Assessing factors related to the pharmacologic management of laryngeal diseases and disorders

Dysphonia in Children; Clinical Profile, Conservative Treatment Modalities and Outcomes: An Institutional Experience

Dysphonia in children represents broad-spectrum voice problems. Global prevalence of hoarseness in school-aged children is 6-23%. It impairs communication of child, thus affects social life. This study shows importance of appropriate preventive measures for paediatric dysphonia and diagnosis of voice problems in early stages. Continuous voice abuse in children can cause recurrent voice disorders as well as speech problems. This prospective study included 104 patients(78 males and 26 females) of 6-15 years, with voice problems, in a tertiary care centre, North Kerala, during June 2022-March 2023. Chief complaints and risk factors evaluated. Voice analysis using maximum phonation time (MPT), Child Voice Handicap Index for Parents (CVHI-10-P), Reflux Symptom Index (RSI) and clinical examination including indirect laryngoscopy (IDL) and 70degree scopy were done. Treatment given for a maximum of 2 weeks. Advised voice rest and voice therapy throughout. All patients followed up after 2 weeks and up to 3 months. Voice abuse was the commonest risk factor and voice change, the commonest symptom. MPT reduced in 23% males and 14% females. According to CVHI-10-P, screaming was present in 52% children and symptoms present mostly in afternoon. RSI identified the role of LPRD in dysphonia. IDL and 70 scopy identified most common diagnosis as vocal nodule. Treatment given and follow-up period noted. All except vocal polyp had complete relief. Most common diagnosis was vocal nodule which resulted from chronic voice abuse. Appropriate preventive measures, early diagnosis and adequate treatment of voice problems should be considered. Conservative management in early stages is recommended.

Hoarseness Guidelines Redux: Toward Improved Treatment of Patients with Dysphonia

The Hoarseness Guideline Update provides an evidence-based approach to a patient who presents to the clinic with hoarseness. The guidelines cover management decisions in acute and chronic dysphonia for patients of all ages before and after laryngeal examination. The present review discusses the process used to develop these guidelines, including limitations of the process and each key action statement.

Associations between Community-Acquired Pneumonia and Proton Pump Inhibitors in the Laryngeal/Voice-Disordered Population

OBJECTIVES

To examine the relationship between community-acquired pneumonia (CAP) and proton pump inhibitor (PPI) treatment among patients with laryngeal/voice disorders.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

Large national administrative US claims database.

SUBJECTS AND METHODS

Patients were included if they were ≥18 years old; had outpatient treatment for a laryngeal/voice disorder from January 1, 2010, to December 31, 2014 (per International Classification of Diseases, Ninth Revision, Clinical Modification codes); had 12 months of continuous enrollment prior to the index date (ie, first diagnosis of laryngeal/voice disorder); had no preindex diagnosis of CAP; and had prescription claims captured from 1 year preindex to end of follow-up. Patient demographics, comorbid conditions, index laryngeal diagnosis, number of unique preindex patient encounters, and CAP diagnoses during the postindex 3 years were collected. Two models-a time-dependent Cox regression model and a propensity score-based approach with a marginal structural model-were separately performed for patients with and without pre-index date PPI prescriptions.

RESULTS

A total of 392,355 unique patients met inclusion criteria; 188,128 (47.9%) had a PPI prescription. The 3-year absolute risk for CAP was 4.0% and 5.3% among patients without and with preindex PPI use, respectively. For patients without and with pre-index date PPI use, the CAP occurrence for a person who had already received a PPI is 30% to 50% higher, respectively, than for a person who had not yet had a PPI but may receive one later.

CONCLUSIONS

Patients without and with pre-index date PPI use experienced a roughly 30% to 50% increased likelihood of CAP, respectively, as compared with patients who had not had PPI prescriptions.

Pharmacologic management of voice disorders by general medicine providers and otolaryngologists

OBJECTIVES

1) To compare laryngeal diagnoses from general medical providers (GMP) to otolaryngologists following GMP-based medication trial, and 2) to evaluate associations between GMP medication trials and pharmacologic treatment by otolaryngologists.

METHODS

Retrospective cohort analysis using large, national administrative U.S. claims database. Patients with laryngeal/voice disorders as per the International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2010, to December 31, 2012, seen by a GMP and then an otolaryngologist between 2 weeks to 3 months after the GMP visit, were included. Patient demographics, comorbid conditions, medication use, and initial GMP and otolaryngology laryngeal diagnoses were collected. Logistic regression was performed to evaluate the association between GMP and otolaryngologist medication trials.

RESULTS

A total of 12,475 unique laryngeal/voice-disordered patients met inclusion criteria. At the initial GMP visit, 15.3% received an antibiotic, 14.0% a proton pump inhibitor (PPI), and 7.7% an oral steroid. After the otolaryngology visit, increased diagnoses of vocal fold paralysis/paresis, benign vocal fold/laryngeal pathology, chronic laryngitis, and multiple diagnoses occurred. The adjusted odds for an otolaryngologist prescribing an antibiotic, PPI, or oral steroid, respectively, given that a GMP prescribed an antibiotic, PPI, or oral steroid, was roughly two to three times higher that of a GMP not prescribing the given medication.

CONCLUSION

Patients with structural and neuromuscular laryngeal disorders were treated with medications by GMPs, and similar mediations often were repeated after otolaryngology evaluation. These findings suggest potential areas of unnecessary pharmacologic treatment of laryngeal/voice-disordered patients.

LEVEL OF EVIDENCE

2b. Laryngoscope, 128:682-689, 2018.

Correlation between Reflux and multichannel intraluminal impedance pH monitoring in untreated volunteers

OBJECTIVES/HYPOTHESIS

Although probable causative agents have been identified (e.g., refluxate components, tobacco smoke), the definitive mechanism for inflammation-related laryngeal mucosal damage remains elusive. Multichannel intraluminal impedance combined with pH monitoring (MII/pH) has emerged as a sensitive tool for diagnosis and characterization of gastroesophageal reflux disease with laryngopharyngeal manifestations. To determine the relationship between laryngeal signs and MII/pH, we examined correlations between Reflux Finding Score (RFS) ratings of videostroboscopic laryngeal examinations and findings from MII/pH.

STUDY DESIGN

Correlational study.

METHODS

Healthy, untreated volunteers (n = 142) underwent reflux diagnosis using data acquired from MII/pH testing. Eight trained clinicians performed RFS ratings of corresponding laryngeal examinations. Averaged RFS ratings were compared to MII/pH data using Pearson correlation coefficients. The relationship between RFS and MII/pH findings and demographic/clinical information (age, sex, smoking status, reflux) was assessed using general linear modeling. Rater reliability was evaluated.

RESULTS

Posterior commissure hypertrophy was negatively correlated with minutes of nonacid refluxate (R = -0.21, P = .0115). General linear modeling revealed that 28% to 40% of the variance in ratings of ventricular obliteration, erythema/hyperemia, vocal fold edema, diffuse laryngeal edema, posterior commissure hypertrophy, and granulation/granuloma could be explained by main and interaction effects of age, sex, smoking status, and reflux. Intra- and inter-rater reliability for RFS were poor-fair.

CONCLUSIONS

These results support the theory that the RFS is not specific for reflux in healthy, untreated volunteers, suggesting there may be alternate explanations for inflammatory clinical signs commonly ascribed to reflux in this population.

Patient-Centered Outcomes Research in Voice

Patient-centered outcomes research is critically important to improving the management of patients with voice disorders. Currently, wide variation in outcome definitions and treatment decisions exist. It is the responsibility of voice clinicians and researchers to improve the quality of and access to care for patients with voice disorders through the conduct of collaborative and rigorous patient-centered outcomes and comparative effectiveness research. Patients are the ultimate arbiter of their treatment, but need reliable and valid information to make informed decisions. Improving outcomes research will require collaborations among clinicians and study design experts in epidemiology, biostatistics, and data analysis. Moreover, researchers should be encouraged to compare the effectiveness of current treatments, which, to date, are implemented with little systematic, rigorous reinforcing evidence. Patient-reported outcomes research is increasingly emphasized by funding sources and in health care regulation. Oversight is inevitable and the voice community must ensure that it can justify those treatments that we know are beneficial to patients through compelling and patient-centered outcomes research.