Minimal Important Difference in Voice Handicap Index-10

Prospective Outcomes of Microlaryngoscopy Versus Office Laser Photoangiolysis for Vocal Fold Polyps

OBJECTIVE(S)

The objective of this study is to compare treatment outcomes for vocal fold polyps (VFPs) between operating room microlaryngoscopy and office-based photoangiolysis with the potassium titanyl phosphate (KTP) laser.

METHODS

Prospective nonrandomized cohort study of patients with VFPs undergoing microlaryngoscopy ("OR group") or KTP laser photoangiolysis ("KTP group"). Voice outcomes (patient-reported outcome measures [Voice Handicap Index-10 (VHI-10) and Singing VHI-10 (SVHI-10)], auditory-perceptual measures [Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)], videostroboscopic characteristics [Voice-Vibratory Assessment of Laryngeal Imaging (VALI)], and acoustic and aerodynamic measures) were performed at baseline and regular intervals after intervention.

RESULTS

Forty-four subjects (17 OR group, 27 KTP group) with VFPs were enrolled. Mean VHI-10 significantly improved from baseline to each follow-up interval in both groups, except for the 1-2-week interval in the OR group. Mean SVHI-10 improved for both groups at some intervals. Growth curve models and time-to-event analyses for patient-reported outcomes did not differ between groups. There were significant improvements in all categories of auditory-perceptual voice quality and some categories of videostroboscopic characteristics in both groups. No significant trends were identified in acoustic and aerodynamic measures. Improvements in most outcomes did not significantly differ between groups or based on polyp size. There were no major complications.

CONCLUSIONS

Significant improvements in patient-reported voice outcomes measures, auditory-perceptual voice evaluation, and videostroboscopic characteristics occur following surgical treatment of vocal fold polyps with either microlaryngoscopy or office-based KTP laser. Long-term voice outcomes do not significantly differ between treatment modalities.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:S1-S20, 2024.

Randomized Controlled Trial of Awake Transnasal Laser-Assisted Surgery for Benign Laryngeal Lesions

OBJECTIVE

To compare functional and cost-effectiveness of awake transnasal laser assisted-surgery versus microlaryngeal surgery for benign laryngeal lesions.

METHODS

This was a prospective non-inferiority randomized controlled trial conducted from May 2021 to December 2022 at two tertiary referral hospitals in Hong Kong. Patients were block-randomized to receive either awake transnasal laser-assisted surgery or microlaryngeal surgery, with post-operative follow-up in a multidisciplinary voice clinic for 1-year. Primary outcome was Voice Handicap Index (VHI-30). Secondary outcomes included operation time, complications, length of stay, peri-operative discomfort, recurrence, and medical costs.

RESULTS

Sixty-one patients were randomized to either awake transnasal laser-assisted surgery (n = 30) and microlaryngeal surgery (n = 31). Both groups had comparable demographics and laryngeal pathologies. Both groups showed significant improvement of VHI-30 score over time and had comparable post-operative VHI-30. Awake transnasal laser-assisted surgery group had a significantly shorter length of stay (0.5 vs. 1 day) and less throat discomfort (2 vs. 4) compared to microlaryngeal surgery group. Intraoperative complications were more common in microlaryngeal surgery group (14.3% vs. 0%). Otherwise, both groups had similar operative time and recurrence rate. Cost-analysis showed a significantly lower hospital cost for awake transnasal laser-assisted surgery (USD 3090) compared to microlaryngeal surgery group (USD 5120).

CONCLUSION

Awake transnasal laser-assisted surgery was safe, functionally non-inferior, as measured by VHI-30, to microlaryngeal surgery in managing benign laryngeal lesions, while superior to microlaryngeal surgery in peri-operative discomfort and medical costs.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:3732-3740, 2024.

The Minimal Important Difference of Acoustic Voice Quality Index in the Treatment of Voice Disorders

OBJECTIVES

The acoustic voice quality index (AVQI) is a reliable tool that objectively assesses dysphonia levels using six acoustic parameters. Despite its high criterion-related concurrent validity, diagnostic accuracy, and minimal detectable change derived from test-retest reliability, the minimal important difference (MID) of the AVQI has not been tested before. This study aimed to estimate the MIDs of AVQI for improvement audibly perceived by clinicians and self-reported improvement by patients.

METHODS

A retrospective study was conducted on 110 patients who received treatment for voice disorders. Patients completed AVQI and Voice Handicap Index-10 (VHI-10) questionnaires before and after the therapy. The MIDs of the AVQI were estimated using the anchor of either auditory-perceptual judgment of total dysphonia levels by clinicians or the VHI-10 questionnaire by patients. A distribution-based approach was also used to complement the results.

RESULTS

First, using the auditory-perceptual anchor, a decrease of 0.95 in the AVQI was estimated as the MID for clinicians' perception, as a result of the receiver operating curve. Then, using the patient-reported anchor, an improvement of 1.36 in the AVQI was estimated as the MID for patients' voice-related disability. The distribution-based approach also ensured the anchor-based results of both the MIDs.

CONCLUSIONS

The AVQI is a reliable and valid tool for evaluating voice quality, and a 0.95 decrease in the AVQI represents a meaningful improvement for clinicians' perception, whereas a 1.36 decrease in the AVQI influences patients' self-reported disability. This study contributes to understanding the minimal change necessary for clinicians to make informed decisions and ensure patient satisfaction.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2805-2811, 2024.

Pre- and post-operative voice therapy for benign vocal fold lesions: protocol for a non-randomised, multicentre feasibility trial with embedded process evaluation

BACKGROUND

Management of benign vocal fold lesions (BVFLs) is variable with individuals receiving surgery, voice therapy, or a combination of these approaches. Some evidence suggests that the best outcomes may be achieved when patients are offered pre- and post-operative voice therapy in addition to phonosurgery, but what constitutes pre- and post-operative voice therapy is poorly described. The pre- and post-operative voice therapy (PAPOV) intervention has been developed and described according to the TIDieR checklist and Rehabilitation Treatment Specification System (RTSS) for voice. The PAPOV intervention is delivered by specialist speech and language therapists trained in the intervention and comprises 7 essential and 4 additional components, delivered in voice therapy sessions with patients who are having surgery on their vocal folds for removal of BVFLs.

STUDY DESIGN

Non-randomised, multicentre feasibility trial with embedded process evaluation.

METHOD

Forty patients from two sites who are due to undergo phonosurgery will be recruited to receive the PAPOV intervention. Measures of feasibility, including recruitment, retention, and adherence, will be assessed. The feasibility of gathering clinical and cost effectiveness data will be measured pre-treatment, then at 3 and 6 months post-operatively. An embedded process evaluation will be undertaken to explain feasibility findings.

DISCUSSION

This study will assess the feasibility of delivering a described voice therapy intervention protocol to patients who are undergoing surgery for removal of BVFLs. Findings will be used to inform the development and implementation of a subsequent effectiveness trial, should this be feasible.

TRIAL REGISTRATION

This trial has been prospectively registered on ISRCTN (date 4th January 2023), registration number 17438192, and can be viewed here: https://www.isrctn.com/ISRCTN17438192 .

Variability in Minimal Clinically Important Difference Calculation and Reporting in the Otolaryngology Literature

OBJECTIVE

Best practices for calculation of the minimal clinically important difference (MCID) of outcome measures include the use of complementary methodologies (broadly classified as anchor-based and distribution-based) and reporting of the MCID's predictive ability. We sought to determine MCID calculation and reporting patterns within the otolaryngology literature.

METHODS

A systematic search strategy of Embase, PubMed, and Web of Science databases was developed and implemented to identify studies reporting the determination of an MCID for an outcome measure. Studies specifically within the otolaryngology literature (defined as journals classified as "otorhinolaryngology" in the Journal Citation Reports database) were included. All those journals were additionally searched for relevant articles.

RESULTS

There were 35 articles that met the inclusion criteria. Of these studies, 88.6% reported MCID of a patient-reported outcome measure and the remainder were for objective outcome measurements. Anchor-based methods were used by 82.9% of studies and distribution-based methods were used by 68.6% of studies. Of all studies, 31.4% utilized anchor-based methods alone, 17.1% utilized distribution-based methods alone, and 51.4% used both methods. Only 25.7% of studies reported the sensitivity (median: 60.8%, range: 40.5%-86.7%) and specificity (median: 80.4%, range: 63.5%-88.0%) of the MCID to detect patients experiencing clinically important change.

CONCLUSION

Deviation from best practices in MCID calculation and reporting exists within the otolaryngology literature, with almost half of all studies only using one method of MCID calculation and almost three-quarters not reporting the predictive ability (sensitivity/specificity) of the calculated MCID. When predictive ability is reported, however, MCIDs appear to be more specific than sensitive.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2059-2069, 2024.

Delayed vagal nerve compressive neuropathy following placement of vagal nerve stimulator: case report

Vagal neuropathy causing vocal fold palsy is an uncommon complication of vagal nerve stimulator (VNS) placement. It may be associated with intraoperative nerve injury or with device stimulation. Here we present the first case of delayed, compressive vagal neuropathy associated with VNS coil placement which presented with progressive hoarseness and vocal cord paralysis. Coil removal and vagal neurolysis was performed to relieve the compression. Larger 3 mm VNS coils were placed for continuation of therapy. Coils with a larger inner diameter should be employed where possible to prevent this complication. The frequency of VNS-associated vagal nerve compression may warrant further investigation.

Meta-Analysis of Validated Quality of Life Outcomes Following Voice Feminization in Transwomen

OBJECTIVES

For transwomen undergoing voice feminization interventions, fundamental frequency (F 0 ; vocal pitch) is a commonly reported functional outcome measure in the literature. However, F 0 may not correlate well with improvement in quality of life (QoL). Several validated voice-related QoL instruments have been used to assess QoL improvement in these patients, yet there is no consensus on the most appropriate instrument. This systematic review and meta-analysis aimed to assess the relationship between change in F 0 and QoL improvement following voice feminization, and to compare validated QoL instruments commonly used in this population.

DATA SOURCES

PubMed, Cochrane, and Embase.

REVIEW METHODS

A systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary studies of transwomen undergoing voice feminization, reporting validated QoL outcomes were included. Meta-analyses for associations between mean change in QoL score and mean change in F 0 , as well as variations in mean change in QoL score by QoL instrument, were performed using a multilevel mixed effects model.

RESULTS

No statistically significant correlation was found between change in F 0 and QoL score improvement post-intervention. Different validated instruments showed statistically significant variation in QoL score change, with the Trans Women Voice Questionnaire (TWVQ) capturing a greater improvement in QoL score relative to other instruments.

CONCLUSIONS

Lack of correlation between changes in F 0 and QoL improvement further supports that F 0 alone is insufficient to assess the efficacy of voice feminizing interventions. Validated QoL measures are useful adjuncts. Of these, the TWVQ appears to be the most sensitive for measurement of QoL improvement following voice feminization.

Impact of Sternothyroid Muscle Division on Patient-Reported Voice Outcomes After Thyroid Surgery: A Prospective Study

OBJECTIVE

Division of the sternothyroid muscle during thyroidectomy is a widely accepted surgical technique to provide improved exposure of the thyroid gland, thus facilitating the ligation of superior pole vessels and identification of the laryngeal nerves. However, few have examined the impact on voice outcomes. We evaluate the impact of sternothyroid muscle division on patient-perceived voice outcomes after thyroidectomy.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary academic institution.

METHODS

A prospective cohort study was conducted comparing pre- and postoperative voice outcome data after thyroidectomy, measured using Voice Handicap Index-10. The cohort of 109 patients underwent lobectomy or total thyroidectomy by a single surgeon at 1 institution. The sternothyroid muscle was fully divided in all surgeries. The integrity of the recurrent laryngeal and external branches of the superior laryngeal nerve was assessed using intraoperative nerve monitoring and postoperative laryngoscopy. Pre- and postoperative Voice Handicap Index-10 scores were compared.

RESULTS

No statistically significant difference was found between total pre- and postoperative Voice Handicap Index-10 scores (μpreop  = 1.92, μpostop  = 1.83, p = .87). There were no questions yielding statistically significant responses between pre- and postoperative groups. This was consistent regardless of whether the sternothyroid muscle was cut unilaterally or bilaterally. Men showed a statistically significant improvement in score after surgery.

CONCLUSION

These findings support no difference in postoperative voice outcomes after the intraoperative division of the sternothyroid muscle. This supports the usage of this technique as a safe means to facilitate exposure during thyroid surgery and will serve as important information to guide intraoperative surgical decision-making.

Durability of Titanium Implants Following Type II Thyroplasty for Adductor Type Spasmodic Dysphonia

OBJECTIVE

To determine the durability of current titanium implants (TI) used in voice improvement surgery for adductor spasmodic dysphonia (ADSD), which is type II thyroplasty (T2T), and identify the effects of their fractures on vocal functions.

METHODS

A total of 36 ADSD patients who underwent T2T had the following exams: The CT scans of the larynx were performed 1 year after the surgery to assess the fractures of TI. The improvement in the mean voice handicap index 10 (VHI-10) scores and the success rate between nonfractured (NFR) and fractured (FR) groups were compared.

RESULTS

It was indicated that TI was broken in 21 cases (58.3%). In one case (2.7%), a fracture on the part of the bridge that connects both sides of the plates was observed, and fractures at holes placed on the plates in the other 35 cases (55.6%). The mean VHI-10 score improved from 27.2 ± 8.1 to 11.4 ± 7.9 in the NFR group and from 26.3 ± 4.9 to 9.7 ± 7.9 in the FR group. The success rates were 66.6% in the NFR group and 71.5% in the FR group. No statistical difference was observed in the improvement in the mean VHI-10 scores, and the success rate between the two groups. However, two cases resulted in failure in the FR group, whereas no worsened case was observed in the NFR group.

CONCLUSION

The current TI used in T2T has low durability and could result in the worsening of vocal symptoms after the surgery.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:3028-3033, 2023.

Efficacy of Kinesio taping on Mutational Falsetto: A Double Blind, Randomized, Sham-controlled Trial

OBJECTIVES

This study aimed to assess the efficacy of Kinesio taping on male patients with mutational falsetto undergoing voice therapy.

DESIGN

Double blind, randomized, sham-controlled clinical trial.

PARTICIPANTS

Interviews were conducted with thirty seven mutational falsetto patients. Included 32 participants were randomized and divided into two groups. Two were dropped out due to irregular attendance, 30 participants were included in final analysis.

INTERVENTIONS

The study group was treated with voice therapy and applications of three different therapeutic Kinesio taping techniques with seven Kinesio tapes four times over two weeks, and the control group was treated with voice therapy, and applied to sham Kinesio taping.

OUTCOME MEASURES

The values of fundamental frequency, jitter, shimmer, noise-harmonic ratio, maximum phonation time, Voice Handicap Index-10 scores, and Grade-Roughness-Breathiness-Asthenia-Strain Scale scores were recorded at the baseline and after the two weeks.

RESULTS

There were significant differences between the study group and the control group with respect to the values of fundamental frequency (P = 0.011), jitter (P = 0.041), shimmer (P = 0.036), noise-harmonic ratio (P = 0.003), maximum phonation time (P ≤ 0.001), Voice Handicap Index-10 scores (P = 0.036), and Grade-Roughness-Breathiness-Asthenia-Strain Scale scores (P = 0.007; P ≤ 0.021; P = 0.022; P = 0.002; P = 0.021, respectively) at the end of the study.

CONCLUSIONS

The study demonstrated that Kinesio taping with voice therapy is an efficient and effective technique for treating mutational falsetto patients.

Voice outcomes in high-grade Reinke's edema: Comparing microflap excision and microdebrider surgery

Objectives

Patients presenting with hoarseness and diagnosed with high-grade Reinke's edema (RE) will often require surgical intervention for polypoid changes of the true vocal folds. We compared patient outcomes in patients who had microflap or microdebrider excision surgeries.

Methods

Patients with the diagnosis of grade II or grade III RE based on laryngoscopy or videostroboscopy who failed conservative management underwent surgery using the standard excision practice of the primary surgeon. Voice outcomes were compared using VHI-30 (Voice Handicap Index), V-RQOL (Voice-Related Quality of Life), and MPT (maximum phonation time) preoperatively and at 1-month and 6-months postoperatively.

Results

Of the 115 patients included, there were 46 RE grade II patients and 69 RE grade III patients with 52 patient undergoing microflap surgery and 63 patients undergoing microdebrider surgery. Both procedures resulted in significant improvement in VHI-30, V-RQOL, and MPT at 1-month and 6-months postoperatively. The microdebrider group had better 6-month VHI scores (40.84) than the microflap group (44.54) (CI -7.27 to -0.12). The microdebrider group also had better 6-month V-RQOL measures (62.56) than the microflap group (57.79) (CI 0.38-9.16).

Conclusion

Both microflap excision and microdebrider excision for high-grade RE lesions resulted in significant improvement in VHI-30, V-RQOL, and MPT at 1-month and 6-months postoperatively with the microdebrider excision group scoring statistically significantly better at 6 months in comparison to the microflap group. Overall, the results support the use of both surgical modalities for treating high-grade RE patients.

Level of evidence

3.

Safety and Effectiveness of OnabotulinumtoxinA in Patients with Laryngeal Dystonia: Final Report of a 52-Week, Multicenter Postmarketing Surveillance Study

This postmarketing surveillance study was conducted to evaluate the safety and effectiveness of onabotulinumtoxinA in Japanese patients with laryngeal dystonia (LD). Patients receiving onabotulinumtoxinA for the first time were enrolled and observed for up to 12 months following the first injection. Safety assessment included adverse drug reactions (ADRs), and effectiveness assessments included the Voice Handicap Index-10 (VHI-10) and physician's global assessment (PGA). ADRs were observed in 48 (5.8%) of 834 patients in the safety analysis set, including dysphonia in 43 (5.2%) patients and dysphagia in 7 (0.8%) patients. The change in total VHI-10 score (mean) in 790 patients included in the effectiveness analysis set showed that improvement in adductor LD peaked at 2 months after the first injection, while patients with abductor or mixed LD showed a gradual attenuation of effect 2-4 weeks post-injection. The change in total VHI-10 score in subsequent injections was generally similar to that following the first injection. The overall effectiveness rate according to the PGA was 93.4% (738/790 patients). The results demonstrate that onabotulinumtoxinA is a well-tolerated and effective treatment for LD in real-world clinical practice.

Reducing Vocal Fatigue While Preserving Realism During Video Game Voice-Overs Using the Vocal Combat Technique: A Randomized Controlled Trial

OBJECTIVE

Vocal Combat Technique (VCT) teaches indirect and direct behavioral voice techniques to voice-over artists performing in violent video games. Although previous work on VCT has shown promise for mitigating dysphonia symptoms, a randomized clinical trial has yet to be undertaken. Therefore, we completed a randomized, controlled trial between a group of experienced video game voice-over actors receiving VCT and a control group comparison.

METHODS

A total of 24 video game voice-over actors completed this study. Participants were randomly assigned to receive VCT or indirect vocal hygiene training prior to completing an intensive 1-hour video game voice recording session. The primary outcome was a change in Voice Handicap Index-10 (VHI-10) preperformance/postperformance. Secondary measures included a modified version of the Evaluation of the Ability to Sing Easily (m-EASE), the Vocal Tract Discomfort Scale (VTDS), and questions regarding return to work. Participants were also rated on the realism of their vocal performance by a blinded video game director.

RESULTS

The VCT group showed a significantly smaller change in VHI-10 and m-EASE scores postperformance, and a higher increased likelihood to return to work compared to the control group. There were no group differences for VTDS or realism ratings. Four participants from the control group exhibited outlier behavior with more pronounced phonotraumatic symptoms following performance than all other participants.

CONCLUSIONS

VCT shows evidence of mitigating symptoms of dysphonia while preserving the realism of the vocal performance. More work is needed to understand performers at risk for more severe vocal symptoms following extreme voice-over work, so as to target them for preventative techniques and voice preservation.

Safety of Platelet-Rich Plasma Subepithelial Infusion for Vocal Fold Scar, Sulcus, and Atrophy

OBJECTIVE

To demonstrate the safety profile of platelet-rich plasma (PRP) as an injectable therapeutic for the treatment of vocal fold scarring and atrophy.

METHODS

Preliminary report on a prospective clinical trial of patients with vocal fold scar or atrophy undergoing unilateral vocal fold subepithelial infusion with autologous PRP. Enrolled patients underwent four subepithelial injections spaced 1 month apart. Adverse events were assessed peri and post-injection at each session. Patient-reported outcomes were collected at every visit using the Voice Handicap Index-10 (VHI-10) and Vocal Fatigue Index (VFI) questionnaires.

RESULTS

Twelve patients underwent unilateral vocal fold injection with autologous PRP prepared according to Eclipse PRP® system protocol. Forty-three injections were performed using a peroral or percutaneous approach. An average of 1.57 ± 0.4 cc (range 0.6-2.0 cc) injectate was used. All patients tolerated the procedure without difficulty or peri-procedural complications. The average duration of follow-up was 3.6 ± 1.8 months. No significant inflammatory reactions or adverse events were seen to date. There was statistically significant improvement in patient-reported outcomes at the 3 month follow up (n = 9) follow-up (mean ΔVHI-10 = 10.8, p < 0.001, mean ΔVFI = 18.9, p = 0.01, t test, paired two sample for means, two-tail). All nine patients who completed the series of four injections subjectively (yes/no) reported they were satisfied with the results.

CONCLUSION

This prospective study cohort demonstrated a favorable safety profile, with no adverse events or peri-procedural complications. Subjective improvements in vocal quality and reduction in vocal fatigue need to be clinically correlated with further study.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:647-653, 2023.

Prevalence and Predictors of Post-Thyroidectomy Voice Dysfunction in a Nigerian Cohort

BACKGROUND

Advances in surgical techniques have significantly improved the safety of thyroidectomy. Quality of life issues, such as voice changes, however continue to be important considerations. This study evaluated the prevalence and determinants of voice changes following thyroidectomies for non-malignant goiters in a Nigerian Hospital.

METHODOLOGY

Consecutive adults who had thyroidectomy for non-malignant goiters were evaluated. Preoperatively, each participant had laryngoscopy and voice assessment using the Voice Handicap Index-10. At surgery, the intubation difficulty score, size of endotracheal tubes, and duration of operation were recorded. Laryngoscopy and VHI-10 assessments were repeated 1 week, 1 month, and 3 months after surgery. Pre and postoperative assessments were compared.

RESULT

Fifty-four patients completed the study. Subtotal thyroidectomy was the commonest operation performed in 17 patients (31.48%), with 14 (25.93%) having total thyroidectomy. Baseline median VHI-10 score was 6.5(IQR-10). Five patients had abnormal preoperative laryngoscopy findings (benign vocal cord lesions). Postoperatively, seven patients had endoscopic evidence of vocal cord paralysis, six were unilateral while one was bilateral. Ten patients (18.5%) had early voice changes. Median VHI-10 score at one week was significantly higher than baseline (10 vs. 6.5, p = 0.01). At 3 months, VHI-10 reverted back to baseline in five of the ten patients while five patients (9.3%) had persistent voice changes. Abnormal endoscopic findings predicted the occurrence of early postoperative voice changes.

CONCLUSION

Thyroidectomy for non-malignant goiters is associated with transient voice changes, many of which revert to normal over time. Abnormal endoscopic findings predict its occurrence.

Most-Cited Patient-Reported Outcome Measures Within Otolaryngology-Revisiting the Minimal Clinically Important Difference: A Review

Importance

Patient-reported outcome measures (PROMs) allow clinicians and researchers to assess health-related information from a patient's perspective. These measures have been used more frequently over the last several decades, but an associated minimal clinically important difference (MCID) is needed to optimize their utility. This narrative review identified the top 100 most-cited otolaryngology-related PROM development and validation publications and assessed the presence and characteristics of the PROMs' associated MCID.

Observations

In this narrative review, a literature search in Scopus and Web of Science was conducted on June 29, 2022, using keywords related to PROM development and validation studies in otolaryngology and reference lists. Studies that met the definition of a PROM and assessed an otolaryngologic disorder or study population were included for full-text review. After full-text review of 188 articles, the top 100 most-cited PROM development and validation publications, resulting in 106 total PROMs, were chosen for review. A total of 39 (37%) of the identified PROMs had an associated MCID. Of those reporting an MCID, 14 (35.9%) used an anchor-based method, 12 (30.8%) used a distribution-based method, 10 (25.6%) used both, and 3 (7.7%) did not specify or used neither method. Rhinology had the greatest number of PROMs with an associated MCID (16 of 24, 66%), and pediatrics had the fewest (1 of 13, 7.7%). The median number of citations of PROMs with an MCID was higher than those without an MCID.

Conclusions and Relevance

The majority of the most-cited PROMs in otolaryngology lack an associated MCID. These data indicated that there are a multitude of PROMs that have been cited hundreds of times and used for decades without the ability to identify whether a particular change in score on the instrument is clinically meaningful. There is a need to determine and validate MCIDs for commonly used PROMs to aid clinical research and trial interpretation.

Patient reported outcome measures: The impact of environment on VHI-10 responses

Objective

A key outcome measure in the clinical evaluation of dysphonia is the Voice Handicap Index (VHI-10). The clinical validity of the VHI-10 was established from surveys administered in the physician's office. We aim to understand whether VHI-10 responses remain reliable when the questionnaire is completed in settings other than the physician's office.

Methods

This is a prospective observational study conducted over a 3-month period in the outpatient laryngology setting. Thirty-five adult patients presenting with a complaint of dysphonia, which was symptomatically stable for the preceding 3 months, were identified. Each patient completed a VHI-10 survey during the initial office visit, followed by three weekly out-of-office (termed "ambulatory") VHI-10 surveys, over the course of 12 weeks. The specific setting in which the patient completed the survey was recorded (social, home, or work). The Minimal Clinically Important Difference (MCID) is defined as 6 points based on existing literature. T-tests and a test of one proportion were used for analysis.

Results

A total of 553 responses were collected. Of these, 347 ambulatory scores (63%) differed from the Office score by at least the MCID. Specifically, 94 (27%) were higher than the in-office score by 6 or more points while 253 (73%) were lower.

Conclusion

The setting in which the VHI-10 is completed affects how the patient answers the questions. The score is dynamic, reflecting effects of the patients' environment during completion. Utilization of VHI-10 scores to measure clinical treatment response is only valid if each response is obtained in the same setting.

Level of Evidence

4.

The Degree of Change and Relationship in Self-perceived Handicap and Acoustic Voice Quality Associated With Voice Therapy

INTRODUCTION

Outcome measures describing acoustic voice quality and self-perceived vocal handicap are commonly used in clinical voice practice. Previous reports of the relationship between acoustic and self-perceived measures have found only limited associations, but it is unclear if acoustic measures associated with voice quality and self-perceived voice handicap change in a similar manner over the course of voice treatment. The current study, therefore, considered the relationship between the degree of change in Acoustic Voice Quality Index (AVQI) and Voice Handicap Index (VHI-30 and VHI-10) in dysphonic patients receiving treatment in a private practice voice clinic.

METHODS

Data were collected retrospectively from patient records of a private practice voice clinic over 80 consecutive months. For each patient, their voice disorder diagnosis, age, and biological sex were collected as well as pre-and post-treatment measures of the AVQI and VHI-30 or VHI-10 depending on which version was used. Correlations were calculated between the AVQI and VHI-30 and the AVQI and VHI-10 before and after treatment as well as for the percentage change of AVQI and VHI-30/VHI-10. Friedman and Kruskal-Wallis tests were used to determine the pre-and post-treatment effect and group differences respectively.

RESULTS

Seventy-eight patients were included in the analyses. The scores of the AVQI (χ²[1] = 24.01, P < 0.001), VHI-30 (χ²[1] = 18.00, P < 0.001), and VHI-10 (χ²[1] = 38.35, P < 0.001) all improved significantly after treatment. However, correlations between the AVQI and VHI-30, and the AVQI and VHI-10 were all non-significant, except for a moderate correlation between the AVQI and VHI-10 before treatment (r[43] = 0.31, P = 0.04). The percentage change of the AVQI and the VHI-30/VHI-10 did not correlate significantly.

CONCLUSIONS

Voice therapy significantly improved acoustic and self-perceived vocal outcome measures. However, there was no significant relationship between these measures before or after treatment, nor was there a relationship in their degree of change. Results support the notion that VHI and AVQI measure unique constructs and that voice therapy can have a positive impact on both.

Voice rest after vocal fold polyp surgery: A Swedish register study of 588 patients

Objective

To evaluate the impact of voice rest on patient‐reported voice outcome 4 months after vocal fold polyp surgery.

Methods

Preoperative information was collected about age, sex, and smoking habits and the voice handicap index‐10 (VHI‐10). Four months postoperatively, voice rest (total voice rest, spoke single words, and spoke normally), and pre and postoperative voice therapy were reported. This was correlated to voice satisfaction from a two‐category subjective evaluation “satisfied/ not satisfied” and to VHI‐10. Logistic regression models with relative risk for NOT being satisfied with voice after surgery were performed.

Results

Data from 588 patients were available. The group “spoke normally” showed the highest degree of patient satisfaction (92%). Younger patients (<59 years) were more satisfied than older (90% vs. 81.5%). High age and low VHI‐10 scores before surgery were statistically significant for negative voice outcome. Gender or voice rest type did not significantly affect outcome. The largest improvement in VHI‐scores was in the group who spoke normally and least in the group who spoke single words.

Conclusion

We found no significant difference in the two‐category subjective voice outcome depending on voice rest. VHI‐10 showed a statistically significant positive effect on self‐evaluated voice outcome, with the largest improvement in the group with no voice rest. However, the clinical relevance of the VHI changes is unclear. The present study does not show any advantage of total voice rest as compared to relative voice rest or speaking freely. High age and low preoperative VHI scores were significant risk factors for worse voice outcome.

Level of evidence: 4

Improvement in Work Productivity After Group Voice Therapy in Professional Voice Users

OBJECTIVE

A disordered voice may significantly impair the ability of workers to perform optimally on the job, especially those classified as professional voice users (PVU). Voice therapy is a common treatment option for voice disorders, but there are few studies demonstrating its effect on work productivity. The objective of this study was to evaluate the change in work productivity in PVU after group voice therapy.

STUDY DESIGN

Prospective cohort study SETTING: Academic Voice Center METHODS: PVUs whose primary treatment for their voice disorder was voice therapy were recruited. Participants completed a 7-week group voice therapy course from January 2018 to December 2020. Participants completed the validated Work Productivity and Activity Impairment questionnaire (WPAI) which measured presenteeism (on the job work productivity impairment) and absenteeism (time missed from work), general self-efficacy scale (GSES), and Voice handicap index -10 (VHI-10) before and after group voice therapy. Changes in scores before and after therapy were compared using a Wilcoxon Signed-Rank test.

RESULTS

Twenty-seven PVU were recruited; 25 had complete data (100% female, mean age 45.4 years, 68% teachers). Presenteeism (SD) decreased from 72.0% (23.3) to 36.8% (24.8), which represented a significant improvement of 35.2% (27.8) [95% CI 21.7-38.7; P < 0.001]. Activity impairment decreased from 48.4% (32.0) to 25.6% (23.8), which represented a significant improvement of 22.8% (26.5) [95% CI 20.7-37.0; P < 0.00]. There was no change in absenteeism (P = 0.27). Patients had high mean GSES of 34.4 (3.7) and abnormal mean VHI-10 of 18.2 (7.2). Changes in VHI-10 and GSES were not significant.

CONCLUSION

PVU had an improvement in work productivity that was largely represented by decreased presenteeism after completing group voice therapy.

Correlation Between a Diagnosis of Anxiety or Depression and Initial VHI-10 Scores in Benign Dysphonia

OBJECTIVE

Anxiety and depression have demonstrated a positive correlation with vocal handicap among patients with benign causes of dysphonia. Our objective is to explore differences in initial Vocal Handicap Index-10 (VHI-10) scores between patients with a mental health history of anxiety or depression and those without.

STUDY DESIGN

Retrospective cohort study.

SETTING

Demographic data, diagnoses, and initial VHI-10 scores were collected for patients presenting with dysphonia to 2 tertiary laryngology clinics.

METHODS

A Kruskal-Wallis test and subsequent Mann-Whitney U test for pairwise comparisons were used to compare distribution of VHI-10 scores among patients with anxiety, depression, anxiety and depression, and no such conditions. Bonferroni correction was used to control for multiple comparisons. Robust regression was used for multivariable analysis.

RESULTS

A total of 620 cases of benign dysphonia were analyzed. Forty-two percent of the patient cohort had a preexisting diagnosis of anxiety (n = 121, 20%), depression (n = 64, 10%), or anxiety and depression (n = 74, 12%). VHI-10 scores were higher in patients with depression than in those without anxiety or depression (median difference, 4 [95% CI, 1-8]; P = .005) but did not differ significantly among the other groups. The effects of depression and anxiety status on initial VHI-10 scores among the causes of benign dysphonia varied.

CONCLUSIONS

Patients with a history of depression who presented with dysphonia had worse vocal handicap than those without anxiety/depression history. Future studies may clarify how optimization of anxiety and depression can affect patient-reported vocal handicap.

Oncological and functional outcomes following treatment of T1a glottic squamous cell carcinoma with transoral laser microsurgery

Background

Laryngeal cancers of glottic origin comprise a large proportion of head and neck malignancies. Transoral laser microsurgery (TLM) and radiation therapy are mainstays in the treatment of early stage glottic cancer, but debate persists as to which modality is functionally superior. Furthermore, there is a paucity of North American data related to functional and oncological outcomes in T1a glottic cancer. Here, we assessed oncological and functional outcomes of T1a glottic squamous cell carcinoma (SCC) with TLM to supplement evidence from jurisdictions outside North America.

Methods

This study is a retrospective cohort study performed from a prospectively collected tertiary center institutional TLM database. Patients who were diagnosed with T1a glottic SCC and underwent TLM as their primary treatment were included. Functional outcomes were analyzed using the Voice Handicap Index-10 (VHI-10) questionnaire. Ultimate control with TLM only was considered to be those patients with locoregional control with repeat TLM procedures, but without addition of other modalities. Student’s t-test was used to test significance and Kaplan–Meier survival analysis was used to assess oncological outcomes.

Results

48 patients met study criteria. The mean follow-up time was 74 months. The 5-year locoregional, ultimate control with TLM only and laryngeal preservation rates were 83.2%, 90.4% and 100%, respectively. The overall survival and disease-specific survival were 87.2% and 100%, respectively. VHI-10 scores were available for 13/48 patients and mean scores improved non-significantly from pre-op (mean: 11.23; range: 2 to 30; median: 10) and post op (mean: 7.92; range: 0 to 18; median: 8) scoring (p-value = 0.15). Sub-stratification of voice data revealed a significant improvement between pre and post-operative scores (mean difference − 10.6, 95% CI: − 0.99 to − 20.21, p-value = 0.035) for patients with abnormal pre-operative scores (VHI > 11).

Conclusion

To our knowledge, the current work represents one of the first North American studies to report both functional and oncologic outcomes for TLM treatment of T1a glottic SCC. The oncologic and functional outcomes presented here add to existing evidence in favor of TLM as a safe and effective primary treatment option for early staged T1a glottic cancer.

Graphical abstract

Present state bias in transition ratings was accurately estimated in simulated and real data

OBJECTIVE

Patient-reported transition ratings are supposed to reflect the change between a previous baseline health state and a present follow-up state, but may reflect the present state to a greater extent. This so-called 'present state bias' (PSB) potentially threatens the validity of transition ratings. Several criteria have been proposed to assess PSB. We examined how well these criteria perform and to which extent confirmatory factor analysis (CFA) for categorical data provides an accurate assessment of the degree of PSB.

STUDY DESIGN AND SETTING

We simulated a multiple samples with baseline and follow-up item responses to a hypothetical questionnaire, and transition ratings. The samples varied with respect to various distributional characteristics and the degree of PSB. The performance of criteria proposed in the literature, and a new CFA-based criterion, were evaluated by the proportion of explained variance in PSB. In addition, four real datasets were analyzed.

RESULTS

The known criteria explained 36-74% of the variance in PSB. A new CFA-based criterion, namely the ratio of the factor loadings of the transition ratings plus one, explained 81-98% of the variance in PSB across the samples.

CONCLUSION

Present state bias in transition ratings can be estimated accurately using CFA.

Physical Therapy for Muscle Tension Dysphonia with Cervicalgia

OBJECTIVES

This study investigated the effectiveness of a specialized manual physical therapy (PT) program at improving voice among patients diagnosed with concomitant muscle tension dysphonia (MTD) and cervicalgia at a tertiary care voice center.

MATERIALS AND METHODS

Cervicalgia was determined by palpation of the anterior neck. Both voice therapy (VT) and PT was recommended for all patients diagnosed with MTD and cervicalgia. PT included full-body manual physical therapy with myofascial release. Patients underwent: 1) VT alone, 2) concurrent PT and VT (PT with VT), 3) PT alone, 4) VT, but did not have PT ordered by treating clinician (VT without PT order) or 5) VT followed by PT (VT then PT). The pairwise difference in post-Voice Handicap Index-10 (VHI-10) controlling for baseline variables was calculated with a linear regression model.

RESULTS

178 patients met criteria. All groups showed improvement with treatment. The covariate-adjusted differences in mean post-VHI-10 improvement comparing the VT alone group as a reference were as follows: PT with VT 9.95 (95% confidence interval 7.70, 12.20); PT alone 8.31 (6.16, 10.45); VT without PT order 8.51 (5.55, 11.47); VT then PT 5.47 (2.51, 8.42).

CONCLUSION

Among patients diagnosed with MTD with cervicalgia, treatment with a specialized PT program was associated with improvement in VHI-10 scores regardless of whether they had VT. While VT is the standard of care for MTD, PT may also offer benefit for MTD patients with cervicalgia.

Supraglottic Botulinum Toxin Improves Symptoms in Patients with Laryngeal Sensory Dysfunction Manifesting as Abnormal Throat Sensation and/or Chronic Refractory Cough

Laryngeal sensory dysfunction (LSD) encompasses disorders of the vagal sensory pathways. Common manifestations include chronic refractory cough (CRC) and abnormal throat sensation (ATS). This study examined clinical characteristics and treatment outcomes of LSD using a novel approach of laryngeal supraglottic Onabotulinum toxin Type A injection (BTX). This was a retrospective review of clinical data and treatment outcomes of supraglottic BTX in patients with LSD. Between November 2019 and May 2021, 14 patients underwent 25 injection cycles of supraglottic BTX for treatment of symptoms related to LSD, including ATS and CRC. Primary outcome measures included the Newcastle Laryngeal Hypersensitivity Questionnaire (LHQ), Cough Severity Index (CSI), Reflux Symptom Index (RSI), and Voice Handicap Index-10 (VHI-10) at baseline and within three months of treatment. Pre- and post-treatment data were compared using a linear mixed model. After supraglottic BTX, LHQ scores improved by 2.6. RSI and CSI improved by 8.0 and 5.0, respectively. VHI-10 did not change as a result of treatment. Short-term response to SLN block was significantly associated with longer term response to BTX treatment. These findings suggest that LSD presents clinically as ATS and CRC along with other upper airway symptoms. Supraglottic BTX injection is a safe and effective technique in the treatment of symptoms of LSD.

The role of voice rest after micro-laryngeal surgery for benign vocal fold lesions

PURPOSE

To compare post-operative vocal outcomes of a voice rest regimen versus no voice restrictions following micro-laryngeal surgery for benign glottic lesions.

METHODS

This was a combined prospective and retrospective cohort study on 167 patients who underwent micro-laryngeal surgery for benign focal fold lesion removal. Participants were divided into two regimens: standard voice rest (n = 92) or no voice restriction (n = 75). The primary outcome was post-operative vocal improvement, evaluated using voice handicap index questionnaire (VHI-10), GRBAS scale, and computerised acoustic analysis (shimmer, jitter, and the harmonic-to-noise ratio). The secondary outcome was emergence of vocal fold mucosal abnormalities in the immediate post-operative period. Parameters were collected at baseline and at the last clinical visit.

RESULTS

There was no statistically significant difference between the voice rest and no-voice rest groups regarding baseline parameters of age, gender, laryngeal pathology, and voice use. Improvement in GRBAS scale values and VHI-10 scores between pre- and post-operative periods between groups did not demonstrate any statistically significant differences (P = 0.5303 and P = 0.1457, respectively). Similarly, the results of computerized voice analysis also showed no differences between groups in terms of shimmer (P = 0.9590), jitter (P = 0.5692), and harmonic-to-noise ratio (P = 0.1871). No correlation was found between the post-operative vocal fold's mucosal abnormalities and the type of voice rest regimen.

CONCLUSION

Voice quality and wound healing were similar regardless of the type of voice rest regimen applied. No voice rest at all was as good as voice rest after micro-laryngeal surgery.

Association of Laryngeal Botulinum Neurotoxin Injection With Work Productivity for Patients With Spasmodic Dysphonia

Importance

A disordered voice can affect an individual across both work and non-work-related life domains. There is insufficient research on the effect of spasmodic dysphonia or its treatment with botulinum neurotoxin (BoNT) injections on work productivity.

Objective

To assess whether employed patients with spasmodic dysphonia experience voice-related work productivity impairment before BoNT injection, and had a 10% or greater improvement in productivity 1 month after treatment with BoNT injection.

Design, Setting, and Particpants

This prospective case series carried out in 2 laryngology outpatient clinics from November 1, 2015, to August 30, 2018 included a consecutive sample of adult employed patients diagnosed with spasmodic dysphonia. Analysis was conducted between November 1, 2015, to July 31, 2018.

Exposures

Treatment with BoNT injection into the intrinsic laryngeal musculature.

Main Outcomes and Measures

Eligible participants completed the following validated outcomes instruments immediately before and 1 month after outpatient laryngeal BoNT injection: the Work Productivity and Activity Impairment instrument (WPAI), Voice Handicap Index (VHI), and WorkHoarse. Demographic, comorbidity, and occupational voice use data were also collected at baseline. The changes in outcome measures (primary, WPAI Work Productivity Impairment domain) were tested using a paired 2-tailed t test. Exploratory subgroup analyses were analyzed with multivariable linear regression, adjusting for demographic, comorbidity, and voice use variables.

Results

Of the 101 patients enrolled, 75 completed the study. The mean (SD) age of the 75 completing participants was 55.7 (11.8) years and 53 (71%) were women. The participants who completed the study had mean (SD) voice-related work productivity impairment of 43% (27%) at baseline and 22% (23%) at 1 month after BoNT injection (difference, 20% [27%] improvement; 95% CI, 14%-27%; effect size, 0.74).

Conclusions and Relevance

This case series study found that employed patients with spasmodic dysphonia reported voice-related work productivity impairment, which improved significantly 1 month after treatment with BoNT injection. The association of spasmodic dysphonia with voice-related work productivity appeared greater in women than men with comparable outcomes with BoNT treatment, but this exploratory sex-associated difference requires independent validation.

Visual identification and neuromonitoring vs. no sighting the external branch of the superior laryngeal nerve in thyroid surgery: a randomized clinical trial

To evaluate the incidence of external branch of the superior laryngeal nerve (EBSLN) injuries after thyroid surgical procedures with or without the functional and visual identification of the EBSLN before ligation at the superior thyroid pole. Patients with papillary thyroid carcinoma (PTC) enrolled from a single tertiary referral academic medical center were assigned to functional and visual identification of EBSLN group (study group) or no identification of EBSLN group (controlled group). The main outcome measures were the incidence of EBSLN injury detected by the intraoperative neuromonitoring and Voice Handicap Index-10 (VHI-10) and Impairment Index-5 (VII-5) valuation questionnaires. Postoperative complications were recorded. A total of 140 (50.4%) patients were enrolled in study group and 138 (49.6%) in controlled group. In the study group, 110 (39.3%) EBSLNs were direct visual recognized and 170 (60.7%) nerves were visually identified with the help of neuromonitoring. Three patients in the study group and two patients in the controlled group were diagnosed with vocal cord paralysis. Six (4.4%) patients in the identification group and 37 (27.2%) patients in the no identification group presented no response from the stimulation of sternothyroid-laryngeal triangle. The VII-5 scores of the study group were significantly higher than those of the controlled group at one and three months postoperatively (P = 0.024 and P = 0.034). With significant lower scores of VII-5 and VHI-10, functional and visual identification of EBSLN might be necessary during thyroid surgery to protect the structural integrity and motor activity of the nerve.

Normative Value for the Laryngopharyngeal Measure of Perceived Sensation

OBJECTIVES/HYPOTHESIS

The Laryngopharyngeal Measure of Perceived Sensation (LUMP) is a recently validated patient-reported outcome measure (PROM) aimed at evaluating the symptom severity of patients with globus pharyngeus (GP). The objective of this study was to define the normative values for the LUMP questionnaire.

STUDY DESIGN

Prospectively collected, descriptive research/scale development.

METHODS

The LUMP questionnaire was completed by 88 subjects. Individuals without throat-related symptoms such as dysphagia, dysphonia, or cough were provided LUMP. The results of the eight-item questionnaire were analyzed for standard error of the mean (SEM), mean, and standard deviation (SD).

RESULTS

Review of the 88 LUMP questionnaires elucidated a mean of 0.42 (SEM = 0.10, SD = 0.96) in the normative population. By gender, the female (n = 50) mean was 0.24, SD = 0.66, SEM = 0.09; for males (n = 38), the mean was 0.66, SD = 1.21, SEM = 0.20.

CONCLUSIONS

This study provides normative data for the LUMP, a recently established PROM useful in patients with GP. A LUMP score greater than or equal to 3 should be considered abnormal and warrants additional attention.

LEVEL OF EVIDENCE

3 Laryngoscope, 2021.

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.

Short-Term Effect of Intensive Speech Therapy on Dysarthria in Patients With Sporadic Spinocerebellar Degeneration

Purpose The aim of this study was to investigate a structured approach for effective speech therapy (ST) for dysarthria and speech-related quality of life in patients with sporadic spinocerebellar degeneration (SCD), including cerebellar-type multiple-system atrophy and cerebellar cortical atrophy. Method Twenty-two patients with SCD (cerebellar-type multiple system atrophy, 15 patients; cerebellar cortical atrophy, seven patients) who underwent intensive ST were examined. Dysarthria was evaluated using the Scale for Assessment and Rating of Ataxia Speech Dysfunction, Assessment of Motor Speech for Dysarthria Articulation, oral diadochokinesis (OD), and Voice Handicap Index-10 (VHI-10). Respiratory muscle strength (inspiratory and expiratory pressure) and respiratory-phonatory coordination (maximum phonation time) were measured. Cognitive function was evaluated using the Montréal Cognitive Assessment and the word fluency test. Mood was evaluated using the Hospital Anxiety and Depression Scale. The relationships between dysarthria scales (particularly, VHI-10) and clinical data were analyzed using stepwise regression. The differences in outcomes after intensive ST were analyzed using the Wilcoxon signed-rank test. The alpha level (p) for statistical significance was set at .0125 by Bonferroni correction. Results For both pre- and post-ST, the patient's OD (p = .002) and maximum phonation time (p = .002) significantly improved, except for Speech Dysfunction scores of the Scale for Assessment and Rating of Ataxia (p = .705) and the VHI-10 (p = .018). The Assessment of Motor Speech for Dysarthria Articulation, OD, and inspiratory pressure were identified as independent variables of VHI-10 (adjusted R ² = .820) for speech-related quality of life; no correlations among the Montréal Cognitive Assessment, word fluency test, and Hospital Anxiety and Depression Scale scores were observed. Conclusion OD and VHI-10 showed improvements due to changes in speech function and respiratory-phonatory coordination, justifying intensive ST treatment for dysarthria in patients with SCD.

Prospective cohort study of voice outcomes following secondary tracheoesophageal puncture in gastric pull-up reconstruction after total laryngopharyngoesophagectomy

Background

Gastric pull-up is a reconstructive option for circumferential defects after resection of advanced laryngopharyngeal malignancy. Voice loss is expected and vocal rehabilitation remains a challenge. Our study objectives were to investigate the feasibility of secondary tracheoesophageal puncture following gastric pull-up and to analyze voice outcomes.

Methods

This was a prospective cohort study of patients with advanced laryngopharyngeal malignancies who underwent gastric pull-up and secondary tracheoesophageal puncture between 1988 and 2017 at a tertiary-care academic institution. Objective acoustic measures included fundamental frequency and vocal intensity. Perceptual analysis was performed using voice recordings (“Rainbow Passage”) randomly presented in a blinded fashion to four clinicians using the validated GRBAS scale. Speech intelligibility was assessed in a blinded fashion using a validated 7-point scale. Additionally, the Voice Handicap Index-10 was administered as a validated patient self-reporting tool.

Results

Ten patients (7 male, 3 female) were included, all of whom preferentially used tracheoesophageal puncture for communication. These patients had abnormal median fundamental frequency of 250 (interquartile range (IQR) 214–265) Hz and a limited median vocal intensity of 65.8 (IQR 64.1–68.3) dB. Perceptual analysis (GRBAS) revealed a median ‘moderate’ degree of impairment [grade 2 (IQR 2–3), roughness 2 (IQR 2–3), breathiness 3 (IQR 2–3), asthenia 2 (IQR 1–2), strain 2 (IQR 1–2)] as did median intelligibility scores [median 5 (IQR 4–7)]. Most patients self-reported an abnormal voice handicap-10 [median 26.5 (IQR 22.8–35.0)].

Conclusion

Secondary tracheoesophageal puncture is a safe and feasible option for voice rehabilitation after gastric pull-up. Although analyses demonstrated moderate subjective and objective impairment, tracheoesophageal puncture provided patients with a self-reported means of functional verbal communication and was their preferred method of communication.

Graphical abstract

Effect of Vitamin B12 Injection on the Vocal Performance of Professional Singers: A Randomized, Double-blind, Placebo-Controlled, Crossover Trial

Importance

One-third of singers and vocal professionals report experiencing a benefit from empirical vitamin B12 injections for improvement of mild singing-related symptoms (eg, reduced stamina, vocal fatigue, and effort). However, there is no objective evidence to support or refute these claims.

Objective

To assess the presence and magnitude of the effect of empirical vitamin B12 injection on the vocal performance of singers.

Design, Setting, and Participants

A randomized, double-blind, placebo-controlled, crossover trial was conducted from November 7, 2017, to November 30, 2018, at an academic voice center among 20 active adult singers without dysphonia but with mild vocal symptoms. Individuals with known or suspected vitamin B12 deficiency or active or recent vitamin B12 treatment were excluded. Analysis was on a per-protocol basis.

Interventions

Participants were randomized to receive an intramuscular (deltoid) injection of either vitamin B12 (1000 μg of cyanocobalmin) or placebo (0.9% sodium chloride). After a washout period of at least 4 weeks, participants were crossed over to receive the opposite injection. Both the investigators and participants were blinded to the order of injections.

Main Outcomes and Measures

The participants completed the Singing Voice Handicap Index-10 (SVHI-10), the Voice Fatigue Index (VFI), and the Evaluation of the Ability to Sing Easily (EASE) before each injection and at intervals of 1 hour, 3 hours, 24 hours, 72 hours, and 1 week after the injection. The primary time point assessment was 72 hours after injection, and the SVHI-10 score was the primary outcome measure.

Results

Twenty singers (10 men; median age, 22 years [range, 19-42 years]) were enrolled. The improvements after either placebo or vitamin B12 injections were comparable to each other. At 72 hours after the vitamin B12 injection, the median difference in the SVHI-10 score was 1 (95% CI, -1 to 2) compared with 3 (95% CI, 0-4) after placebo. The median difference between differences at 72 hours between placebo and vitamin B12 injections were 1.5 (95% CI, -2 to 5) for the SVHI-10, 1 (95% CI, -9 to 9) for the VFI, and -1 (95% CI, -3 to 2) for the EASE. The improvements after both injections failed to reach the estimated minimal clinically important difference. Of the 20 participants, 4 (20%) reached the estimated minimal clinically important difference in their SVHI-10 score after 72 hours for both vitamin B12 and placebo injections.

Conclusions and Relevance

This randomized, double-blind, placebo-controlled, crossover trial found that after empirical vitamin B12 injection to improve mild voice-related symptoms, the improvement in self-reported voice measures in singers shows no meaningful difference compared with placebo.

Trial Registration

ClinicalTrials.gov Identifier: NCT03437824.

A retrospective analysis of revision framework surgeries for unilateral vocal fold paralysis

INTRODUCTION

Revision framework surgeries might be required for unilateral vocal fold paralyses. However, outcomes and indications of revision surgeries have not been adequately documented. For a better understanding of indications for the procedure and to help in achieving better vocal outcomes, we performed a retrospective chart review of patients who underwent revision framework surgeries for unilateral vocal fold paralysis.

OBJECTIVES

This study aimed to present clinical features of patients who underwent revision framework surgeries for the treatment of unilateral vocal fold paralysis.

METHODS

Of the 149 framework surgeries performed between October 2004 and October 2019, 21 revision framework surgeries were performed in 19 patients. Self-assessments by patients using the voice handicap index-10 questionnaire, and objective aerodynamic and acoustic assessments performed pre- and post-operatively were analyzed using the Wilcoxon's signed-rank test for paired comparisons.

RESULTS

Undercorrection was indicated as reasons for revision surgeries in all cases. The revision techniques included type I thyroplasty, type IV thyroplasty, and arytenoid adduction, and revision surgeries were completed without any severe complication in all cases. Pre- and post-operative voice handicap index-10 scores were obtained in 12 cases, and other parameters were evaluated in 18 cases. Significant improvements were observed in voice handicap index-10 scores, maximum phonation time, mean flow rate, Current/Direct Current ratio, and pitch perturbation quotient.

CONCLUSION

Undercorrection was observed in all patients who underwent revision framework surgeries for unilateral vocal fold paralysis, and the initial assessment and planning are thought to be important in order to avoid revision surgeries. Revision surgeries were performed safely in all cases, and significantly improved vocal outcomes were observed, even after multiple procedures. Revision surgery should be considered for patients with unsatisfactory vocal functions after primary framework surgeries for unilateral vocal fold paralysis.

Voice and Respiratory Characteristics of Men and Women Seeking Treatment for Presbyphonia

BACKGROUND AND OBJECTIVES

Impaired respiratory function could potentially explain why some older speakers experience voice-related handicap whereas others do not, despite presenting with similar age-related laryngeal characteristics. The objectives of this study were therefore to (1) describe voice and respiratory function across men and women in a sample of treatment-seeking patients with presbyphonia; (2) assess how respiratory function differed from the general elderly population, based on normative data; and 3) discuss how respiratory function may play a role in the development of voice symptoms across men and women.

METHODS

Twenty one participants with presbyphonia underwent respiratory assessments (spirometry and respiratory muscle strength testing) in addition to standard of care voice assessments. Respiratory variables included forced vital capacity (FVC), forced expiratory volume in one second (FEV₁), FEV₁/FVC, maximum inspiratory pressure (MIP), and maximum expiratory pressure (MEP).

RESULTS

Voice features were consistent with the diagnosis of presbyphonia and values did not different significantly between males and females, although some trends were noted. Regarding respiratory variables, one-third of the participants (n = 7) presented with FVC and FEV₁ less than 80% of predicted, and 57% (n = 12) were <90% of predicted. Nine percent of the males (n = 1) and none of the females had a MIP below the lower limit of normal (LLN) expected for their age, sex, and weight. Eighteen percent of the males (n = 2) and 20% of the females (n = 2) fell below the LLN for MEP.

CONCLUSION

Our sample of participants with presbyphonia included a non-negligible proportion of patients with decreased percent predicted values of FVC and FEV₁, and with respiratory muscle strength (MEP) below the LLN. Standardized values of pulmonary function were not different across sexes, indicative of a similar respiratory health. However, a lower raw pulmonary function and respiratory muscle strength in women may compound laryngeal changes and have an impact on perceived voice-related handicap. Together, findings warrant further studies to explore the impact of decreased respiratory function on voice and, ultimately, on the response to voice therapy in patients with presbyphonia.

Laryngeal Electromyography-Guided Hyaluronic Acid Vocal Fold Injections for Glottic Insufficiency

OBJECTIVES

To assess voice outcomes using the novel technique of in-office laryngeal electromyography-guided vocal fold injections (LEVFI) with hyaluronic acid to treat glottal insufficiency. Secondary objectives included determining the complication/completion rates and if any factors were associated with improved voice outcomes.

METHODS

Retrospective review of patients who received their first LEVFI from August 2017 to December 2018. Three- and six-month voice outcomes were assessed. Outcomes included voice handicap index-10 (VHI-10), maximum phonation time (MPT), perceptual analysis of voice (GRBAS), fundamental frequency, and stroboscopy.

RESULTS

Of the 121 eligible patients (55.4% male, age 63.7 years), 94 (77.7%) had complete 3-month data and 59 (48.8%) had complete 6-month data. VHI-10 was significantly improved from 25.7 ± 7.5 to 20.9 ± 10.9 at 3 months (P < .001) and to 19.1 ± 11.5 at 6 months (P < .001). MPT improved from 6.2 ± 5.4 seconds to 9.4 ± 7.1 seconds at 3 months (P < .001) and to 11.3 ± 8.2 seconds at 6 months (P < .001). GRBAS was improved in 74.8% of patients ([65.2, 82.8] 95% CI) at 3 months and 80.8% ([69.9, 89.1]) 95% CI) at 6 months. Stroboscopy showed a glottic gap improvement in 74.8% of patients ([65.8, 82.4] 95% CI) at 3 months and in 80.3% ([65.9, 88.5] 95% CI) at 6 months. Fundamental frequency was unchanged, as expected. Multivariate analysis reported that no factors were associated with better voice outcomes. Overall, 177/181 (97.8%) injections were completed. There were no complications.

CONCLUSION

In-office LEVFI is an effective, novel technique to treat glottic insufficiency with improved voice outcomes, high completion rate, and no significant complications.

Crosscultural Adaption and Validation of the Danish Voice Handicap Index-10

BACKGROUND

The Voice Handicap Index 30 (VHI-30) is a much-used voice specific quality of life questionnaire. A shortened 10 item version has been developed by eliminating redundant items using item analyses. This is the first Danish translation of the VHI-10.

OBJECTIVES

To evaluate the psychometric properties of the Danish VHI-10 questionnaire.

STUDY DESIGN

Cross-sectional survey study.

METHODS

A Danish translation of the VHI-10 was answered by 72 patients with voice disorders of different etiology (neurogenic, functional, and structural) and by a control group of 94 vocally healthy individuals. Thirty-two patients and 68 controls participated in a test-retest reliability analysis. The internal consistency, test-retest reliability, and clinical validity were assessed.

RESULTS

Excellent internal consistency was found in the patient group with a Cronbach's α of >0.90. In the control group the internal consistency was good with a Cronbach's α of 0.88. Test-retest reliability was good with intra class correlation coefficient of 0.94 (95% confidence interval [95%CI]: 0.88-0.97) for patients and 0.82 (95%CI: 0.73-0.89) for the control group. This indicates a sufficient reliability of the questionnaire. The correlation between the Danish VHI-10 score and the patient's perception of the severity of the voice disorder was 0.75 (P < 0.001) indicating good clinical validity of the Danish VHI-10.

CONCLUSION

The newly translated Danish VHI-10 was validated and performs similar to the original VHI-10. It showed good internal consistency, test-retest reliability, and clinical validity. The questionnaire is preferably for use in patients with moderate to severe voice complaints as its ability to distinguish mild voice changes from healthy voices is limited. However, the questionnaire is capable of assessing patients' perception of the severity of their voice disorder and is available for use in daily practice and in research projects.

The development and validation of the laryngopharyngeal measure of perceived sensation

OBJECTIVES

Globus pharyngeus (GP) is described as the subjective sensation of having a "lump" in the throat in the absence of correlating physical findings or dysphagia. Historically, despite the frequency of patient complaints, GP has been difficult to quantify with current outcome measures. This is in large part due to lack of a user-friendly, modernized, objective patient-reported outcome measure (PROM) of symptom severity. The aim of this study is to develop a modernized, practical, validated PROM for evaluating GP symptom severity.

METHODS

The Laryngopharyngeal Measure of Perceived Sensation (LUMP questionnaire) was created in three phases: 1) item generation by an expert panel involving two laryngologists and two speech language pathologists developed from common patient-reported GP symptoms, with patient confirmation; 2) line-item reduction based on internal consistency and reliability; 3) and instrument validity, which was assessed by administering the questionnaire to patients complaining of GP as well as patients without GP.

RESULTS

A 19-item questionnaire was developed from an expert panel, which was then administered to 110 patients, 100 of whom met inclusion criteria. After statistical analysis, less internally consistent or relevant questions were removed, leaving eight items with an internal consistency (Cronbach alpha) of 0.892. When administered to 54 patients with GP versus 31 normal patients, the mean score was found to be higher in those with GP versus normal patients (P value <0.0001).

CONCLUSION

Preliminary results suggest the eight-item LUMP questionnaire is a valuable PROM for evaluating GP symptom severity.

LEVEL OF EVIDENCE

NA Laryngoscope, 2019.

Injection laryngoplasty as adjunct treatment method for muscle tension dysphonia: Preliminary findings

Objectives

This study examined the effectiveness of injection laryngoplasty (IL) in muscle tension dysphonia (MTD) patients who did not fully respond to voice therapy. It was hypothesized that IL would improve voice quality and voice‐related quality of life measures in MTD.

Methods

A retrospective review was conducted on 37 patients with a primary diagnosis of MTD who underwent IL following a suboptimal response to voice therapy (mean age = 43.0 years; standard deviation [SD] = 13.4; range = 23 to 71). Outcome measures included laryngoscopic signs of supraglottic constriction, Voice Handicap Index‐10 (VHI‐10) scores, maximal phonation time, vowel fundamental frequency (F0), standard deviation of F0 (F0SD), harmonics‐to‐noise ratio (HNR), and smoothed cepstral peak prominence. These were compared between baseline and within 3 months following the IL procedure.

Results

There was significant decrease in supraglottic constriction. Mean (SD) of VHI‐10 scores decreased from 25.4 (5.7) at baseline to 15.3 (9.3) following IL. This improvement in VHI‐10 was observed in patients with and without baseline glottal insufficiency (GI). Mean (SD) of HNR (decibels) increased from 21.1 (5.4) at baseline to 22.8 (4.3) after IL. Only patients with GI demonstrated a significant improvement in HNR from baseline to post‐IL. No statistically significant differences in other acoustic measures were observed.

Conclusions

IL resulted in positive changes in voice‐related quality of life in MTD patients with and without GI. Acoustically, only those with GI demonstrated an increase in HNR following IL. Further studies are needed to examine the effects of IL in MTD.

Level of Evidence

4 Laryngoscope, 130:980–985, 2020

Investigation of the Safety of Injection Laryngoplasty under Antithrombotic Therapy

BACKGROUND

Glottic insufficiency negatively affects phonation and swallowing function. Injection laryngoplasty is a convenient and minimally invasive treatment for glottic insufficiency. This study assessed whether injection laryngoplasty is safe under continued administration of antithrombotic drugs, and aimed to establish measurable laboratory values under which such a procedure can be safely performed.

METHOD

This retrospective medical record review covered the period from November 2012 to June 2018. We examined 17 patients who underwent injection laryngoplasty (47 injections) under continued administration of antithrombotic drugs at the University of Tokyo Hospital. We analyzed clinical and demographic profiles, complications, and blood test values. Statistical analyses were performed regarding the risks of complications due to injection side, route of administration, and number of antithrombotic drugs.

RESULTS

No patients exhibited airway narrowing or dyspnea; however, bleeding after injection laryngoplasty was observed in 3 patients. All patients exhibited values within the optimal treatment range. There were no significant differences regarding the risks of complications due to injection side, route of administration, or number of antithrombotic drugs.

CONCLUSIONS

When the platelet count, prothrombin time-international normalized ratio, and activated partial thromboplastin time were within the optimal range prior to treatment, injection laryngoplasty could safely be performed, regardless of the administration of antithrombotic drugs.

Web-Based Perceived Present Control Intervention for Voice Disorders: A Pilot Study

OBJECTIVE

Voice disorders are common and negatively affect various life domains such as occupational functioning and emotional well-being. Perceived present control, a factor that is amenable to change, may reduce the effect of voice disorders on these outcomes. This pilot study aimed to (1) establish the feasibility, usability, and acceptability of a web-based perceived present control intervention for individuals with voice disorders and (2) gather preliminary data on the effectiveness of the intervention. This study is the first to assess whether a web-based psychological intervention would decrease self-reported voice handicap in this population.

METHODS

Participants (N = 20) were recruited from an otolaryngology clinic at a large, Midwest university and the surrounding urban community, and completed a 3-week web-based intervention that incorporated psychoeducation and written exercises on increasing perceived present control.

RESULTS

Supporting feasibility, the intervention components had high completion rates (75%-95%). Most participants planned to continue the perceived control exercises after study completion and would recommend the intervention to others, demonstrating usability and acceptability. There was a significant decrease in self-reported voice handicap (Voice Handicap Index-10) from pretest (M = 18.38, standard deviation = 4.41) to post-test (M = 15.22, standard deviation = 4.55) with a large effect size (within-group d = -0.86, P < 0.05).

CONCLUSIONS

Focusing on perceived present control as a teachable skill may be a useful addition to voice disorder treatment armamentarium. Future studies will incorporate a comparison group and larger sample sizes to assess further the role of perceived present control interventions in voice care.