Patients' Demographics and Risk Factors in Voice Disorders: An Umbrella Review of Systematic Reviews.

OBJECTIVES: This study aimed to provide a comprehensive overview of the systematic reviews that focus on the prevalence of voice disorders (VDs), associated risk factors, and the demographic characteristics of patients with dysphonia. An umbrella review was conducted to identify general research themes in voice literature that might guide future research initiatives and contribute to the classification of VDs as a worldwide health concern. STUDY DESIGN: Umbrella review of systematic reviews. METHODS: Pubmed/Medline and Embase were searched for eligible systematic reviews by two authors independently. Extracted data items included the study publication details, study design, characteristics of the target population, sample size, region/country, and incidence and/or prevalence of the VD(s) of interest. RESULTS: Forty systematic reviews were included. Sixteen reported a meta-analysis. Great heterogeneity in methods was found. A total of 277,035 patients across the included studies were included with a prevalence ranging from 0%-90%. The countries represented best were the United States and Brazil, with 13 studies each. Aging, occupational voice use, lifestyle choices, and specific comorbidities, such as obesity or hormonal disorders, seem to be associated with an increased prevalence of dysphonia. CONCLUSIONS: This review underscores the influence of VDs on distinct patient groups and the general population. A variety of modifiable or non-modifiable risk factors, having varied degrees of impact on voice qualities, have been identified. The overall effect of VDs is probably underestimated due to factors, such as sample size, patient selection, underreporting of symptoms, and asymptomatic cases. Employing systematic reviews with consistent methodologies and criteria for diagnosing VDs would enhance the ability to determine the prevalence of VDs and their impact.

Rehearsal Sound Exposure and Choir Singers' Hearing: A Pilot Field Study.

Exposure to high- and moderate-intensity sound is inevitable for professional singers during their working day, the majority of which is spent in rehearsal, preparing for a performance. The impact of self-produced sound exposure on singers' hearing within the rehearsal setting has not been examined. OBJECTIVES: This original pilot field study investigates the feasibility of data collection and hypothesis testing of singers' hearing within the rehearsal environment. METHODS: 18 professional choir singers are examined for hearing threshold changes following routine rehearsal sound exposure. Pure Tone Audiometry is measured before, immediately after, and approximately 24 hours after rehearsal. RESULTS: This study does not identify definitive Temporary Threshold Shift in this population under these conditions. That said, mean temporary threshold shift was found 3.61 dB higher than the recovery threshold shift in the right ear at 3000 Hz (P = 0.06), and this may be important to look at for future studies. CONCLUSIONS: Methodological challenges of this field study include dynamic experimental conditions intrinsic to the rehearsal process, environmental and musical influence on Pure Tone Audiometry results and estimation of sound intensity exposure.

Adjustment of Health-Care Service Delivery Among Phoniatricians and ENT Specialists During the COVID-19 Pandemic, A UEP Survey.

BACKGROUND: Applying measures that prioritize staff safety, while protecting patient safety and care, represents a challenge during the current pandemic. Many documents of recommendations toward safe practice have been developed for this purpose. OBJECTIVE: To assess adjustments that have been undertaken by phoniatricians and otolaryngologists in the delivery of health-care services during the pandemic in order to reduce staff exposure to COVID-19 and improve safety. STUDY DESIGN: Cross-sectional. METHODS: An online self-administered survey was used during the first wave of the COVID-19 pandemic in June 2020 to collect data related to demographics of participants, their sources of information, administrative alterations, and changes they adopted when meeting patients for a consultation/procedure/surgery. RESULTS: The eligible 154 responses were grouped into 4 groups based on country of residence. Alterations to service delivery amongst the different groups were compared. CONCLUSIONS: The majority of participants were following the suggested recommendations to service delivery adjustments, with some inconsistencies in practice across countries.

Severe distinct dysautonomia in RFC1-related disease associated with Parkinsonism.

Biallelic repeat expansions in replication factor C subunit 1 (RFC1) have recently been found to cause cerebellar ataxia, neuropathy and vestibular areflexia syndrome (CANVAS). Additional features that have been described include Parkinsonism and a multiple system atrophy (MSA)-like syndrome. CANVAS can include features of dysautonomia, but they are much milder than typically seen in MSA. We report a detailed autonomic phenotype of multisystem RFC1-related disease presenting initially as CANVAS. Our patient presented aged 61 with a sensory ataxic neuropathy who rapidly developed widespread autonomic failure and Parkinsonism. The autonomic profile was of a mixed pre- and post-ganglionic syndrome with progressive involvement of sympathetic and parasympathetic cardiovascular and sudomotor function. The Parkinsonism did not respond to levodopa. We present a patient with CANVAS and biallelic RFC1 expansions who developed Parkinsonism with severe autonomic involvement similar to that seen in classical MSA. The link between MSA and CANVAS remains uncertain.

'Malregulative' Rather Than 'Functional' Dysphonia: A New Etiological Terminology Framework for Phonation Disorders-A Position Paper by the Union of European Phoniatricians (UEP).

Practitioners in the field of voice are often faced with patients who are 'dysphonic', but who do not have identifiable abnormalities of the vocal tract structures or any neural or hormonal alteration affecting the phonatory function. For lack of better nomenclature describing the origin of the disorder, this group of patients has been labeled as having 'non-organic' or 'functional' dysphonia. 'Non-organic' only states what the dysphonia is not, and 'functional' does not have any etiological implication. Hence 'functional disorder' as a determination of the origin is at best vague, imprecise and often misleading. In truth, the terms "functional" and 'non-organic' are by now so muddled and confused in everyday clinical usage and parlance that it is unclear what they mean in any given clinical setting or for any particular clinical case. Thus, the UEP Voice Committee (VC) has come to the conclusion that it is best to adopt a new term that is clearly defined, universally agreed to, and indicative of a different and more useful perspective. We have reviewed the literature relating to terminology of these phonatory disorders. We now propose replacement of the phrase 'functional dysphonia' with 'malregulative dysphonia', since the indication of faulty regulation represents an etiological connotation. We also propose a restructuring of the etiological terminology of phonation disorders. We believe this to be a biologically clearer framework for the labeling of 'non-organic' phonatory disorders, and hope that its routine use will allow for more clarity of presentation and discussion in the future.

Assessment and Management of Preoperative Anxiety.

BACKGROUND: Preoperative anxiety has the potential to alter the dynamics of an elective procedure and has been shown to detrimentally affect patients both cognitively and physiologically. If mismanaged, it can lead to essential procedures being postponed or canceled, delay postoperative recovery, and increase patients' requirements for medical intervention postoperatively. These outcomes have harmful implications both clinically and economically. Our primary objective was to evaluate the levels of anxiety patients experience immediately before elective otorhinolaryngologic procedures. Our secondary outcome was to assess the subjects' views on potential management strategies to tackle their anxiety. METHODS: This is an observational cross-sectional project evaluating 53 patients who were selected consecutively from a list of elective otorhinolaryngologic procedures. All procedures were to be completed under general anesthetic, and all patients had received the same preoperative assessment preparation. 29 male and 24 female patients were included, aged between 19 and 76 years (mean 45). The Spielberger State-Trait Anxiety Inventory was used to assess preoperative anxiety directly before the otorhinolaryngologic procedure. The Service Improvement questionnaire was used to assess whether patients would favor the introduction of anxiety-reduction measures. RESULTS: There was neither a significant increase in patient anxiety levels preoperatively (P = 0.37) nor a significant increase in anxiety levels preoperatively when results were stratified according to patient gender and age (P = 0.45 and P = 0.27). 54% of the patients felt that their anxiety would have been reduced if they had read a procedural information leaflet, and 22% felt it would have been reduced if they had received preoperative behavioral training. 17% of the patients wanted more information from the surgical team. However, 12% of the patients would have liked less information from the surgical team preoperatively. CONCLUSIONS: Patients did not have a significant increase in their anxiety levels preoperatively. On the basis of our findings, we will work to improve the information we provide to patients preoperatively and to identify patient subgroups that require additional preoperative support.

Otorhinolaryngology and Diving-Part 1: Otorhinolaryngological Hazards Related to Compressed Gas Scuba Diving: A Review.

IMPORTANCE: Scuba diving is becoming increasingly popular. However, scuba diving is associated with specific risks; 80% of adults and 85% of juvenile divers (aged 6-17 years) have been reputed to have an ear, nose, or throat complaint related to diving at some point during their diving career. Divers frequently seek advice from primary care physicians, diving physicians, and otorhinolaryngologists, not only in the acute setting, but also related to the long-term effects of diving. OBSERVATIONS: The principles underpinning diving-related injuries that may present to the otorhinolaryngologist rely on gas volume and gas saturation laws, and the prevention of these injuries requires both that the diver is skilled and that their anatomy allows for pressure equalization between the various anatomical compartments. The overlapping symptoms of middle ear barotrauma, inner ear barotrauma, and inner ear decompression sickness can cause a diagnostic conundrum, and a thorough history of both the diver's symptoms and the dive itself are required to elucidate the diagnosis. Correct diagnosis and appropriate treatment result in a more timely return to safe diving. CONCLUSIONS AND RELEVANCE: The aim of this review is to provide a comprehensive overview of otorhinolaryngological complications during diving. With the increasing popularity of diving and the frequency of ear, nose, or throat-related injuries, it could be expected that these injuries will become more common and this review provides a resource for otorhinolaryngologists to diagnose and treat these conditions.

Otorhinolaryngology and Diving-Part 2: Otorhinolaryngological Fitness for Compressed Gas Scuba Diving: A Review.

IMPORTANCE: Self-contained underwater breathing apparatus (scuba) diving has become increasingly popular with millions of people diving each year. Otorhinolaryngologists are often consulted either by patients or diving physicians regarding fitness to dive, and at present, the guidelines do not provide comprehensive information regarding the evaluation of this patient cohort. The aim of this review is to provide a comprehensive overview of existing otorhinolaryngological guidelines for fitness to dive recreationally. OBSERVATIONS: There is a paucity of guidelines for assessing otorhinolaryngological fitness to dive in the recreational diver. Comprehensive guidelines exist from US, European, and UK regulatory bodies regarding fitness for commercial diving; however, not all of these can be directly extrapolated to the recreational diver. There are also a variety of conditions that are not covered either by the existing fitness for recreational diving guidelines or the commercial regulatory bodies. CONCLUSIONS AND RELEVANCE: With the paucity of recreational fitness to dive guidelines we must draw on information from the commercial diving regulatory bodies. We have provided our own recommendations on the conditions that are not covered by either of the above, to provide otorhinolaryngologists with the information they require to assess fitness for recreational diving.

Acute dystonic reaction to general anesthesia with propofol and ondansetron: a graded response.

Propofol and ondansetron, alone and in combination, have been associated with acute dystonic reactions during recovery from anesthesia. We report the case of a 44-year-old woman who had undergone microlaryngoscopic fat injection to the vocal folds three times over a period of 10 months. Each procedure was performed by the same surgeon. On each occasion, the patient received an identical anesthetic that was administered by the same anesthetist. The anesthetic regimen included propofol and ondansetron. Following the first procedure, the patient experienced no reaction to these agents. However, she experienced a mild reaction after the second procedure and a severe acute dystonic reaction after the third. We believe this is the first report of a graded reaction to either propofol or ondansetron.

A comparison of the voice handicap index-10 scores between medical and musical theater students.

OBJECTIVE: Elite professional voice users experience a high vocal load and if voice quality deteriorates, their livelihoods are affected. Our aim was to assess how an elite professional voice user group, musical theater students (n=49), perceive their voices in comparison with medical students (n=43). STUDY DESIGN: Cross-sectional study. METHODS: Participants completed a confidential questionnaire including demographics and the Voice Handicap Index-10 (VHI-10) in September 2010. RESULTS: Response rate was 100% (92/92). The mean age of the medical students was 25 years and of musical theater students was 20 years. The mean overall VHI-10 score was higher in musical theater students compared with that of medical students (mean score, 5.56 and standard deviation [SD], 4.13 vs mean score, 3.79 and SD, 3.02, P=0.02), particularly in three VHI-10 items: voice strain, lack of clarity, and being upset from voice problem (mean score, 0.82 and SD, 0.86 vs mean score, 0.44 and SD, 0.67, P=0.02; mean score, 0.92 and SD, 0.89 vs mean score, 0.53 and SD, 0.70, P=0.02; and mean score, 0.49 and SD, 0.79 vs mean score, 0.07 and SD, 0.26, P=0.001, respectively). Furthermore, musical theater students report higher possible voice problems in the past (6/43 [14%], 21/49 [43%], P=0.002). CONCLUSIONS: In this small group, musical theater students report more handicap compared with medical students. It is possible that this difference may be because of the musical theater students experiencing greater voice use over time or better recognition of potential voice problems. This may mean that we need to do more to protect student's voices by optimizing vocal care during their training, without neglecting the vocal needs of other students.

An investigation of abdominal muscle recruitment for sustained phonation in 25 healthy singers.

OBJECTIVES: The purpose of this study was to investigate the baseline muscle thickness and recruitment patterns of the transversus abdominis muscle (TAM) and the internal oblique muscle (IOM) during semisupine phonation in a group of healthy performers. STUDY DESIGN: This was a 2 × 3×2 within-group, repeated-measure study in which 25 professional vocalists--12 male and 13 female performed a series of sustained pitches in differing vocal qualities. Measurements were taken with ultrasound (Sonosite Micromaxx Ultrasound System) of the baseline thickness and % recruitment during voicing, of two deep abdominal muscles--TAM and the IOM. Correlations between TAM and IOM absolute change scores, TAM and IOM percentage change scores, and changes in muscle thickness (absolute and percentage) and age were examined using Spearman's correlations. Gender differences in the four types of change scores within each combination of pitch and quality were conducted with one-way analysis of variances. Differences in muscle thickness change 1) absolute scores and 2) percentage change in TAM and IOM, by pitch and quality (and their interactions) were analyzed using linear mixed models, using restricted maximum likelihood estimations, employing a Toeplitz variance-covariance matrix structure in SPSS (IBM, 2011). Post hoc analyses for independent variable group differences used Sidak's correction for multiple comparisons. Alpha level was set to 0.05. RESULTS: In terms of absolute contractions (changes in the actual millimeter thickness of the muscle), the IOM was greater than the TAM. However in terms of percentage changes in muscles during phonation, the TAM was always greater than the IOM. The TAM as a percentage change was recruited preferentially and significantly in most vocal qualities tested. Although there were differences in muscle mass and recruitment patterns between genders, and males had thicker muscle mass at rest, differences due to muscle mass were not conclusive. CONCLUSIONS: Overall this study supports the argument that the peri-abdominal muscles do indeed play a role in supporting the "performing" or athletic voice in healthy subjects, and will hopefully act as a database for further research in individuals with healthy and injured voices.

Allergic laryngitis as a cause of dysphonia: a preliminary report.

OBJECTIVES: To investigate the relationship between air-borne allergen exposure and Voice Handicap Index scores in patients seeking medical treatment for rhinitis. METHODS: As we had previously identified a higher-than-expected incidence of allergy in patients presenting to a voice clinic, we undertook a prospective audit of patients without specific voice-related complaints presenting to a rhinology clinic to see if these patients might have unrecognized vocal dysfunction. To this end 70 consecutive patients with no pre-reported voice-related symptoms presenting to a teaching hospital rhinology clinic underwent skin prick testing to common air-borne allergens and completed the Voice Handicap Index (VHI) questionnaire. Discriminant performances in the Voice Handicap Index and its individual domains and questions were determined using analysis of variance. An allergy-specific subset of the VHI was constructed and tested using receiver operating characteristic (ROC) statistics. RESULTS: There were 30 males and 40 females. Mean age was 36 ± 12 years. Dust mite (83%), house dust mite (55%), and grass pollen (40%) were the commonest allergens, and 23 patients did not react to common allergens. Mean VHI score was 23.7 ± 20.1 in patients with ≥ 4 allergens, 10.8 ± 21.3 in patients with fewer than 4 allergies, and 7.8 ± 8.5 in non-allergics (P = 0.044; analysis of variance). Nine VHI questions best discriminated between allergic and non-allergic patients (P < 0.05), and the combined VHI-9 score had a ROC area under the curve of 0.85. CONCLUSIONS: Patients with more air-borne allergies have a higher incidence of undiagnosed vocal dysfunction, as determined by the raised Voice Handicap Index score, than those with fewer or no such allergies. As noted, earlier work has shown that, conversely, patients with vocal dysfunction have a high incidence of undiagnosed allergy.

A single-centre retrospective review of unilateral and bilateral Dysport injections in adductor spasmodic dysphonia.

We reviewed the results and side-effect profile of the Dysport preparation of botulinum toxin A (BTA) in the management of the adductor spasmodic dysphonia. We performed 272 injection episodes in 68 patients, 42 (62%) female, 26 (38%) male. A total of 116 of these injections were unilateral, and 156 were bilateral; 94% of the injections were considered to have been successful with a voice score of 2 or higher. The mean duration of effect (injection intervals) was 128.8 days in the unilateral cohort and 118.7 days in the bilateral (P > 0.05). We injected a relatively lower dose of BTA for unilateral injection episodes in our institution compared to those reported by others to produce comparable results and side-effect profiles.

Is dysphonia due to allergic laryngitis being misdiagnosed as laryngopharyngeal reflux?

OBJECTIVES: Voice problems affect up to 30% of the population at some time during their life, and in particular it affects those who use their voice professionally. Patients who commonly present with dysphonia are often found to have symptoms of both allergy and reflux. Clinical examination of the larynx often makes it difficult to differentiate between the main causative factors of dysphonia, as the clinical findings on nasendoscopy between reflux and allergy are similar. Laryngopharyngeal reflux (LPR), an entity of gastro-oesophageal reflux, is a common diagnosis made in the voice out-patient clinic. Few studies have been able to successfully correlate management of LPR and outcome of dysphonia. Allergy or more specifically allergic rhinitis is said to affect approximately 24% of the population, but few studies have investigated its role in dysphonia. DESIGN: Prospective observational study. SETTINGS: University teaching hospital otolaryngology department. PARTICIPANTS: Fifteen new patients with primary voice disorder were investigated for possible LPR and allergy from April 2007 to October 2007. All patients were tested using the validated reflux symptom index (RSI), reflux finding score (RFS) to diagnose LPR, and both skin prick tests (SPT) and nasal nitric oxide (NO) levels to diagnose the presence of allergy. MAIN OUTCOME MEASURES: Prevalence of symptoms of reflux and allergy in patients presenting with primary voice disorders, and also whether dysphonia thought to be caused by LPR could actually be due to allergy. RESULTS: No positive correlation or statistical significance was found between reflux and allergy. From our sample 20% (three patients) were diagnosed with LPR and 67% (ten patients) with allergy. The three patients diagnosed with LPR also had concomitant allergy. CONCLUSIONS: In our patient cohort, three times as many patients demonstrated allergy compared with LPR. This has led us to question if some patients with allergic laryngitis are being misdiagnosed with LPR and thereby being over-treated with proton pump inhibitors (PPIs).

The difficult airway: the use of subglottic jet ventilation for laryngeal surgery.

High-frequency subglottic jet ventilation was used in 352 cases of adults treated with suspension microlaryngoscopy. Of these, 89 had difficult airways, and these are the subject of this manuscript. All cases were managed by the senior anaesthesiologist (AP) and the senior surgeon (JR), between 2000 and 2004. There were minimal complications associated with this technique in this series. The subglottic catheter never proved impossible to insert, and was used on one occasion in a rescue mode after supraglottic jetting led to oxygen desaturation. Body habitus did not prevent use of the technique in this series. There were only 3 instances in the entire series (n=352) of cases requiring replacement by the supraglottic catheter due to limitation of visualization of the posterior glottis. The technique was used in a wide variety of surgical pathology, from benign hyperfunction-related laryngeal pathology, through paralytic vocal fold conditions, papilloma, granuloma, dysplasia and malignancy. Advantages and disadvantages over traditional intubation techniques and supraglottic jet ventilation are reviewed, including such issues as: ease of intubation/ventilation; surgical exposure/control; maintenance of O(2) and CO(2) levels; use in the limited/borderline airway.

Musculoskeletal patterns in patients with voice disorders.

This study correlated the ear, nose, and throat (ENT) and physiotherapy input on 26 patients who presented with voice problems and were found by the ENT surgeon to have a degree of musculoskeletal issues. It also looked for patterns of musculoskeletal findings. Although all patients referred were found by the physiotherapist to have musculoskeletal abnormalities, the correlation proved to be excellent among the subgroup of performers, but only fair-to-good among the other voice professionals. Certain patterns of musculoskeletal abnormalities were frequently encountered, including a high held larynx, a shortening or contraction of the stylohyoid and sternocleidomastoid muscles, and a weak deep flexor mechanism. In this small group, most patients seemed to improve, although it must be noted that management was not limited to physiotherapy. In summary, physiotherapy input proved helpful in the evaluation and management of this group of patients presenting with voice problems.

Subglottic jet ventilation for suspension microlaryngoscopy.

High-frequency subglottic jet ventilation was used in 142 consecutive adults with grade I airways treated with suspension microlaryngoscopy. All cases were managed by the senior anesthesiologist (AP) and the large majority by the senior surgeon (JR), between 2000 and 2002. The laser was used in 30% of cases. There were few complications, none serious, associated with this technique in this series. The subglottic catheter never proved impossible to insert and only needed to be replaced by the supraglottic catheter in two patients because of limitation of visualization of the posterior glottis. The technique was used in a wide variety of surgical pathology from benign hyperfunction-related laryngeal pathology through paralytic vocal fold conditions through papilloma. Advantages and disadvantages over traditional intubation techniques and supraglottic jet ventilation are reviewed, including such issues as ease of intubation/ventilation, surgical exposure/control, maintenance of O2 and CO2 levels, and use in the limited/borderline airway.

The potential role of ultrasound in differentiating solid and cystic swellings of the true vocal fold.

UNLABELLED: This study was designed to investigate the potential role of ultrasound in the diagnosis of cysts of the true vocal fold. MATERIALS AND METHODS: Grayscale ultrasound of the larynx was carried out in 29 patients with a swelling of the true vocal fold and dysphonia. The findings were then compared with those at subsequent microlaryngoscopy, in the majority of cases. RESULTS AND CONCLUSIONS: Whereas preoperative laryngeal ultrasound correctly predicted the surgical findings of a cystic lesion in only 5 of 11 cases, it correctly identified that no cyst was present in 15 of 16 instances when this had been queried. This study suggests that ultrasound may have some role in investigation of unilateral vocal fold pathology, but that further fine-tuning of the technique may be necessary.