for findings consistent with presbylaryngis (vocal fold bowing, vocal process prominence, glottic insufficiency). Main Outcomes and Measures: Voice Handicap Index-10, Reflux Symptom Index, Cough Severity Index, Dyspnea Index, Singing Voice Handicap Index-10 , Eating Assessment Tool -10, Voice-Related Quality of Life (VRQOL), and Short-Form Health Survey; face-sheet addressing social situation, work, marital status, education, voice use, transportation; acoustic and aerodynamic measures; and a full otolaryngologic examination, including videostroboscopic imaging. Results: A total of 31 participants with dysphonia (21 were female; their mean age was 83 years [range, 75-97 years]) and 26 control participants (16 were female; their mean age was 81 years [range, 75-103 years]) completed the study. Presbylaryngis was visible in 27 patients with dysphonia (87%) and 22 controls (85%). VHI-10 and VRQOL scores were worse in patients with pathologic presbyphonia (median [range] VHI-10 scores, 15 (0-40) vs 0 (0-16) and median VRQOL score, 19 [0-43] vs 10 [10-23]). All other survey results were indistinguishable, and no social differences were elucidated. Acoustic measures revealed that both groups averaged lower than normal speaking fundamental frequency (mean [SD], 150.01 [36.23] vs 150.85 [38.00]). Jitter was 3.44% (95% CI, 2.46%-4.61%) for pathologic presbyphonia and 1.74% (95% CI, 1.35%-2.14%) for controls (d = 0.75). Shimmer means (95% CI) were 7.8 2 (6.08-10.06) for the pathologic presbyphonia group and 4.84 (3.94-5.72) for controls (d = 0.69). Aerodynamic measures revealed an odds ratio of 3.03 (95% CI, 0.83-11.04) for patients with a maximum phonation time of less than 12 seconds who had complaints about dysphonia. Conclusions and Relevance: Presbylaryngis is present in most ambulatory people older than 74 years. Some will endorse pathologic presbyphonia that has a negative effect on their voice and quality of life. Pathologic presbyphonia seems to be influenced by respiratory capacity and sex. Further study is required to isolate other social, physiologic, and general health characteristics that contribute to pathologic presbyphonia.

Perception and duration of pain after office-based vocal fold injection augmentation.

OBJECTIVES/HYPOTHESIS: In-office laryngology procedures are important in the treatment of voice and swallowing disorders. Patient tolerance determines which procedures can be performed without sedation or formal anesthesia. This study examines pain perception during and after in-office vocal fold injection augmentation. STUDY DESIGN: Prospective cohort study. METHODS: Patients scheduled for office-based vocal fold injection augmentation were prospectively enrolled at an academic voice center. The short-form McGill Pain Questionnaire was administered before, during, and after the procedure and on postprocedure days 1, 3, and 7. Pre- and postprocedure vital signs were recorded and heart rate was continuously monitored. Telephone questionnaires were completed on postprocedure days 1 and 3. RESULTS: Forty-five patients consented to participate in our study (24 males, mean age 61 years). Most patients experienced mild to moderate pain with increasing heart rate during the procedure. Pain remained or increased 20 minutes after the procedure and improved but persisted for 1 day. Sensory and affective discomfort was endorsed by the majority. A minority of patients experienced bruising and changes in swallowing with diet modification for 3 days after the procedure. Sixteen percent had discomfort after 1 week. CONCLUSIONS: This is the first prospective study examining patient perception of pain during and after in-office injection augmentation using a validated scale and pain descriptors with extended follow-up. The results may offer guidance for patient counseling, consent, and treatment to improve tolerance and success. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:929-934, 2018.