Vocal cord dysfunction in former World Trade Center (WTC) rescue and recovery workers and volunteers

Cluster Analysis of World Trade Center Related Lower Airway Diseases

ABSTRACT

Introduction: Cluster analysis can classify without a priori assumptions the heterogeneous chronic lower airway diseases found in former workers at the World Trade Center (WTC) disaster site. Methods: We selected the first available chest computed tomography scan with quantitative computed tomography measurements on 311 former WTC workers with complete clinical, and spirometric data from their closest surveillance visit. We performed a nonhierarchical iterative algorithm K-prototype cluster analysis, using gap measure. Results: A five-cluster solution was most satisfactory. Cluster 5 had the healthiest individuals. In cluster 4, smoking was most prevalent and intense but there was scant evidence of respiratory disease. Cluster 3 had symptomatic subjects with reduced forced vital capacity impairment (low FVC). Clusters 1 and 2 had less dyspneic subjects, but more functional and quantitative computed tomography evidence of chronic obstructive pulmonary disease (COPD) in cluster 1, or low FVC in cluster 2. Clusters 1 and 4 had the highest proportion of rapid first-second forced expiratory volume decliners. Conclusions: Cluster analysis confirms low FVC and COPD/pre-COPD as distinctive chronic lower airway disease phenotypes on long-term surveillance of the WTC workers.

Examining the Influence of Chemosensation on Laryngeal Health and Disorders

Inhaled airborne stimuli are associated with laryngeal disorders affecting respiration. Clinically, several themes emerged from the literature that point to specific gaps in the understanding and management of these disorders. There is wide variation in the types of airborne stimuli that trigger symptoms, lack of standardization in provocation challenge testing using airborne stimuli, and vague reporting of laryngeal symptoms. Scientifically, evidence exists outside the field of voice science that could prove useful to implement among patients with impaired laryngeal-respiration. To expand this area of expertise, here we provide a thematic overview of relevant evidence and methodological tools from the discipline of chemosensory sciences. This review provides distinctions across the three chemosensory systems of olfaction, trigeminal chemesthesis, and gustation, guidance on selecting and delivering common chemosensory stimuli for clinical testing, and methods of quantifying sensory experiences using principles of human psychophysics. Investigating the science of chemosensation reveals that laryngeal responses to inhaled airborne stimuli have explanations involving physiological mechanisms as well as higher cognitive processing. Fortunately, these findings are consistent with current pharmacological and nonpharmacological interventions for impaired laryngeal-respiration. Based on the close relationships among inhaled airborne stimuli, respiration, and laryngeal function, we propose that new perspectives from chemosensory sciences offer opportunities to improve patient care and target areas of future research.

World Trade Center Health Program best practices for diagnosing and treating chronic rhinosinusitis

The most frequent adverse physical health effect among World Trade Center Health Program (WTCHP) members is chronic rhinosinusitis (CRS), with some evidence supporting its association with the exposures to dust, gases, and toxicants. We selected the International Consensus Statement on Allergy and Rhinology: Rhinosinusitis (ICARS-RS-2021) as a comprehensive evidence-based guide on best practices for CRS diagnosis and treatment for the WTCHP.

Long-Term Outcome of Occupational Asthma From Irritants and Low-Molecular-Weight Sensitizers

BACKGROUND

The short-term asthma outcome of irritant-induced asthma (IIA) is poorer than that of low-molecular-weight (LMW) sensitizer-induced occupational asthma (OA).

OBJECTIVES

To evaluate the long-term asthma outcome of IIA and LMW-induced OA and to determine which baseline features are associated with a poor long-term outcome.

METHODS

This follow-up questionnaire study assessed 43 patients diagnosed with IIA and 43 patients with LMW-induced OA at the Finnish Institute of Occupational Health in 2004-2018. The baseline results were analyzed to detect features associated with uncontrolled asthma (Asthma Control Test [ACT] score of ≤19, or ≥2 exacerbations or ≥1 serious exacerbation within 1 year) at follow-up.

RESULTS

The median interval since OA diagnosis was 6.3 years (interquartile range [IQR]: 4.4-11.3 years). Uncontrolled asthma was more frequent with IIA than with LMW-induced OA (58% vs 40%, adjusted odds ratio [OR]: 3.60, 95% confidence interval [CI]: 1.20-10.81). Poor symptom control was the main factor for this difference (median [IQR] ACT score of 18 [15-22] vs 21 [18-23], P = .036, respectively). Among all participants, older age (OR: 1.08 per year, 95% CI: 1.02-1.15), a fractional exhaled nitric oxide (FeNO) value <20 ppb (OR: 5.08, 95% CI: 1.45-17.80), and uncontrolled asthma at baseline (OR: 3.94, 95% CI: 1.31-11.88) were associated with uncontrolled asthma at follow-up.

CONCLUSIONS

Long-term asthma control of IIA appears to be inferior to that of LMW-induced OA. Older age, a low FeNO value, and uncontrolled asthma at baseline might indicate a worse long-term outcome among those with IIA and LMW-induced OA.

Clinical Characteristics of Irritant-Induced Occupational Asthma

BACKGROUND

Work is a substantial contributing factor of adult-onset asthma. A subtype of occupational asthma (OA) is caused by irritant agents, but knowledge of the clinical outcomes of irritant-induced asthma (IIA) is incomplete.

OBJECTIVES

To evaluate whether the clinical picture of IIA differs from that of sensitizer-induced OA.

METHODS

This retrospective study analyzed acute and subacute IIA patients diagnosed in an occupational medicine clinic during 2004 to 2018. Sixty-nine patients fulfilled the inclusion criteria, and their characteristics were analyzed at the time of the diagnosis and 6 months later. The results were compared with those of 2 subgroups of sensitizer-induced OA: 69 high-molecular-weight (HMW) and 89 low-molecular-weight (LMW) agent-induced OA patients.

RESULTS

Six months after the diagnosis, 30% of the patients with IIA needed daily short-acting β-agonists (SABA), 68% were treated with Global Initiative for Asthma, 2020 report (GINA) step 4-5 medication, and 24% of the patients had asthma exacerbation after the first appointment. IIA depicted inferiority to LMW-induced OA in daily need for SABA (odds ratio [OR]: 3.80, 95% confidence interval [CI]: 1.38-10.46), treatment with GINA step 4-5 medication (OR: 2.22, 95% CI: 1.08-4.57), and exacerbation (OR: 3.85, 95% CI: 1.35-11.04). IIA showed poorer results than HMW-induced OA in the latter 2 of these features (OR: 2.49, 95% CI: 1.07-5.79 and OR: 6.29, 95% CI: 1.53-25.83, respectively).

CONCLUSIONS

Six months after the OA diagnosis, a significant proportion of the patients with IIA remain symptomatic and the majority of these patients use asthma medications extensively suggesting uncontrolled asthma. The short-term outcomes of IIA appear poorer than that of sensitizer-induced OA.

Work-Related Upper-Airway Disorders

Work-related rhinitis and laryngeal disorders are common and can significantly contribute to work absences and presenteeism. Each can cause respiratory symptoms that may be misdiagnosed as asthma symptoms, and each may occur as an isolated disorder or may also accompany asthma. Suspicion of these disorders and correct management require a careful medical and occupational history. Investigations for work-related rhinitis include examination of the nose, allergy skin tests, and in some cases, monitoring of peak inspiratory nasal flows at work and off work, or specific challenge tests. Work-related laryngeal disorders require assistance from an otolaryngologist and speech language pathologist.

Mental health, long-term medication adherence, and the control of asthma symptoms among persons exposed to the WTC 9/11 disaster

Objective: A positive association between mental health conditions and poor asthma control has been documented in the World Trade Center-exposed population. Whether factors such as medication adherence mediate this association is unknown.Methods: The study population was drawn from adult participants of the World Trade Center Health Registry Cohort who self-reported as asthmatic after the disaster and who were currently prescribed a long-term control medication (LTCM). Multivariable linear regression was used to estimate the associations between mental health condition (PTSD, depression, or anxiety) and continuous adherence and Asthma Control Test (ACT) scores.Results: In the study sample of 1,293, 49% were not adherent to their LTCM and two thirds reported poorly or very poorly controlled asthma. Presence of any mental health condition was associated with a 2-point decline in ACT and half a point decrease in adherence scores. However, in the multivariable model, better adherence was statistically significantly associated with slightly worse control.Conclusions: The total effect of mental health on asthma control was opposite in sign from the product of the paths between mental health and adherence and adherence and asthma control; we therefore found no evidence to support the hypothesis that adherence mediated the negative association between poor mental health and adequate asthma control. More research is needed to understand the complex causal mechanisms that underlie the association between mental and respiratory health.

Dynamic tonsillar prolapse masquerading as paradoxical vocal fold movement dysfunction

INTRODUCTION

Paradoxical vocal fold movement dysfunction (PVFMD) is a disorder in which the vocal folds involuntarily adduct during inspiration resulting in stridor, cough, dysphonia and dyspnea. Diagnosis of PVFMD is difficult given the episodic nature of the disorder and the often-normal laryngeal exam in between episodes. Moreover, additional sources of obstruction have been identified as sources of Periodic Occurrence of Laryngeal Obstruction (POLO). Treatments can vary with site of obstruction.

OBJECTIVE

To evaluate pediatric patients presenting to a Vocal Fold Dysfunction Center for evaluation of exertional, inspiratory, harsh breath sounds and dyspnea suggestive of PVFMD whom were found to have a dynamic obstruction of the upper airway due to adenotonsillar hypertrophy and prolapse.

METHODS

Retrospective chart review of patients diagnosed with exertional dynamic tonsillar prolapse whom have undergone adenotonsillectomy. Clinical characteristics, spirometry, exam findings and response to adenotonsillectomy were recorded.

RESULTS

Seven patients with exercise induced dyspnea and respiratory distress with whom underwent exercise spirometry then subsequent adenotonsillectomy were identified. Symptomatic co-morbidities were common and included: rhinitis (43%), reflux (29%), sleep disordered breathing (29%), asthma (14%), obesity (14%), prematurity (14%) and anxiety/post-traumatic stress disorder (PTSD) (14%). Preoperative use of bronchodilators or reflux medications was common. All patients were noted to have >50% oropharyngeal obstruction secondary to tonsillar hypertrophy and dynamic lateral pharyngeal collapse or tonsillar prolapse with inspiration. No exercise induced paradoxical vocal fold dysfunction was identified. All baseline and most exertion FVC, FEV1, FEV1/FVC and FEF 25-75% were normal. Four patients had flow volume loops suggestive of obstruction. All patients had symptomatic improvement after adenotonsillectomy.

CONCLUSIONS

Dynamic tonsillar prolapse can result in subjective exertional dyspnea and objective upper airway resistance mimicking PVFMD and treatment with adenotonsillectomy can greatly reduce symptoms.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Objective

This guideline provides evidence-based recommendations on treating patients who present with dysphonia, which is characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication and/or quality of life. Dysphonia affects nearly one-third of the population at some point in its life. This guideline applies to all age groups evaluated in a setting where dysphonia would be identified or managed. It is intended for all clinicians who are likely to diagnose and treat patients with dysphonia.

Purpose

The primary purpose of this guideline is to improve the quality of care for patients with dysphonia, based on current best evidence. Expert consensus to fill evidence gaps, when used, is explicitly stated and supported with a detailed evidence profile for transparency. Specific objectives of the guideline are to reduce inappropriate variations in care, produce optimal health outcomes, and minimize harm. For this guideline update, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of advanced practice nursing, bronchoesophagology, consumer advocacy, family medicine, geriatric medicine, internal medicine, laryngology, neurology, otolaryngology–head and neck surgery, pediatrics, professional voice, pulmonology, and speech-language pathology.

Action Statements

The guideline update group made strong recommendations for the following key action statements (KASs): (1) Clinicians should assess the patient with dysphonia by history and physical examination to identify factors where expedited laryngeal evaluation is indicated. These include, but are not limited to, recent surgical procedures involving the head, neck, or chest; recent endotracheal intubation; presence of concomitant neck mass; respiratory distress or stridor; history of tobacco abuse; and whether the patient is a professional voice user. (2) Clinicians should advocate voice therapy for patients with dysphonia from a cause amenable to voice therapy. The guideline update group made recommendations for the following KASs: (1) Clinicians should identify dysphonia in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces quality of life (QOL). (2) Clinicians should assess the patient with dysphonia by history and physical examination for underlying causes of dysphonia and factors that modify management. (3) Clinicians should perform laryngoscopy, or refer to a clinician who can perform laryngoscopy, when dysphonia fails to resolve or improve within 4 weeks or irrespective of duration if a serious underlying cause is suspected. (4) Clinicians should perform diagnostic laryngoscopy, or refer to a clinician who can perform diagnostic laryngoscopy, before prescribing voice therapy and document/communicate the results to the speech-language pathologist (SLP). (5) Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency. (6) Clinicians should offer, or refer to a clinician who can offer, botulinum toxin injections for the treatment of dysphonia caused by spasmodic dysphonia and other types of laryngeal dystonia. (7) Clinicians should inform patients with dysphonia about control/preventive measures. (8) Clinicians should document resolution, improvement or worsened symptoms of dysphonia, or change in QOL of patients with dysphonia after treatment or observation. The guideline update group made a strong recommendation against 1 action: (1) Clinicians should not routinely prescribe antibiotics to treat dysphonia. The guideline update group made recommendations against other actions: (1) Clinicians should not obtain computed tomography (CT) or magnetic resonance imaging (MRI) for patients with a primary voice complaint prior to visualization of the larynx. (2) Clinicians should not prescribe antireflux medications to treat isolated dysphonia, based on symptoms alone attributed to suspected gastroesophageal reflux disease (GERD) or laryngopharyngeal reflux (LPR), without visualization of the larynx. (3) Clinicians should not routinely prescribe corticosteroids for patients with dysphonia prior to visualization of the larynx. The policy level for the following recommendation about laryngoscopy at any time was an option: (1) Clinicians may perform diagnostic laryngoscopy at any time in a patient with dysphonia.

Disclaimer

This clinical practice guideline is not intended as an exhaustive source of guidance for managing dysphonia (hoarseness). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and it may not provide the only appropriate approach to diagnosing and managing this problem. Differences from Prior Guideline (1) Incorporation of new evidence profiles to include the role of patient preferences, confidence in the evidence, differences of opinion, quality improvement opportunities, and any exclusion to which the action statement does not apply (2) Inclusion of 3 new guidelines, 16 new systematic reviews, and 4 new randomized controlled trials (3) Inclusion of a consumer advocate on the guideline update group (4) Changes to 9 KASs from the original guideline (5) New KAS 3 (escalation of care) and KAS 13 (outcomes) (6) Addition of an algorithm outlining KASs for patients with dysphonia

Laryngeal Dysfunction: Assessment and Management for the Clinician

The larynx is one of the most highly innervated organs in humans and serves a number of vitally important, complex, and highly evolved biological functions. On a day-to-day basis, the larynx functions autonomously, addressing several roles including airway protection, swallowing, and phonation. In some situations the larynx appears to adopt a functional state that could be considered maladaptive or "dysfunctional." This laryngeal dysfunction can underpin and account for a number of respiratory symptoms that otherwise appear incongruous with a clinical disease state and/or contribute to the development of symptoms that appear "refractory" to treatment. These include conditions associated with a heightened tendency for inappropriate laryngeal closure (e.g., inducible laryngeal obstruction), voice disturbance, and chronic cough. Recognition of laryngeal dysfunction is important to deliver targeted treatment and failure to recognize the condition can lead to repeated use of inappropriate treatment. Diagnosis is not straightforward, however, and many patients appear to present with symptoms attributable to laryngeal dysfunction, but in whom the diagnosis has been overlooked in clinical work-up for some time. This review provides an overview of the current state of knowledge in the field of laryngeal dysfunction, with a focus on pragmatic clinical assessment and management.

Measuring Quality of Life in Pediatric Paradoxical Vocal Fold Motion Using the SF-36v2

OBJECTIVES

Paradoxical vocal fold motion (PVFM) consists of intermittent adduction of the vocal folds during inspiration, resulting in stridor and worsened by anxiety and stress. The purpose of this study was to assess the impact of PVFM on quality of life in our pediatric patient population.

STUDY DESIGN

This is a prospective, descriptive survey study.

METHODS

Thirty-nine consecutive patients (ages 12-17 years) presenting with a PVFM diagnosis for respiratory retraining sessions with speech-language pathology were recruited. Patients completed a brief demographic questionnaire and the Short Form 36, version 2, a validated tool for measuring health-related quality of life.

RESULTS

There were 31 (79%) girls and 8 (21%) boys with a mean age of 15.5 years. Subjects reported regular participation in competitive extracurricular activities, including track or cross country (30.8%), swimming (17.9%), and cheerleading or dancing (15.4%). Of the patients in the study, 46.2% were straight-A students. On the SF-36 (population averages normalized to a score of 50), the general health of patients with PVFM was better than that of the general population (53.27); however, their physical health limited their role activities more severely (42.82). In addition, a greater proportion of the group with PVFM was at risk for first-stage depression screening when compared with the general population (28% versus 18%).

CONCLUSIONS

We demonstrate a measurable detrimental impact of PVFM on health-related quality of life. This is consistent with previously published literature showing a preponderance of females with PVFM, most of whom are high achievers academically and athletically.

Vocal cord dysfunction diagnosis may be improved by a screening check list

BACKGROUND

Many patients with vocal cord dysfunction (VCD), with or without asthma, receive inappropriate treatment because they are misdiagnosed as having difficult-to-control asthma alone. We developed a clinical screening check list designed to aid the diagnosis of VCD.

METHODS

A prospective observational study involving 80 patients aged ≥18 years, diagnosed with severe asthma. After anamnesis and physical examination, physicians completed a check list with 6 questions to identify VCD, for which the answer "yes" counted one point. Then patients underwent spirometry and laryngoscopy. On the basis of the laryngoscopic findings, we created three patient groups: VCD (vocal cord adduction during inspiration, n = 14); unconfirmed VCD (inconclusive findings, n = 29); and control (normal findings, n = 37). We attempted to determine whether any of those groups were associated with the responses to individual questions or sets of questions on the check list.

RESULTS

The proportion of affirmative answers to the question "Does pulmonary auscultation reveal wheezing, predominantly in the cervical region, and/or stridor?" was significantly higher for the VCD group than for the other two groups (P = 0.006), notably in elderly patients. The variable "4 or more affirmative answers" was more common in VCD and unconfirmed VCD groups in comparison to controls (P = 0.022).

CONCLUSIONS

A finding of wheezing or stridor on auscultation of the cervical region is suggestive of vocal cord dysfunction, especially in elderly patients, and such dysfunction can be confirmed through laryngoscopy. Our VCD screening check list proved to be useful in the screening of VCD among patients with severe asthma.

Underlying Mechanisms in Episodic Laryngeal Breathing Disorders

The study and management of episodic laryngeal breathing disorders (ELBD)—characterized by paradoxical laryngeal movement patterns and dyspnea—has traditionally focused on clinical presentation of these conditions. However, the underlying mechanisms driving these entities are largely unknown. This article provides a review of potential underlying mechanisms driving clinical expression in ELBD and suggests approaches to the future study of ELBD etiology.

Eucapnic voluntary hyperpnoea and exercise-induced vocal cord dysfunction

INTRODUCTION

Exercise-induced bronchoconstriction (EIB) is a common condition in endurance athletes. Exercise-induced vocal cord dysfunction (EIVCD) is a frequent confounder of EIB. The diagnosis of EIVCD may be challenging and can be missed as the problem is often intermittent and may only occur during intense exercise. Eucapnic voluntary hyperventilation (EVH) is the best test to detect EIB. This pilot study aimed to assess if EVH could be helpful in the diagnosis of EIVCD associated or not to EIB in athletes.

METHODS

A nasolaryngoscopy was performed during a 6 min EVH test, in 13 female athletes suspected to have VCD, aged 21±7 years. Image analysis was conducted by two Ear Nose and Throat surgeons in random order.

RESULTS

During the EVH, three athletes showed incomplete paradoxical vocal cords movement, without inspiratory stridor. However, 12 athletes showed marked supraglottic movement without inspiratory stridor. In two athletes, this supraglottic movement was severe, one showing a marked collapse of the epiglottis with an almost complete obstruction of the larynx by the arytenoid cartilage mucosa. In 3 of the 12 athletes with supraglottic movement, severe vibration of the mucosa covering the arytenoid cartilages was also observed.

CONCLUSIONS

EVH challenge in athletes can provide information on various types of glottic and supraglottic obstruction in reproducing laryngeal movements during hyperventilation. Our findings make us suggest that exercise induced upper airway obstructions should be named: Exercise-induced laryngeal obstruction (EILO). Then, EILO should be divided in three categories: supraglottic, glottic (EIVCD) and mixed (glottic and supraglottic) obstruction.

Oscillometry complements spirometry in evaluation of subjects following toxic inhalation

The World Trade Center (WTC) destruction released dust and fumes into the environment. Although many community members developed respiratory symptoms, screening spirometry was usually normal. We hypothesised that forced oscillation testing would identify functional abnormalities undetected by spirometry and that symptom severity would relate to magnitude of abnormalities measured by oscillometry. A symptomatic cohort (n=848) from the Bellevue Hospital WTC Environmental Health Center was evaluated and compared to an asymptomatic cohort (n=475) from the New York City Department of Health WTC Health Registry. Spirometry and oscillometry were performed. Oscillometry measurements included resistance (R₅) and frequency dependence of resistance (R_5-20). Spirometry was normal for the majority of subjects (73.2% symptomatic versus 87.6% asymptomatic, p<0.0001). In subjects with normal spirometry, R₅ and R_5-20 were higher in symptomatic versus asymptomatic subjects (median (interquartile range) R₅ 0.436 (0.206) versus 0.314 (0.129) kPa·L^-1·s^-1, p<0.001; R_5-20 0.075 (0.085) versus 0.004 (0.042) kPa·L^-1·s^-1, p<0.0001). In symptomatic subjects, R₅ and R_5-20 increased with increasing severity and frequency of wheeze (p<0.05). Measurement of R_5-20 correlated with the presence and severity of symptoms even when spirometry was within normal limits. These findings are in accord with small airway abnormalities as a potential explanation of the respiratory symptoms.

[Pursed Lips Inspiration for Vocal Cord Dysfunction]

Paradoxical vocal cord motion (PVCM) during vocal cord dysfunction (VCD) generally occurs spasmodically and transiently. After we had experienced 36 cases of VCD and successfully treated with conservative treatment including "pursed lips inspiration" method, we experienced a boy who had persistent PVCM. It was observed his PVCM vanished when he breathed in through pursed lips, while it appeared again when he stopped pursed lips inspiration. An airway reflex has been reported where the negative pressure in the subglottic space resulting from the inspiratory effort against a narrowed glottis activates the vocal cord adductor. VCD is considered to have both acceleration of laryngeal closure reflex against airway stimuli and active adductive movement of vocal cords against negative pressure in the subglottic space as underlying factors. The pursed lips inspiration method enables VCD patients not only to accomplish slow and light breathing but also to decrease the difference in the pressure between the supra--and subglottic space by occluding the nasal cavity and voluntary puckering up of the mouth which generate negative pressure in the supraglottic space. This is the first report of the pursed lips inspiration method as a treatment for VCD. Pursed lips inspiration is a simple method which is easy to perform anytime, anywhere without any special equipment, and is considered to be worth trying for VCD.

EAACI Position Paper on assessment of cough in the workplace

Cough is a nonspecific and relatively common symptom that can present difficulties in diagnosis and management, particularly when it is reported to be associated with the workplace. The present consensus document, prepared by a taskforce of the Interest Group on Occupational Allergy of the European Academy of Allergy and Clinical Immunology by means of a nonsystematic review of the current literature, is intended to provide a definition and classification of work-related chronic cough (WRCC) to assist the daily practice of physicians facing with this symptom. The review demonstrates that several upper and lower airway work-related diseases may present with chronic cough; hence, the possible link with the workplace should always be considered. Due to the broad spectrum of underlying diseases, a multidisciplinary approach is necessary to achieve a definite diagnosis. Nevertheless, more epidemiological studies are necessary to estimate the real prevalence and risk factors for WRCC, the role of exposure to environmental and occupational sensitizers and irritants in its pathogenesis and the interaction with both upper and lower airways. Finally, the best management option should be evaluated in order to achieve the best outcome without adverse social and financial consequences for the worker.

The Impact of Disasters on Populations With Health and Health Care Disparities

Context:A disaster is indiscriminate in whom it affects. Limited research has shown that the poor and medically underserved, especially in rural areas, bear an inequitable amount of the burden.

Objective:To review the literature on the combined effects of a disaster and living in an area with existing health or health care disparities on a community's health, access to health resources, and quality of life.

Methods:We performed a systematic literature review using the following search terms: disaster, health disparities, health care disparities, medically underserved, and rural. Our inclusion criteria were peer-reviewed, US studies that discussed the delayed or persistent health effects of disasters in medically underserved areas.

Results:There has been extensive research published on disasters, health disparities, health care disparities, and medically underserved populations individually, but not collectively.

Conclusions:The current literature does not capture the strain of health and health care disparities before and after a disaster in medically underserved communities. Future disaster studies and policies should account for differences in health profiles and access to care before and after a disaster.

(Disaster Med Public Health Preparedness. 2010;4:30-38)

Vocal cord dysfunction related to water-damaged buildings

BACKGROUND

Vocal cord dysfunction (VCD) is the intermittent paradoxical adduction of the vocal cords during respiration, resulting in variable upper airway obstruction. Exposure to damp indoor environments is associated with adverse respiratory health outcomes, including asthma, but its role in the development of VCD is not well described.

OBJECTIVE

We describe the spectrum of respiratory illness in occupants of 2 water-damaged office buildings.

METHODS

The National Institute for Occupational Safety and Health conducted a health hazard evaluation that included interviews with managers, a maintenance officer, a remediation specialist who had evaluated the 2 buildings, employees, and consulting physicians. In addition, medical records and reports of building evaluations were reviewed. Diagnostic evaluations for VCD had been conducted at the Asthma and Allergy Center of the Medical College of Wisconsin.

RESULTS

Two cases of VCD were temporally related to occupancy of water-damaged buildings. The patients experienced cough, chest tightness, dyspnea, wheezing, and hoarseness when in the buildings. Spirometry was normal. Methacholine challenge did not show bronchial hyperreactivity but did elicit symptoms of VCD and inspiratory flow-volume loop truncation. Direct laryngoscopy revealed vocal cord adduction during inspiration. Coworkers developed upper and lower respiratory symptoms; their diagnoses included sinusitis and asthma, consistent with recognized effects of exposure to indoor dampness. Building evaluations provided evidence of water damage and mold growth.

CONCLUSION

VCD can occur with exposure to water-damaged buildings and should be considered in exposed patients with asthma-like symptoms.

Work-related laryngeal syndromes

PURPOSE OF REVIEW

This review summarizes recent literature regarding the association of nonorganic laryngeal dysfunction with occupational exposures. Laryngeal dysfunction may masquerade as asthma and is an important consideration in patients with work-associated respiratory symptoms.

RECENT FINDINGS

Although there is lack of consensus regarding clinical features, vocal cord dysfunction (VCD) is the most well appreciated form of nonorganic laryngeal dysfunction. There are significant gaps in the literature regarding the occupational epidemiology of laryngeal dysfunction, however, occupational exposures such as upper airway irritants may be associated with the onset of symptoms. Recurrent work-associated laryngeal dysfunction has been described in occupational groups including the military and professional athletes. Recent theories have considered that VCD may be a state of laryngeal hyperresponsiveness associated with both intrinsic and extrinsic factors.

SUMMARY

Laryngeal dysfunction is an important consideration in patients with work-associated respiratory symptoms. Clinicians should have a high index of suspicion, in particular, if symptoms are associated with exposure to a respiratory irritant. Situations of high psychological stress may also be associated with recurrent symptoms. There is a requirement for evidence-based guidelines for the diagnosis and management of laryngeal dysfunction, which should also address work-related factors.

World Trade Center Health Registry--a model for a nanomaterials exposure registry

OBJECTIVE

To describe the development of and some of the early results from the World Trade Center Health Registry (WTCHR). Is the WTCHR a model for a nanomaterials exposure registry? What lessons may be learned from the WTCHR?

METHODS

We describe the steps involved in creation of the WTCHR, from design through implementation.

RESULTS

The lessons learned from the WTCHR include thorough documentation of exposure early in the registry, using multimode surveys to maximize response rate, establishing an institutional home with sufficient resources for core as well as in-depth longitudinal and intervention studies, meeting with stakeholders regularly, making data accessible, and timely publication of findings, including wide dissemination of clinical guidelines.

CONCLUSIONS

The process of creating and maintaining the WTCHR provides important lessons for the possible creation of a nanomaterials exposure registry.

Vocal cord dysfunction: an update

OBJECTIVES

To review the clinical manifestations of vocal cord dysfunction (VCD) and to discuss new developments in the diagnosis and treatment.

DATA SOURCES

PubMed searches were performed for articles published regarding presentation, pathogenesis, diagnosis, and treatment options of VCD using the keywords vocal cord dysfunction, pathogenesis, clinical features, diagnosis, and management.

STUDY SELECTION

Articles were selected based on their relevance to the topic of this review. The newest developments in VCD were defined by articles published in the past 8 years.

RESULTS

The exact cause and pathogenesis remain unclear, although laryngeal hyperresponsiveness likely plays a role in a subset of patients. Certain findings on spirometry are often interpreted to suggest VCD, but recent studies have had varying results on how useful these are in the diagnosis of VCD. Diagnosis is made by direct visualization of the adduction of the vocal cords via rhinolaryngoscopy, but the method used to provoke symptoms and adduction varies. Other noninvasive tests have been evaluated as well.

CONCLUSION

The early recognition and treatment of VCD are imperative to prevent the misdiagnosis and mismanagement of asthma. In addition, VCD and asthma can occur together. The origin and pathogenesis of VCD need to be better defined. More studies comparing the provocation methods during laryngoscopy may be helpful in further standardizing a diagnostic test. Further research is needed to determine whether other noninvasive tests are as effective in diagnosing VCD as laryngoscopy.

Vocal cord dysfunction and asthma

PURPOSE OF REVIEW

Vocal cord dysfunction can occur independently or can co-exist with asthma. It often mimics asthma in presentation and can be challenging to diagnose, particularly in those with known asthma. Vocal cord dysfunction remains under-recognized, which may result in unnecessary adjustments to asthma medicines and increased patient morbidity. There is a need to review current literature to explore current theories regarding disease presentation, diagnosis, and treatment.

RECENT FINDINGS

The underlying cause of vocal cord dysfunction is likely multifactorial but there has been increased interest in hyper-responsiveness of the larynx. Many intrinsic and extrinsic triggers have been identified which in part may explain asthma-like symptomatology. A variety of techniques have been reported to provoke vocal cord dysfunction during testing which may improve diagnosis. There is a significant gap in the literature regarding specific laryngeal control techniques, duration of therapy, and the effectiveness of laryngeal control as a treatment modality.

SUMMARY

Those with vocal cord dysfunction and asthma report more symptoms on standardized asthma control questionnaires, which can result in increasing amounts of medication if vocal cord dysfunction is not identified and managed appropriately. Clinicians need to maintain a high index of suspicion to identify these patients. Videolaryngostroboscopy remains the diagnostic method of choice. Evidence-based guidelines are needed for the most effective diagnostic techniques. Laryngeal control taught by speech pathologists is the most common treatment. Effectiveness is supported in case reports and clinical experience, but not in larger randomized trials which are needed.

Occupational asthma and lower airway disease among World Trade Center workers and volunteers

The World Trade Center (WTC) disaster and its recovery work involved a range of hazardous occupational exposures that have not been fully characterized but can be reasonably assumed to have the potential to cause mucosal inflammation in the upper and lower airways. A high prevalence of lower airway disease (LAD) symptoms was reported by several early surveys. Clinical studies further categorized the diagnoses as irritant-induced asthma (of subacute onset), nonspecific chronic bronchitis, chronic bronchiolitis, or aggravated preexistent obstructive pulmonary disease in a substantial proportion of patients. Risk factors for WTC-related LAD included early (on September 11 or 12, 2001) arrival at the WTC site and work at the pile of the collapsed towers. Cigarette smoking (but not atopy) also seemed to be a risk factor for LAD. No data thus far suggest an increased incidence of neoplastic or interstitial lung disease, but ongoing surveillance is clearly necessary.

Occupational rhinosinusitis and upper airway disease: the world trade center experience

The World Trade Center disaster and its recovery work involved a range of hazardous occupational exposures that have not been fully characterized but that can be reasonably assumed to have the potential to cause mucosal inflammation, preferentially (but not exclusively) in the upper airway. A high prevalence of rhinosinusitis and upper airway disease (UAD) symptoms was reported by several early surveys. Clinical studies demonstrated objective, clinically significant, and persistent chronic perennial rhinosinusitis and UAD-with or without seasonal exacerbation-in a large proportion of patients. Demonstration of an association between UAD and available exposure indicators has been limited. Atopy seemed to be associated with increased UAD symptom severity and to be a risk factor for upper, but not lower, airway disease. World Trade Center-related UAD is considered an irritant-induced disease but not, in many cases, of acute onset. No data thus far suggest an increased upper airway cancer incidence.

Clinical Practice Guideline: Hoarseness (Dysphonia)

Objective:

This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness.

Purpose:

The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology–head and neck surgery, pediatrics, and consumers.

Results

The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patient's larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgment or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem.

Otolaryngologic Symptoms in Persons Exposed to World Trade Center Dust and Particle Pollutants: A Case for Caution in Declaring a Diagnosis of Wtc Syndrome

Since the Sept. 11, 2001, attack on the World Trade Center (WTC), the health status of survivors, rescue and cleanup workers, and residents of Lower Manhattan has been monitored. Exposure to dust and particulate matter resulted in numerous complaints of both upper and lower aerodigestive tract irritation. The symptoms, diagnoses, and management of affected persons have previously been described in the literature. However, evidence establishing causation is scarce, especially with regard to the purported long-term effects of such exposure. Many persons who were exposed to the Ground Zero site have otolaryngologic conditions that are common in persons who were not so exposed. Therefore, otolaryngologists involved in the care of such patients should be cautious about assigning a diagnosis of “WTC syndrome” without a comprehensive examination to look for other possible etiologies. A diagnosis of a treatable, potentially serious health problem should not be missed simply because a patient who was exposed to WTC irritants was presumed to have WTC syndrome. In this review, we discuss the reported otolaryngologic manifestations of exposure to the WTC site, and we describe the specific cases of 2 workers there who continue to have otolaryngologic complaints. Considerable research is needed to establish the existence and nature of any long-term sequelae of exposure to WTC fallout.

Health Care and Social Issues of Immigrant Rescue and Recovery Workers at the World Trade Center Site

This article reviews the experience of a unique occupational group of World Trade Center (WTC) workers: immigrant workers. This group is comprised largely of men, laborers, who are first-generation immigrants. The majority of these workers are from Latin America (predominantly from Ecuador and Colombia) or from Eastern Europe (predominantly from Poland). Our data shows that the disease profile observed in these workers was what we have previously reported for WTC working population as a whole. Recent reports have begun to document the disproportionate burden of occupational hazards, injuries, and illnesses experienced by immigrant workers in the United States. The WTC experience of immigrants exemplified this burden but, additionally, highlighted that this burden is exacerbated by limitations in access to appropriate health care, disability and compensation benefits, and vocational rehabilitation services. A clinical program that was designed to address the complex medical and psychosocial needs of these workers in a comprehensive manner was successfully established. Full justice for these workers depends on larger societal changes.