Dysphonia in Pediatric Professional Voice Users: Is It Just Nodules?

OBJECTIVES/HYPOTHESIS: Professional voice users of any age are often concerned about nodules, particularly in pediatric singers. However, an accurate diagnosis allows formulation of an optimal management plan and a successful continuation of these young patients' careers. There is very little literature regarding pediatric professional singers; we aimed to share our experience of over a decade of referrals to our tertiary pediatric voice clinic. STUDY DESIGN: This was a retrospective review. METHODS: A retrospective review was undertaken of all consecutive patients aged 0-18 years who self-identified as professional voice users and attended our tertiary pediatric voice clinic between December 2010 and December 2021. We analyzed demographics, professional singing status, diagnosis, management, and clinical voice scores. The patients were subdivided into those aged 0-9, 10-16, and 17-18 years. RESULTS: A total of 113 pediatric professional voice users attended the tertiary voice clinic in the study period. The commonest self-reported voice use was as a singer. Within the 0-9 years age group, there was a strong male predominance (22 males and three females) and mostly organic (52%) causes. For ages 10-16 years, there was a noted female predominance (15 males and 29 females). In the 17-18 years age group, there was a strong female predominance (10 males and 34 females), with predominantly functional diagnoses (48%). Of significance, only five of the 113 patients had nodules (4.4%). CONCLUSIONS: We present a large data set of pediatric professional voice users and demonstrate the numerous underlying diagnoses for their dysphonia, particularly functional disorders. Our experience highlights the need for adequate vocal training for pediatric professional voice users and the need for a multidisciplinary diagnostic and management approach.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: An International Electronic Delphi Consensus Study.

INTRODUCTION: Voice therapy management of benign vocal fold lesions (BVFLs) is variable and there are currently no clinical guidelines. Poor descriptions of voice therapy interventions lead to unwarranted variation in treatment. Triangulation of the current evidence identifies a number of potential best practice elements, but also a number of outstanding questions to be explored. The aim of this study was to refine and gain global consensus on "best practice" for a pre- and postoperative voice therapy intervention for adults with BVFLs. METHODS: An international sample of expert voice therapists (n = 42) were recruited to take part in this three-round electronic modified Delphi study. Participants were presented with statements concerning a pre- and postoperative voice therapy intervention. Statements were developed from previous research and based on the TIDieR checklist (eg, why, when, what, how?) Participants rated the extent to which they agreed or disagreed with a statement and gave comments to support their response. Consensus was defined as >75% of participants agreeing or strongly agreeing with a given statement. If consensus was not reached, participant comments were used to generate new statements and were rated in the next round. Stability of consensus between rounds was assessed. RESULTS: The 42 international experts achieved consensus on 33 statements relating to components of a best practice pre- and postoperative voice therapy intervention for patients with BVFLs. Consensus on statements ranged from 81% to 100%. These statements were explicitly mapped to the TIDieR checklist to ensure that all aspects of the intervention were considered and the questions of "why, what, how, when and individual tailoring" were addressed. CONCLUSIONS: This study has significantly enhanced our understanding of what should be in a best practice pre- and postoperative voice therapy intervention. It is important to now test these findings for acceptability and feasibility, prior to considering effectiveness research.

Pre and Post-operative Voice Therapy Intervention for Benign Vocal Fold Lesions: A Systematic Review.

Benign vocal fold lesions cause dysphonia by preventing vocal fold closure, causing irregular vibration and increasing compensatory muscle tension. Voice therapy delivered in addition to phonosurgery may improve voice and quality of life outcomes but the evidence base is lacking and what constitutes voice therapy for this population is not defined. The purpose of this systematic review is to critically evaluate the evidence for pre and post-operative voice therapy to inform the development of an evidence based intervention. STUDY DESIGN: Systematic Review. METHODS: Electronic databases were searched using key terms including dysphonia, phonosurgery, voice therapy and outcomes. Eligible articles were extracted and reviewed by the authors for risk of bias and for information regarding the content, timing and intensity of any pre and post-operative voice therapy intervention. RESULTS: Of the 432 articles identified, 35 met the inclusion criteria and were included in the review. 5 were RCTs, 2 were individual cohort studies, 1 was a case control study and 26 were case series. There was considerable heterogeneity in participant characteristics. Information was frequently lacking regarding the content timing and intensity of the reported voice therapy intervention, and where present, interventions were highly variable. CONCLUSION: Reporting in relevant literature is limited in all aspects of content, timing and intensity of intervention. Further intervention development work is required to develop a robust voice therapy treatment intervention for this population, before effectiveness work can commence.

From Voice Clinic to Operating Room: Are We Out of Tune?

INTRODUCTION: To determine the consistency and accuracy of preoperative diagnosis in the voice clinic with intraoperative diagnosis and to suggest a standardized laryngeal examination protocol in the UK that is supported by evidence-based findings. METHOD: From January 2011-September 2014, 164 patients were referred to the Multidisciplinary Team voice clinic and diagnosed with laryngeal pathology that required phonosurgery. The visualization (videostrobolaryngoscopy) in clinic was performed using either rigid laryngoscope or a video-naso-laryngoscope. Intraoperatively, laryngeal visualization and surgical procedure was conducted using Storz Aida HD system, 10-mm rigid laryngoscope 0° or 5-mm rigid laryngoscope 0°/30° and a Zeiss S7 microscope. RESULTS: Of the 164 patients seen in the multidisciplinary voice clinic, 86 clinic diagnoses were confirmed intraoperatively (52.4%), 15 patients had the diagnosis confirmed intraoperatively with additional lesion found (9.1%). The clinic diagnosis changed intraoperatively in 63 cases (38.4%). 61 (37.2%) patients seen in the voice clinic were diagnosed with cyst, in 39.3% the diagnosis was confirmed intraoperatively with 5 cases (8.2%) having an additional diagnosis. Twenty (12.2%) patients were diagnosed with polyps, with 80% confirmation intraoperatively; 3 patients (10%) had an additional diagnosis. CONCLUSION: Videolaryngostroboscopy imaging of the larynx provides an outpatient tool for accurately diagnosing more than 50% of laryngeal pathologies when interpreted by multidisciplinary voice clinicians. However direct laryngeal examination under general anesthesia remains the gold standard when obtaining accurate diagnoses of laryngeal pathology. Patients diagnosed with nonorganic voice disorders should be considered for direct laryngoscopy under general anesthetic should they fail to respond to conservative management.

Management of laryngeal papillomatosis using coblation: another option of surgical intervention.

PURPOSE: Recurrent respiratory papillomatosis is a disease caused by the human papilloma virus (HPV). HPV is frequently localised in the larynx. The disease tends to recur and frequent intervention is usually required. Management modules include surgical intervention using microdebriders or laser ablation as well as adjuvant treatments which aim mainly at maintaining an adequate airway and secondly to manage dysphonia caused by the growth on the vocal folds. In this pilot study, another surgical modality is trialled using plasma-mediated radio-frequency ablation (coblation). METHODS: Retrospective study examining management of 15 adult patients diagnosed with recurrent laryngeal papillomatosis and surgically treated using coblation. One patient required multiple procedures. Pre-operative assessment in voice clinic evaluating voice quality and its impact on patients' life-quality using voice parameters and self-assessment questionnaires. Follow-up post-operatively using the same parameters from 4 to 6 weeks after surgery until up to 2 years later to check recurrence rate. No other adjuvant treatment was used and all patients received post-operative voice therapy. RESULTS: 78.6% of patients did not show evidence of recurrence during the study period. Improvement in voice handicap following first intervention is reported and recurrence rate in the rest of the sample reported. CONCLUSIONS: The results of this small sample seem to support the previous small studies' findings that coblation is a good excisional technique to use for removal of laryngeal papillomatosis. Recurrence rates seem to be slightly lower than rates reported in the literature for the other surgical modalities. LEVEL OF EVIDENCE: IV.