Evaluation of the prevalence of and factors associated with laryngeal diseases among the general population

Describing the Cellular Impact of IQOS™ Smoke Extract and Vibration on Human Vocal Fold Fibroblasts

OBJECTIVES

The isolated or combined effects of vibration and smoke extract (SE) from the IQOS™ "heat-not-burn" technology on human vocal fold fibroblasts (hVFF) were evaluated in an in vitro setting in order to elucidate their influence on vocal fold (patho-) physiology.

STUDY DESIGN

Experimental pilot study using intervention with IQOS™-SE in vitro.

METHODS

Immortalized hVFF were exposed to IQOS™-SE or control medium under static or vibrational conditions. A phonomimetic bioreactor was used to deliver vibrational patterns to hVFF over a period of 5days. Cytotoxicity was quantified by lactate dehydrogenase assay. Effects on extracellular matrix production, inflammation, fibrogenesis, and angiogenesis were assessed by reverse transcription-quantitative polymerase chain reaction, western blot, enzyme-linked immunosorbent assay, and Magnetic Luminex assays.

RESULTS

We observed significant changes induced either by IQOS™-SE exposure alone (matrix metalloproteinase 1, fibronectin, cyclooxygenase (COX)1, interleukin-8 gene expression), or by the combination of IQOS™-SE and vibration (hyaluronidase 2, COX2, interleukin-8 protein levels, vascular endothelial growth factor D).

CONCLUSION

Short-term in vitro exposure of hVFF to IQOS™-SE did not result in cytotoxicity and reduced the gene expression of measured inflammation mediators, but had no effect on their protein expression. However, the clinical effects of long-term IQOS™ use are still not known and further research is needed in order to assess, if IQOS™ is in fact less harmful than conventional cigarettes.

Method for Collecting Single Epithelial Cells from the Mouse Larynx

OBJECTIVE

The larynx is lined by specialized epithelial cell populations. Studying molecular changes occurring in individual epithelial cell types requires a reliable method for removing these cells from the larynx. Our objective was to develop a method to harvest individual epithelial cells from the mouse larynx while minimizing contamination from non-laryngeal sites and non-epithelial laryngeal cells.

METHODS

Mice were euthanized, and the larynx was carefully exposed and separated from non-laryngeal sites. A small dental brush was inserted into the laryngeal inlet and rotated to obtain epithelial cells. Cells were transferred to collection media, counted, and cytospin preparations stained for laryngeal epithelial (i.e., Pan-Keratin, EpCAM, NGFR, p63, K5, β-tubulin, MUC5AC) and non-epithelial (i.e., vimentin) cell markers. Histopathology was completed on brushed laryngeal tissue sections to evaluate the depth of cell collection. Preliminary Single-cell RNA sequencing (scRNA-seq) was performed to confirm this method can capture diverse laryngeal cell types.

RESULTS

We collected 6000-8000 cells from a single larynx and 35000-40000 cells from combining brushings from three tissues. Histopathology demonstrated brushing removed the epithelial layer of the larynx and some underlying tissue. Immunofluorescence staining demonstrated the phenotype of harvested cells was primarily epithelial. Preliminary scRNA-seq was successfully conducted and displayed nine unique cell clusters.

CONCLUSION

We developed a reliable method of harvesting individual epithelial cells from the mouse larynx. This method will be useful for collection of laryngeal cells for a variety of downstream cellular and molecular assays, including scRNA-seq, protein analyses, and cell-culture-based experiments, following laryngeal injury.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:786-794, 2024.

Impact of the Severity of Reinke's Edema on the Parameters of Voice

Objective

This study aimed to classify the degree of edema in patients with Reinke's edema (RE) and examine its impact on their voice parameters using both objective and subjective assessment methods.

Methods

Objective and subjective voice data of 104 patients diagnosed with RE between 2018 and 2021 were evaluated retrospectively. RE is classified into 4 groups (types 1, 2, 3, and 4). The evaluation included videolaryngostroboscopic examination, acoustic voice analysis, and aerodynamic measurements, GRBAS, Voice Handicap Index-10 (VHI-10), Voice-Related Quality of Life Scale (V-RQOL), and Reflux Septum Index (RSI).

Results

Patients with type 1 RE had a significantly lower mean age than those with types 3-4. Although there were no significant differences in acoustic and aerodynamic parameters between the groups, it was observed that F0 and the maximum phonation time decreased as the degree of edema increased. The GRBASTotal, G, and R scores of types 1 and 2 were significantly lower than those of types 3 and 4, as were the scores of type 1 S. There were no statistically significant differences between the RE groups in terms of VHI-10, V-RQOL, and RSI scores.

Conclusion

It has been observed that as the severity of RE increases, voice perception and quality (especially types 3 and 4) are negatively affected. Determining the degree of edema will guide the clinician in both the planning of the intervention phase and the follow-up phase.

Prevalence of Benign Vocal Fold Lesions: Long-Term Results From a Single European Institution

OBJECTIVES/HYPOTHESIS

Hoarseness and limited voice capacity are often associated with benign vocal fold (VF) lesions. Despite their high clinical prevalence, epidemiological investigations focusing on these structural alterations are rare. The aim of the study was to present current European data on five typical lesion types (VF nodules, polyp, cyst, contact granuloma, Reinke´s edema).

STUDY DESIGN

Retrospective investigation.

METHODS

Video recordings of laryngoscopies from all patients with one of the above-mentioned VF pathologies were subjected to a review process. Data collected arose from a single institution over a period of 13 years. They were evaluated statistically with respect to lesion type, sex, age at first diagnosis, and affected side.

RESULTS

In a total of 535 patients, VF polyps occurred most frequently, followed by Reinke's edema and nodules. Each of the lesion types studied was significantly associated with sex and, except VF cysts, all diagnoses were also significantly related to age. Female sex was a risk factor for VF nodules, cysts, and Reinke's edema, whereas male sex was associated with polyps and contact granulomas. VF nodules occurred predominantly in young patients, VF polyps in middle-aged, Reinke's edema, and contact granulomas in later adulthood. The predominantly affected side (bilateral, right, or left VF) depended on sex.

CONCLUSIONS

Different prevalences from previous studies resulted from inconsistencies in terms of classification framework, terminology, and definition. In addition to endoscopic findings, socio-cultural backgrounds must also be considered when studying benign VF lesions. Prophylactic voice care education for all populations and concomitant efficacy studies are required. Further research is needed to verify possible correlations between sex and the affected side. A non-binary view could broaden the spectrum of phoniatric research issues.

Smoking and Carcinoma Trends in Recurrent Respiratory Papillomatosis Patients

INTRODUCTION

Recurrent respiratory papillomatosis (RRP) is a chronic disease of the upper respiratory tract caused by human papillomavirus types 6 and 11. The disease course is characteristically unpredictable, ranging from spontaneous remission to aggressive, recurrent disease. Thus, management is often challenging and requires unique approaches tailored to each individual patient. While recent literature has described risk factors for more aggressive disease, few sources have investigated the impact of smoking on RRP disease course and risk for malignant transformation.

METHODS

A retrospective chart review was conducted for adult RRP patients evaluated at an academic tertiary care center between 2005 and 2020. A total of 188 patients were identified. Demographic and clinical data were collected, including smoking and alcohol history, HPV subtype, history of dysplasia and/or carcinoma, voice handicap index scores, Derkay scores, debulkings (in office and operating room), and days to papilloma recurrence.

RESULTS

Malignant degeneration in RRP occurred in 16.3% of smokers and 3.6% of nonsmokers. Smokers who developed carcinoma had less debulkings per years of evaluation than those not developing carcinoma (0.21 vs 0.92, P = .004). Additionally, patients that either presented with or developed carcinoma during their course had a higher pack-year smoking history (18.0 vs 12.21, P = .0002). No difference in days to recurrence or inter-surgical interval was demonstrated between smokers and nonsmokers.

CONCLUSIONS

The report demonstrates that smoking can increase the risk of malignant transformation in RRP patients.

Esketamine versus Sufentanil Applied Prior to Placement of Suspension Laryngoscope

OBJECTIVE

In laryngeal microsurgery, the insertion of the suspension laryngoscope is a strong stimulus that may cause hemodynamic fluctuations and adverse cardiovascular events. The purpose of this study was to compare the effect of preemptive treatment with esketamine and sufentanil on maintaining hemodynamics and reducing the occurrence of adverse cardiovascular events during the insertion of suspension laryngoscope.

METHODS

In this double-blind randomized controlled trial, patients undergoing general anesthesia for laryngeal microsurgery were randomly assigned (1:1) to esketamine 0.5 mg kg-1 (esketamine group) and sufentanyl 0.125 μg kg-1 (sufentanil group) before inserting the laryngoscope, respectively.

RESULTS

During the insertion of suspension laryngoscope, the incidence of bradycardia (HR < 60 beats/min) was 39.3% (22/56) in esketamine group, lower than 60.0% (33/55) in sufentanil group (odds ratio [OR], 2.32 [95% CI, 1.11-5.08]; p = 0.029). The incidence of hypotension (MAP <65 mmHg) was 33.9% (19/56) in esketamine group, lower than 56.4% (31/55) in sufentanil group (odds ratio [OR], 2.52 [95% CI, 1.91-5.27]; p = 0.018). The frequency of hypotension in esketamine group was lower than that in sufentanil group (0.36 ± 0.52 vs. 0.56 ± 0.50, p = 0.035). The time-weighted average of HR dropping above 30% of baseline was smaller in esketamine group than in sufentanil group (0.52 ± 2.06 vs. 1.08 ± 2.77, p = 0.006).

CONCLUSIONS

These findings showed that compared with preemptive treatment of sufentanil (0.125 μg kg-1 ), esketamine (0.5 mg kg-1 ) was effective in reducing the incidence of cardiovascular adverse events, including bradycardia and hypotension induced by the insertion of suspension laryngoscope during the laryngeal microsurgery.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:3021-3027, 2023.

Artificial intelligence for the recognition of benign lesions of vocal folds from audio recordings

Objective

The diagnosis of benign lesions of the vocal fold (BLVF) is still challenging. The analysis of the acoustic signals through the implementation of machine learning models can be a viable solution aimed at offering support for clinical diagnosis.

Materials and methods

In this study, a support vector machine was trained and cross-validated (10-fold cross-validation) using 138 features extracted from the acoustic signals of 418 patients with polyps, nodules, oedema, and cysts. The model's performance was presented as accuracy and average F1-score. The results were also analysed in male (M) and female (F) subgroups.

Results

The validation accuracy was 55%, 80%, and 54% on the overall cohort, and in M and F, respectively. Better performances were observed in the detection of cysts and nodules (58% and 62%, respectively) vs polyps and oedema (47% and 53%, respectively). The results on each lesion and the different patterns of the model on M and F are in line with clinical observations, obtaining better results on F and detection of sensitive polyps in M.

Conclusions

This study showed moderately accurate detection of four types of BLVF using acoustic signals. The analysis of the diagnostic results on gender subgroups highlights different behaviours of the diagnostic model.

Reinke's Edema: New Insights into Voice Analysis, a Retrospective Study

PURPOSE

Reinke's edema (RE) is a pathological condition involving increased volume of the vocal folds and resulting in significant impact on speech, fundamental frequency, and vocal range. Literature reports few studies which analyze vocal features according to the severity of RE. The aims of this study were to investigate the aerodynamics, acoustic characteristics, and sound spectrograms of a group of RE patients and to assess whether there was any correlation with their endoscopic grading.

METHODS

A total of 98 patients were included in the study, 49 patients with RE and 49 healthy volunteers (HV). Multidimensional Voice Program was used to perform objective voice assessment. Maximum phonation time (MPT) and Voice Handicap Index (VHI) questionnaire were collected. The spectrograms of the vowel /a/ and of the word /aiuole/, which contains the five Italian vowels, of each patient were analyzed according to the classification of Yanaghiara modified by Ricci Maccarini and De Colle. Laryngological assessment was used to record vocal folds morphology according to Yonekawa's classification. Univariate analysis was used to compare group outcomes. Bivariate analysis was used to compare endoscopic grading and voice analysis results.

RESULTS

Univariate analysis of the HV and RE groups revealed statistically significant differences (P < 0.05) for the following parameters: jitter%, shimmer%, harmonic-to-noise ratio (NHR), voice turbulence index (VTI), MPT, VHI except for soft phonation index. Spearman's rank correlation showed a positive correlation between vocal parameters such as jitter%, shimmer%, NHR, VTI, and RE gradings. A negative correlation was found between MPT and RE gradings. Bivariate analysis indicated a strong positive correlation between RE grading and the spectrogram classification performed both with the vowel / a / (Rho 0.86; P = 0.0001) and with the word / aiuole / (Rho 0.81; P = 0.0001).

CONCLUSION

The present study demonstrates that patients with RE have different voice characteristics compared to HV. In particular, the voice analysis highlighted acoustic parameters that correlated to differing degrees of RE. In addition, spectrogram analysis should be considered for acoustic assessments before and after medical and surgical therapy and also in forensic medicine.

Prevalence of Allergy in Patients with Primary Dysphonia

Objective

The purpose of this investigation is to examine the prevalence of allergy in patients with primary dysphonia.

Methods

The medical records of patients diagnosed with primary dysphonia and who underwent allergy testing during the period extending from June 2018-2020 were reviewed. Patients' demographics, laryngoscopic findings and allergy skin prick testing were analyzed.

Results

A total of 22 patients were included. Eleven out of twenty-two patients (50%) tested positive to at least 2 allergens, and eight (36%) tested positive for at least 3 allergens. The most common allergens tested positive were D. Farinae for household inhalants, followed by Chenopodium, Russian thistle and weed mix for weeds. In patients with a positive allergy testing, the most common laryngeal findings included edema in 36%, followed by excess mucus and MTD in 18% of cases each.

Conclusion

Allergy is common in patients presenting with primary dysphonia and non-specific laryngeal findings. Allergy testing should be part of the diagnostic work-up of affected patients.

The Efficacy of Different Voice Treatments for Vocal Fold Polyps: A Systematic Review and Meta-Analysis

BACKGROUND

Vocal fold polyps (VFP) are a common cause of voice disorders and laryngeal discomfort. They are usually treated by behavioral voice therapy (VT) or phonosurgery, or a combination (CT) of both. However, the superiority of either of these treatments has not been clearly established.

METHODS

Three databases were searched from inception to October 2022 and a manual search was performed. All clinical trials of VFP treatment were included that reported at least auditory-perceptual judgment, aerodynamics, acoustics, and the patient-perceived handicap.

RESULTS

We identified 31 eligible studies (VT: n = 47-194; phonosurgery: n = 404-1039; CT: n = 237-350). All treatment approaches were highly effective, with large effect sizes (d > 0.8) and significant improvements in almost all voice parameters (p-values < 0.05). Phonosurgery reduced roughness and NHR, and the emotional and functional subscales of the VHI-30 were the most compared to behavioral voice therapy and combined treatment (p-values < 0.001). Combined treatment improved hoarseness, jitter, shimmer, MPT, and the physical subscale of the VHI-30 more than phonosurgery and behavioral voice therapy (p-values < 0.001).

CONCLUSIONS

All three treatment approaches were effective in eliminating vocal fold polyps or their negative sequelae, with phonosurgery and combined treatment providing the greatest improvement. These results may inform future treatment decisions for patients with vocal fold polyps.

Modulation of mouse laryngeal inflammatory and immune cell responses by low and high doses of mainstream cigarette smoke

Cigarette smoking is a major risk factor for laryngeal diseases. Despite well-documented cigarette smoke (CS) induced laryngeal histopathological changes, the underlying immunopathological mechanisms remain largely unexplored. The goal of this study was to evaluate inflammatory and immune cell responses in a CS-exposed larynx. Specifically, we used a 4-week subacute whole-body CS inhalation mouse model to assess these responses in the laryngeal mucosa upon exposure to low (LD; 1 h/day) and high dose (HD; 4 h/day) CS. Laryngeal tissues were harvested and evaluated using a 254-plex NanoString inflammation panel and neutrophil/macrophage/T-cell immunohistochemistry (IHC). NanoString global and differential gene expression analysis revealed a unique expression profile only in the HD group, with 26 significant differentially expressed genes (DEGs). StringDB KEGG pathway enrichment analysis revealed the involvement of these DEGs with pro-inflammatory pathways including TNF/TNFα and IL-17. Furthermore, inflammatory responses remained inhibited in conjunction with predicted activated states of anti-inflammatory regulators like PPARγ and NFE2L2 upon Ingenuity Pathway Analysis (IPA). Subglottic T-cell levels remained significantly inhibited as corroborated by IPA predictions. Overall, our key findings are consistent with HD exposures being anti-inflammatory and immunosuppressive. Furthermore, the identification of important regulatory genes and enriched pathways may help improve clinical interventions for CS-induced laryngeal diseases.

Incidence of Asthma, Atopic Dermatitis, and Allergic Rhinitis in Korean Adults before and during the COVID-19 Pandemic Using Data from the Korea National Health and Nutrition Examination Survey

The prevalence of allergic diseases has been increasing globally prior to COVID-19. The pandemic resulted in changes in lifestyle and personal habits such as universal mask-wearing and social distancing. However, there is insufficient information on the impact of the COVID-19 pandemic on the prevalence of allergic conditions such as asthma, atopic dermatitis, and allergic rhinitis. We analyzed the incidence rate for self-reported and doctor-diagnosed cases of allergic diseases of asthma, atopic dermatitis, and allergic rhinitis. A total of 15,469 subjects were registered from a national cohort dataset of the National Health and Nutrition Examination Survey. Using multiple logistic regression analysis, we calculated the adjusted odds ratio (OR) for each disease in 2020 compared to 2019. Subgroup analyses were performed according to age and sex. There were no statistically significant differences between the incidence of doctor-diagnosed and current allergic diseases in 2019 and 2020 (asthma, p = 0.667 and p = 0.268; atopic dermatitis, p = 0.268 and p = 0.973; allergic rhinitis, p = 0.691 and p = 0.942, respectively), and subgroup analysis showed consistent results. Among the Korean population from 2019 to 2020, the incidence of the allergic diseases asthma, atopic dermatitis, and allergic rhinitis did not decrease as expected.

Unsedated Office-Based Blue Laser Therapy in Female Patients With Reinke's Edema: A Retrospective Review of 8 Cases

OBJECTIVES

To report on the outcomes of unsedated blue laser therapy in female patients with Reinke's edema.

STUDY DESIGN

Retrospective chart review.

METHODS

A retrospective chart review of female patients undergoing unsedated office-based blue laser treatment of Reinke's edema between February 2020 and March 2022 at the Hamdan Voice and Swallowing Unit at the American University of Beirut Medical Center in Beirut, was conducted. Patients were assessed before and after the procedure with a follow-up interval of 3-6 weeks. Demographic data included age, history of smoking and grade of Reinke's edema. Voice outcome measures included the Voice Handicap Index-10 questionnaire, perceptual evaluation (GRBAS scale), acoustic analysis and maximum phonation time. Vocal fold lesions were evaluated using indirect laryngeal endoscopy.

RESULTS

A total of eight patients were reviewed. The mean age was 59.63 ± 7.98 years. One patient was lost to follow-up. We report on a total of 10 Reinke's edema lesions treated with the blue laser. There was a significant decrease in the mean VHI-10 score (14.86 ± 5.84-6.71 ± 7.32; P < 0.01) as well as in the means of three perceptual evaluation parameters (G, R, B; P < 0.05). There was also a nonstatistically significant increase in the mean fundamental frequency and habitual pitch. Laryngeal examination showed complete regression in 50% of the lesions, and partial regression in the remaining 50%.

CONCLUSIONS

Office-based blue laser treatment of Reinke's edema under local anesthesia can be considered an effective treatment modality as evidenced by improvement in post-procedure voice outcome measures.

DNA rare copy number alterations in Reinke’s Edema

INTRODUCTION

Reinke's Edema (RE) is a laryngeal lesion related to excessive tobacco smoking, voice overuse, and laryngopharyngeal reflux. Although the risk of malignancy has been considered low in literature, RE is classified among precancerous lesions.

OBJECTIVES

We investigated DNA Copy Number Alterations (CNAs) in specimens of RE and its potential association with malignant progression.

METHODS

We used array-based comparative genomic hybridization (aCGH, Agilent 4 × 180 K platform) to study eight RE cases. All patients were heavy tobacco users for at least 30 years, and none of them progressed to cancer in the follow-up (>8 years). Two RE presented mild dysplasia, one moderate dysplasia, and no histological alterations were found in the remaining five cases. CNAs were compared with the Database of Genomic Variants (DGV) and genes mapped on altered regions had their functions annotated.

RESULTS

Six of eight patients showed different rare copy number alterations on chromosomes 2q37.3, 4q13.1, 4q13.3, 7q11.22, 10p14, and 13q34. A gain of the whole chromosome 8 were detected in one case. Of interest, four of eight RE cases showed copy number imbalances involving genes previously described in several tumor types (RASA3, COL6A3, LINC00707, LINP1, SMR3A, and SMR3B).

CONCLUSION

The genomic imbalances herein found in RE have the potential to contribute to the phenotype but with limited or no risk of cancer. A long-term follow-up in a large series of patients could clarify the mechanisms involved in the malignant progression of RE.

LEVEL OF EVIDENCE: 4

Physical Activity and Sedentary Time in Korean Adults before and during the COVID-19 Pandemic Using Data from the Korea National Health and Nutritional Examination Survey

Several recent studies suggested reduced physical activity (PA) related to the COVID-19 pandemic without consensus. This study investigated the changes in PA and sedentary time during the COVID-19 pandemic compared to before the COVID-19 era. The Korea National Health and Nutrition Examination Survey 2019 and 2020 were used. The ≥19-year-old population was examined in 2019 and 2020 for time spent engaging in high- and moderate-intensity PA and sedentary time. Based on the recommended level of PA by the World Health Organization, ≥75 min/wk of high PA and ≥150 min/of moderate PA were classified. A sedentary time of ≥120 min/d was selected. Multiple logistic regression analysis with complex sampling was conducted for ≥75 min/wk of high PA, ≥150 min/wk of moderate PA, and ≥120 min/d of sedentary time in the 2020 group compared to the 2019 group. The ≥75 min/wk high PA was not lower in the 2020 group than in the 2019 group (adjusted odds ratio (aOR) = 0.96, 95% confidence intervals (95% CIs) = 0.79-1.18, P = 0.696). The ≥150 min/wk of moderate PA was also not lower in the 2020 group (aOR = 1.12, 95% CI = 0.94-1.32, p = 0.201). However, the ≥150 min/wk of moderate PA in the female group was higher in the 2020 group than in the 2019 group (aOR = 1.29, 95% CI = 1.01-1.65, p = 0.042). Sedentary time ≥ 120 min/d was lower in the 2020 group (aOR = 0.35, 95% CI = 0.17-0.72, p = 0.005). This association was consistent in the 19-39-year-old and female group. In conclusion, during the COVID-19 pandemic, high and moderate PA were not decreased in Korean adults, while sedentary time was reduced.

Distribution and Appearance of Ki-67, IL-1α, IL-10, and PGP 9.5 in Reinke's Oedema-Affected Larynx Tissue Compared with Control Tissue

Smoking, laryngopharyngeal reflux, and vocal fold abuse can promote the development of Reinke’s oedema, leading to vocal fold dysfunction and injury. The aim of the work was to investigate the appearance and distribution of proliferation marker Ki-67 (Ki-67), interleukin 10 (IL-10), interleukin 1 alpha (IL-1α), and protein gene peptide 9.5 (PGP 9.5) in Reinke’s oedema-affected larynx tissue. Methods: A routine histological and immunohistochemical Reinke’s oedema and control group patient analysis was conducted. We used the biotin–streptavidin biochemical method to detect Ki-67, IL-10, IL-1α, and PGP 9.5 The semiquantitative grading method was used to evaluate immunoreactive cells’ appearance and local distribution. A Mann–Whitney U test and Spearman’s rank coefficient were performed. Results: A low positive correlation between IL-1α epithelial and subepithelial immunoreactive cells in the patient group was found. Mann–Whitney U tests revealed significant patient and control group immunoreactive marker differences. All examined markers showed a higher number of immunoreactive structures in the patient group. Conclusions: Intensive proliferation of the surface epithelium was observed in patient tissues. The notable increase in IL-10 positive structures indicates the dominant anti-inflammatory tissue response. An increased number of IL-1α structures in the larynx epithelium and subepithelium in the patient group is linked to inflammation, proliferation, and tissue remodelling. The PGP 9.5 expression increase is involved in the morphopathogenesis of Reinke’s oedema.

Mainstream Cigarette Smoke Impacts the Mouse Vocal Fold Epithelium and Mucus Barrier

OBJECTIVES/HYPOTHESIS

Cigarette smoke (CS) is a primary risk factor for the development of numerous benign and malignant laryngeal diseases. The epithelium and mucus lining the vocal folds (VF) are the first barriers against CS. The primary objective of this study was to investigate epithelial and mucus barrier changes in the mouse laryngeal mucosa upon exposure to subacute CS. The secondary objective was to compare mucus barrier changes in mice and human smokers and nonsmokers. Study Design Animal model.

METHODS

Mice were exposed to CS for 4 weeks for 4 hours (N = 12, high dose [HD]) or 1 hour (N = 12, low dose [LD]) per day. Air-exposed mice were used as a control group (N = 10). Larynges were harvested and VF epithelial barrier integrity was evaluated including cellular proliferation and expression of cell junctions. We also investigated mucus production by examining mucus cell area and mucin expression in mice and human smokers and nonsmokers.

RESULTS

HD CS increased VF epithelial cellular proliferation but did not alter the expression of cell junctions. HD CS also induced hypertrophy of the mucus-producing submucosal glands. However, only LD CS increased MUC5AC gene expression. MUC5AC staining appeared elevated in laryngeal specimens from smokers, but this was not significant as compared to nonsmokers.

CONCLUSIONS

These findings help us identify potential adaptive mechanisms to CS exposure as well as set the foundation for further study of key aspects of epithelial and mucus barrier integrity that may be implicated in laryngeal disease development following prolonged smoking.

LEVEL OF EVIDENCE

NA Laryngoscope, 131:2530-2539, 2021.

Analysis of Surgical Recurrence after Larynx Microsurgery for Benign Lesions

Introduction  The study of larynx lesions is of great importance. More than 50% of people with vocal complaints have benign vocal fold alterations and some require surgery. Objective  To determine which factors are related to surgical recurrence of benign laryngeal lesions and to determine which videolaryngoscopic diagnoses are related to the risk or protection of surgical relapses over time. Methods  Observational, analytical, cross-sectional study with retrospective data collection of 1,383 surgeries in 1,301 patients. Results  The mean age at the first surgery was 39.2 years old. The predominant gender was female (65.6%). There were 396 cases of polyps (25.34%), 349 cases of cysts (22.33%), 261 cases of Reinke edema (16.7%), 175 cases of nodules (11.2%), 153 cases of minor structural alterations (MSAs) (9.79%), 94 cases of leukoplakia (6.01%), 77 cases of granulomas (4.93%) and 58 cases of pseudocysts (3.71%). The age presented statistical significance with the risk of surgical relapses ( p  = 0.016). Male gender was associated with the greatest chance of relapse. Diagnosis of granuloma ( p  < 0.001) and of leukoplakia ( p  < 0.001) were associated with a higher risk of surgical recurrence. Cyst diagnosis was associated with protection ( p  = 0.015) in relation to the chance of further surgeries. Patients with associated lesions, bilaterals or voice professionals did not present a statistically significant association with surgical recurrence. Conclusion  Age and gender are statistically related to the increase of surgical relapses. Leukoplakia and granuloma are associated with increased surgical relapses. Patients submitted to cyst microsurgery appear to be protected against surgical recurrence.

Detection of human papillomavirus (HPV) DNA in benign laryngeal lesions and role of cigarette smoking as an inducing factor

The association of human papillomavirus (HPV) in laryngeal malignancies is largely known. This study evaluated the association between HPV and benign laryngeal lesions and also the role of smoking and alcohol consumption in increasing the prevalence of HPV in such benign lesions. Seventy-eight specimens of benign laryngeal lesions including 26 polyps, 26 dysplasia, and 26 other lesions such as nodules and cysts were enrolled in this study. Polymerase chain reaction (PCR) technique was used to detect HPV DNA in the tissues. The role of smoking and alcohol consumption in the prevalence of HPV was also evaluated through appropriate statistical tests. This study showed that the prevalence of HPV in benign laryngeal lesions was not statistically significant. The Cohen's effect size for comparing polyps vs. other lesions was nearly 0.7, indicating that HPV prevalence in laryngeal polyps may be clinically meaningful. Another finding in our study is the role of smoking in increasing the HPV prevalence in laryngeal polyps (P = 0.034). In benign laryngeal polyps, HPV prevalence may be clinically important. Smoking acts as a co-factor to induce HPV infection in laryngeal polyps in our study.

Low Thyroid-stimulating Hormone Levels Are Associated With Annoying Tinnitus in Adult Women: Korea National Health and Nutrition Examination Surveys

OBJECTIVE

This study aimed to investigate the relationship between thyroid function and tinnitus.

STUDY DESIGN

A cross-sectional study.

SETTING

The Korean National Health and Nutrition Examination Survey from 2013 was used.

PATIENTS AND INTERVENTIONS

A total of 1,165 participants ≥ 40 years old who were surveyed for the presence of tinnitus and underwent thyroid function tests were included. The presence of discomfort from tinnitus was defined as annoying tinnitus. The control group included participants with "no tinnitus" or "no discomfort from tinnitus." The participants were divided into the annoying tinnitus group and the control group.

MAIN OUTCOME MEASURES

The associations of free thyroxine and thyroid-stimulating hormone (TSH) with annoying tinnitus were analyzed using logistic regression with complex sampling methods. Subgroup analyses were performed according to sex.

RESULTS

The low TSH level group had 2.35-fold greater odds of annoying tinnitus than the control group (95% confidence interval  = 1.10-5.12, p = 0.027). Even in patients with a normal free thyroxine level, a low TSH level was related to 2.78-fold higher odds of annoying tinnitus (95% confidence interval  = 1.21-6.38, p = 0.016). In subgroup analyses, this association was apparent in the female subgroup. The male subgroup did not show a relationship between low TSH levels and annoying tinnitus.

CONCLUSIONS

Subclinical hyperthyroidism was related to an increased risk of annoying tinnitus. This relationship was apparent in the female subgroup.

Allergic Rhinitis and Laryngeal Pathology: Real-World Evidence

Allergic rhinitis (AR) is correlated with diseases including allergic laryngitis, chronic obstructive pulmonary disease (COPD), asthma, and chronic rhinosinusitis (CRS). The unified airway model suggests that inflammation can spread in both lower and upper respiratory tracts. Moreover, some voice problems-laryngeal edema, dysphonia, and vocal nodules-have been associated with AR. We examined the association between AR and laryngeal pathology. We investigated 51,618 patients with AR between 1 January 1997 and 31 December 2013, along with 206,472 patients without AR matched based on age, gender, urbanization level, and socioeconomic status at a 1:4 ratio. We followed patients up to the end of 2013 or their death. The occurrence of laryngeal pathology was the primary outcome. Individuals with AR had a 2.43 times higher risk of laryngeal pathology than the comparison cohort group (adjusted HR: 2.43, 95% CI: 2.36-2.50, p < 0.001). Patients diagnosed as having AR exhibited higher comorbidity rates, including of asthma, COPD, CRS, gastroesophageal reflux disease, and nasal septum deviation, than those of the comparison cohort. Our results strongly indicate that AR is an independent risk factor for laryngeal pathology. Therefore, when treating AR and voice problems, physicians should be attuned to possible laryngeal pathology.

Dietary factors associated with inflammatory laryngeal disease in South Korea

Laryngeal inflammation causes not only benign diseases of the larynx, such as laryngitis and granuloma, but also malignancy. Dietary factors are known to control or modulate the inflammatory reaction in the body. To date, the association between laryngeal inflammation and dietary factors has not been reported using nationwide population-based data. The aim of this study was to analyze the association between several dietary factors and inflammatory laryngeal disease in the Korean population. This study analyzed the data from Korean National Health and Nutrition Examination Surveys which is cross-sectional nationwide-population-based study. Association between the dietary nutrient intake and the prevalence of inflammatory laryngeal diseases was analyzed in 21,116 participants who underwent a laryngoscopy and filled in the dietary intake questionnaires. Of the 21,116 participants included in the analysis, 758 (3.59%) were diagnosed with inflammatory laryngeal disease. Prevalence of inflammatory laryngeal disease was higher in men (4.58%) than in women (2.84%). The mean age of patients was 53.77 years. When analyzing the risk using propensity score matching, ILD group tend to consume more coffee and to intake less fiber and iron than normal group. On Logistic regression analysis, an increased intake of carbohydrate, fiber, and iron was associated with lowered risk of having ILD in female. The association between inflammatory laryngeal disease and dietary factors was prominent in the group aged ≥50 years and female. Increased intake of fiber, iron, and vitamin A were associated with lower risk in the group aged ≥50 years. In female, increased intake of fiber, iron were associated with lower risk of having ILD. In the group aged ≤50 years, only an increased consumption of makgeolli, Korean traditional rice wine, was associated with a higher risk of ILD.

The Prevalence and Impact of Voice Problems in Nonprofessional Voice Users: Preliminary Findings

BACKGROUND

Studies reporting the prevalence of voice problems in the non-professional voice users are rare. Thus, the objective of this preliminary investigation was to explore; (1) the prevalence of self-reported voice problems, and (2) its impact on the nonprofessional voice users.

METHOD

This was a cross-sectional survey that was distributed to 500 nonprofessional voice users working in different educational institutions in the Manipal city of Karnataka state, India. The results of the study are discussed based on the 426 qualified questionnaire responses.

RESULTS

The lifetime prevalence of voice problem was 21.6% (n = 92), with 4.9% (n = 21) of the participants reporting it on the day of the survey. The self-reported prevalence of voice problems was significantly higher (P = 0.001) in female (64%, n = 59) as compared to male participants (35.8%, n = 33). Voice problems affected job performance by 34.7% (n = 32) and caused work absenteeism in 11.9% (n = 11).

CONCLUSIONS

The results of this preliminary study indicated that a significant number of nonprofessional voice users suffer from voice problems, and it has a significant impact on their job performance. Hence, in future large scale, epidemiological studies are needed with randomly selected samples of different age groups, gender, income status, educational level, area of residence to understand the possible risk factors, and impact of voice problem on the quality of life in general working and not working nonprofessional voice users in India.

Exploring the Pathophysiology of Reinke's Edema: The Cellular Impact of Cigarette Smoke and Vibration

Objectives

To explore the isolated or combined effects of cigarette smoke extract (CSE) and vibration on human vocal fold fibroblasts (hVFF) in an in vitro setting in order to elucidate their influence in the pathophysiology of Reinke's edema (RE).

Study design

Immortalized hVFF were exposed to CSE or control medium under static or vibrational conditions. A phonomimetic bioreactor was used to deliver vibrational patterns to hVFF over a period of 5 days.

Methods

Cytotoxicity was quantified using a lactate dehydrogenase assay. We employed reverse transcription–quantitative polymerase chain reaction, enzyme‐linked immunosorbent assay, and Magnetic Luminex^(R) assays (R&D Systems, Minneapolis, MN) to assess the influence on extracellular matrix production, fibrogenesis, inflammation, and angiogenesis.

Results

We observed significant changes induced by CSE alone (hyaluronic acid, matrix metalloproteinase 1, Interleukin‐8, cyclooxygenase [COX]1, COX2, vascular endothelial growth factor [VEGF]D), as well as settings in which only the combination of CSE and vibration led to significant changes (transforming growth factor beta 1, VEGFA, VEGFC). Also, CSE‐induced levels of COX2 were only significantly reduced when vibration was applied.

Conclusion

We were able to explore the cellular effects of CSE and vibration on hVFF by employing a phonomimetic bioreactor. Whereas cigarette smoke is generally accepted as a risk factor for RE, the role of vibration remained unclear as it is difficult to study in humans. Our data showed that some genes and proteins in the pathophysiological context of RE were only affected when CSE in combination with vibration was applied.

Level of Evidence

NA Laryngoscope, 131:E547–E554, 2021

Seasonal Variations in Public Inquiries into Laryngitis: An Infodemiology Study

OBJECTIVES

Acute laryngitis is a common disease with self-limiting nature. Since the leading cause is attributed to viral infections and thus self-limiting, many affected individuals do not seek professional medical help. However, because the major symptom of hoarseness imposes a substantial burden in everyday life, it might be speculated that web-based search interest on this condition follows incidence rates, with highest peaks during winter months. The aim of this study was to evaluate global public health-information seeking behaviour on laryngitis-related search terms.

METHODS

We utilized Google Trends to assess country-specific, representative laryngitis-related search terms for English and non-English speaking countries of both hemispheres. Extracted time series data from Australia, Brazil, Canada, Germany, the United Kingdom, and the United States of America, covering a timeframe between 2004 and 2019 were first assessed for reliability, followed by seasonality analysis using the cosinor model.

RESULTS

Direct comparisons revealed different, representative laryngitis-related search terms for English- and non-English speaking countries. Extracted data showed a trend of higher reliability in countries with more inhabitants. Subsequent graphical analysis revealed winter peaks in all countries from both hemispheres. Cosinor analysis confirmed these seasonal variations to be significant (all P < 0.001).

CONCLUSION

Public interest in laryngitis-related, online health information displayed seasonal variations in countries from both hemispheres, with highest interest during winter months. These findings emphasize the importance to optimize the distribution of reliable, web-based health education in order to prevent the spread of misinformation and to improve health literacy among general populations.

Unsedated Office-Based Thulium Laser Therapy in Patients With Reinke's Edema

OBJECTIVE

To report the outcome of unsedated office based Thulium laser therapy for Reinke's edema.

MATERIALS AND METHODS

A retrospective chart review of patients operated between March 2017 and November 2018 was conducted. Twelve patients were included, two of whom had two procedures performed. Demographic data included age, gender, smoking status, and grade of Reinke's edema. Outcome measures included Voice Handicap Index-10 (VHI), perceptual evaluation, extent of disease regression, acoustic analysis, and maximal phonation time.

RESULTS

Twelve patients were enrolled in this study, one of whom was lost for follow-up. There were eight females and three males. The mean age was 51.27 ± 9.12 years. Endoscopic evaluation 6-12 weeks after surgery revealed complete and partial regression of disease in three and eight patients, respectively. There was a significant improvement in the mean score of VHI-10 (15.00 ± 9.45 vs 3.07 ± 3.81) and the mean score of GRABS parameters following surgery (P < 0.05). The mean habitual pitch increased from 125.11 ± 28.48 Hz to 155.86 ± 55.14 Hz (P = 0.070). There was improvement in the mean jitter and shimmer but none reached a statistical significance. There was no significant change in the mean Maximum phonation time (MPT) scores before and after surgery.

CONCLUSION

Unsedated office-based Thulium laser therapy can be considered as an alternative therapy to patients with Reinke's edema who are not willing to undergo conventional microlaryngeal surgery.

How Does Our Voice Change as We Age? A Systematic Review and Meta-Analysis of Acoustic and Perceptual Voice Data From Healthy Adults Over 50 Years of Age

Purpose Approximately 30% of adults over the age of 50 years present with altered vocal function. Our understanding of how these changes manifest acoustically and perceptually is derived from relatively modest-sized studies using a diversity of tools. Voice changes can arise from the onset of disease or disorder, but also age-related physiological changes, which may not reflect pathology as such. Here, we bring together data on acoustic, perceptual, and instrumental assessments (electroglottography), with the aim of gaining a better understanding of the changes occurring across these measurement domains. We consider these changes in the context of different acoustic features, software programs, and perceptual protocols. Method Studies of voice function in healthy older adults over the age of 50 years were sought. Literature was systematically searched with 746 abstracts reviewed. Forty-seven studies were included in the review. A meta-analysis of included studies compared voice acoustic parameters between sex and age. Sixteen acoustic parameters collected from 1,475 participants were analyzed in the meta-analysis. These included some previously unpublished analyses using data provided by authors of included studies. Results Data from the systematic review suggest that older individuals are perceived to present with higher overall scores of dysphonia and roughness, breathiness, strain, and instability. Acoustically, males have significantly higher scores on measures of perturbation, including noise-to-harmonic ratio and absolute jitter. The meta-analysis outcomes suggest that participants aged 80-89 years produce significantly higher fundamental frequency, jitter percent, shimmer percent, and shimmer in decibels compared to participants aged 60-69 years and a significant increase in relative average perturbation, jitter percent, and shimmer in decibels compared to participants aged 70-79 years. Limited data were available comparing acoustic measures using the same acoustic software. Conclusions Variations in fundamental frequency and frequency and amplitude perturbation increase as healthy adults age. It was difficult to draw definitive conclusions based on existing literature due to variability in hardware used, limited descriptions of study cohorts, or missing data from statistical analysis. Supplemental Material https://doi.org/10.23641/asha.11868663.

Predictive fiberoptic endoscopic findings of upper airway in children with allergic rhinitis

OBJECTIVE

To determine predictive fiberoptic findings of upper airway in children with allergic rhinitis.

METHOD

129 children had fiberoptic evaluation of nasal cavity, pharynx and larynx. They were divided into allergic rhinitis group and normal group based on skin prick test results. All video recordings were randomly reviewed by three independent national board-certified otolaryngologists who were blinded to the clinical details and outcomes of the participants' allergy testing. Each physician assessed and documented 10-item questionnaire. Intra-rater, inter-rater reliability and correlation between items and allergic status was calculated.

RESULTS

Intra-rater reliability was moderate to perfect for all physicians on all items (kappa = 0.578-0.962). Inferior turbinate hypertrophy (κ = 0.714, p = 0.02), middle turbinate hypertrophy (κ = 0.728, p = 0.01), discoloration of inferior turbinate (κ = 0.685, p = 0.01), adenoid hypertrophy (κ = 0.662, p = 0.02) had good inter-rater reliability and these findings were predictive of allergic rhinitis. Adenoid hypertrophy was less encountered in allergic rhinitis. All other endoscopic findings beyond the nasal cavity were not predictive for allergic rhinitis in children.

CONCLUSION

Nasal cavity findings including inferior turbinate hypertrophy, middle turbinate hypertrophy, discoloration of inferior turbinate and adenoid tissue assessment rather than pharyngolaryngeal findings are predictive of allergic rhinitis in children.

Reinke's Edema

Reinke's edema (RE) is the polypoid degeneration of one or both vocal folds within Reinke's space. The viscoelastic properties of the mucosal folds are characteristically altered by the expansion of the subepithelial space. Most frequently, patients present with dysphonia, with women being more affected than men. The primary risk factor is tobacco use. Voice overuse and laryngopharyngeal reflux are also considered to be contributory. Although RE shares the same primary risk factor as malignancy, the risk of malignancy is low, and dysplasia is found only in 0% to 3% of cases. Treatment is focused on decrease of risk factors, such as implementation of smoking cessation, voice therapy, and reflux control. Surgical techniques aim to decrease redundant polypoid mucosa in order to improve voice and restore the glottic airway. Recurrence of RE is high.

Efficacy of microsurgery in Reinke's oedema evaluated by traditional voice assessment integrated with the Vocal Extent Measure (VEM)

SUMMARY

There are few data analysing to what specific extent phonomicrosurgery improves vocal function in patients suffering from Reinke's oedema (RE). The recently introduced parameter vocal extent measure (VEM) seems to be suitable to objectively quantify vocal performance. The purpose of this clinical prospective study was to investigate the outcomes of phonomicrosurgery in 60 RE patients (6 male, 54 female; 56 ± 8 years ([mean ± SD]) by analysing its effect on subjective and objective vocal parameters with particular regard to VEM. Treatment efficacy was evaluated at three months after surgery by comparing pre- and postoperative videolaryngostroboscopy (VLS), auditory-perceptual assessment (RBH-status), voice range profile (VRP), acoustic-aerodynamic analysis and patient's self-assessment using the voice handicap index (VHI-9i). Phonomicrosurgically, all RE were carefully ablated. VLS revealed removal or substantial reduction of oedema with restored periodic vocal fold vibration. All subjective and most objective acoustic and aerodynamic parameters significantly improved. The VEM increased on average from 64 ± 37 to 88 ± 25 (p #x003C; 0.001) and the dysphonia severity index (DSI) from 0.5 ± 3.4 to 2.9 ± 1.9. Both parameters correlated significantly with each other (rs = 0.70). RBH-status revealed less roughness, breathiness and overall grade of hoarseness (2.0 ± 0.7 vs 1.3 ± 0.7). The VHI-9i-score decreased from 18 ± 8 to 12 ± 9 points. The average total vocal range enlarged by 4 ± 7 semitones, and the mean speaking pitch rose by 2 ± 4 semitones. These results confirm that: (1) the use of VEM in RE patients objectifies and quantifies their vocal capacity as documented in the VRP, and (2) phonomicrosurgery is an effective, objectively and subjectively satisfactory therapy to improve voice in RE patients.

Trends in the Incidence and Treatment of Benign Vocal Fold Lesions in Korea, 2006-2015: A Nationwide Population-based Study

OBJECTIVE

The aim of this study was to determine the prevalence and demographics of benign vocal fold lesions (BVFL) and trends in its treatment in Korea based on data collected from the National Health Insurance Service database.

MATERIAL AND METHODS

Data for patients diagnosed with BVFL (ICM-10 codes J381, J382, J384) from 2006 to 2015 were selected for analysis. Patient characteristics, including sex, age, income, area of residence, and comorbidity, were analyzed. Treatment was divided into surgical management and conservative management using operation codes.

RESULTS

The prevalence and incidence of BVFL increased from 7.07% and 5.29%, respectively, in 2006 to 12.47% and 7.98% in 2015. Compared with the non-BVFL population, patients with BVFL were more likely to be female, reside in an urban area, and have gastroesophageal reflux disease. There was no significant change in the incidence of surgical treatment during the study period (around 6000 per year); however, the surgical treatment rate decreased from 19.29% to 8.38%. The probability of undergoing surgical treatment for BVFL was higher in men, those aged 50-59 years, and those in the lowest quartile for income, except for the medical aid group.

CONCLUSION

In Korea, there was an increase in the number of patients diagnosed with BVFL and a decrease in the operation rate for this condition between 2006 and 2015. Diagnosis of BVFL varied significantly based on income and sex; however, the only variable affecting the operation rate was patient age.

Does Reinke's Edema Grade Determine Premalignant Potential?

OBJECTIVE

Reinke's edema (RE) is a benign disease of the vocal folds with a wide spectrum of clinical severity. We aim to evaluate the clinical impact of RE grade and determine if RE grade correlates with severity of dysplasia and tobacco exposure.

METHODS

Patients with isolated RE who underwent surgical excision between December 2010 and December 2014 were retrospectively reviewed. The RE grade was determined from archived laryngeal videostroboscopy exams. Pathologic severity of dysplasia, categorized by squamous intraepithelial neoplasia (SIN) classification, and tobacco history were extracted from medical records.

RESULTS

Of 95 lesions, 3 (3.16%) were RE grade 1, 33 (34.74%) were RE grade 2, 24 (25.26%) were RE grade 3, and 35 (36.84%) were RE grade 4. Fifty-nine lesions (62.11%) had no dysplasia (SIN0), 19 (20.00%) had mild dysplasia (SIN1), 15 (15.79%) had moderate dysplasia (SIN 2), and 2 (2.11%) had severe dysplasia (SIN3). The 2 patients with severe dysplasia had grade 4 lesions. No statistical correlation was identified between RE grade and the severity of dysplasia. Furthermore, no statistical correlation was seen between tobacco exposure and the severity of dysplasia or the RE grade.

CONCLUSIONS

Size of RE lesion does not reflect premalignancy. The majority of RE lesions, regardless of size, have little to no premalignant potential. Severe dysplasia/carcinoma in situ may be more likely seen in grade 4 lesions; however, the paucity of severe dysplasia published in RE data and in this cohort preclude any formal inference. Further study of grade 4 lesions is warranted.

The Role of Allergy in Phonation

BACKGROUND

Allergies are among the most common chronic conditions worldwide affecting 10%-30% of adult individuals and 40% of children. Phonation can be affected by different allergic conditions in various ways. The role of allergy in phonation has been under-researched and poorly understood and the respective literature is poor. Several studies have investigated the role of certain allergic diseases in phonation. In this review, we tried to include all allergic conditions that can affect voice production.

METHODS

We conducted a bibliography review looking for allergic conditions that can affect phonation. Allergic asthma, allergic laryngitis, allergic rhinitis and sinusitis, oral allergy syndrome, and angioedema were included in our search.

RESULTS

The literature on the impact of allergy in phonation remains poor and many key questions concerning basic information for epidemiology, pathophysiology, and larynx pathology in allergic patients with phonation problems still remain unanswered.

CONCLUSIONS

The role of allergy in voice production remains underinvestigated and many basic questions still remain open. Further research is needed to improve our understanding for these very common conditions.

Allergy and laryngeal disorders

PURPOSE OF REVIEW

This article reviews recent literature on the topic of allergic laryngitis. There has been sustained interest over the past 15 years and epidemiological and experimental studies have led to a clearer description of the nature of the condition and its clinical expression.

RECENT FINDINGS

Recent studies have suggested an epidemiological association between the presence of allergy and concurrent laryngeal symptoms and objective signs. Both population-based studies and smaller investigations have shown a significant relationship between these two variables. In addition, recent studies have questioned the inter-rater reliability and specificity of laryngeal endoscopic examinations, which have often been used to assign a presumptive diagnosis of laryngopharyngeal reflux. The presence of sticky, viscid, thick endolaryngeal secretions, however, appears to be associated with allergic laryngitis, confirming prior observations. Experimental interventions in both laboratory animals and humans suggest that there may be a direct causal relationship for an allergic cause, at least among some individuals.

SUMMARY

Epidemiological and experimental evidence suggests that allergy may be a valid trigger and causative mechanism in some individuals with laryngeal inflammation and symptomatology. Additional research is necessary to further characterize allergic laryngitis and to develop valid diagnostic protocols for assessment.

Allergic laryngitis: unraveling the myths

PURPOSE OF REVIEW

This article provides a thorough review of the literature highlighting the articles that have advanced our knowledge about the sensitivity of the larynx to allergens in the air or ones consumed. This area of inquiry requires continued interest and investigation. As the field of clinical laryngology changes, and more information is discovered about the possible causal association between allergy and vocal pathologies, practicing otolaryngologists, allergists, and other medical professionals may discover more comprehensive methods to evaluate and treat their allergic patients, particularly those who present with complaints of dysphonia, dysphagia, laryngopharyngeal reflux (LPR), and/or dyspnea.

RECENT FINDINGS

There continues to be epidemiological studies designed to describe the relationship of allergy to vocal symptoms and signs. Both population and smaller studies have recently attempted to link these two conditions. Unfortunately, the patient with chronic laryngeal complaints is often tagged by default with the diagnosis of LPR and treated with proton pump inhibitors, which are not always beneficial. The endoscopic assessment may not be as reliable to make the diagnosis of LPR as the examination is subjective and the inter-rater reliability is low. It has been demonstrated by direct laryngeal provocation studies that sticky-viscous endo-laryngeal mucous is the only reliable finding consistently associated with allergy potential allergic tissue reactivity.

SUMMARY

The interrelationship of allergic sensitivity and chronic laryngitis in certain individuals is becoming clearer because our knowledge of inquiry has increased and the available routine technology to diagnose these conditions has remarkably improved. Notwithstanding these advancements, much more research is needed on this subject to reduce the frequency of mis-diagnoses and mis-management of allergic patients.

The Importance of The Occupational Vocal Load for The Occurence and Treatment of Organic Voice Disorders

Introduction

The voice represents a basic working tool for carrying out certain occupations. Hoarseness, as a consequence of vocal fold lesions, presents an important cause of work-related absences for voice professionals.

Methods

Our study was designed as a retrospective cohort one. Data on gender, workplace, vocal load and exposure to risk factors for voice disorders of the patients who had surgery in the 2014-2015 period at the tertiary centre due to benign vocal fold lesions were collected from their clinical records. We compared professional voice users (PVU) to subjects with no vocal load at work (NPVU). The SPSS programme, version 22.0, was used for statistical analysis.

Results

From 2014 to 2015, 103 PVU and 132 NPVU were surgically treated for benign vocal fold lesions. In comparison to the second group, loud speech use was reported significantly more often by PVU (40.8% vs. 14.4%), as was a fast speaking rate (22.3% vs. 9.8%) and additional vocal load outside of the workplace (23.3% vs. 12.9%). The time that had passed between the occurrence of the hoarseness and the surgical treatment did not differ between the groups. The majority of patients were satisfied with the outcome of the operation.

Conclusions

Nearly a half of the operated patients had a considerable vocal load at work. An ENT assessment prior to starting a job as well as priority phoniatric treatment of voice disorders for PVU would significantly reduce the costs of work absences and contribute to a speedier recovery and return to the workplace.

The importance of the occupational vocal load for the occurence and treatment of organic voice disorders

Introduction

The voice represents a basic working tool for carrying out certain occupations. Hoarseness, as a consequence of vocal fold lesions, presents an important cause of work-related absences for voice professionals.

Methods

Our study was designed as a retrospective cohort one. Data on gender, workplace, vocal load and exposure to risk factors for voice disorders of the patients who had surgery in the 2014-2015 period at the tertiary centre due to benign vocal fold lesions were collected from their clinical records. We compared professional voice users (PVU) to subjects with no vocal load at work (NPVU). The SPSS programme, version 22.0, was used for statistical analysis.

Results

From 2014 to 2015, 103 PVU and 132 NPVU were surgically treated for benign vocal fold lesions. In comparison to the second group, loud speech use was reported significantly more often by PVU (40.8% vs. 14.4%), as was a fast speaking rate (22.3% vs. 9.8%) and additional vocal load outside of the workplace (23.3% vs. 12.9%). The time that had passed between the occurrence of the hoarseness and the surgical treatment did not differ between the groups. The majority of patients were satisfied with the outcome of the operation.

Conclusions

Nearly a half of the operated patients had a considerable vocal load at work. An ENT assessment prior to starting a job as well as priority phoniatric treatment of voice disorders for PVU would significantly reduce the costs of work absences and contribute to a speedier recovery and return to the workplace.

A possible association between dysphonia and sleep duration: A cross-sectional study based on the Korean National Health and nutrition examination surveys from 2010 to 2012

BACKGROUND

Sleep is important in terms of good general health and appropriate sleep duration has been linked to quality-of-life. Dysphonia may impair communication and social relationships, and is thus also closely related to quality-of-life. No large-scale, cross-sectional epidemiological study of a sample representative of the population of an entire country has yet assessed the possible existence of a relationship between sleep duration and dysphonia.

METHODS

We investigated a possible association between subjective voice problems and self-reported sleep duration in South Korean subjects using 2010-2012 data from the Korean National Health and Nutrition Examination Survey (KNHANES). Cross-sectional data on 17,806 adults (7,578 males and 10,228 females) over the age of 19 years who completed the KNHANES were analyzed. All participants reported voice problems (if present) and their daily average sleep duration using a self-reporting questionnaire. Sleep duration was classified into five categories as follows: ≤5, 6, 7, 8, and ≥9 h/day.

RESULTS

The overall prevalence of dysphonia was 6.8%; 5.7% in males and 7.7% in females. The prevalence for dysphonia by sleep duration exhibited a U-shape, with the lowest point being at sleep duration of 7-8h. After adjustment for covariates (age, sex, smoking status, alcohol consumption, regular exercise, low income, high-level education), a sleep duration of ≤5 h (OR = 1.454; 95% CI, 1.153-1.832) and a sleep duration of ≥9 h (OR = 1.365; 95% CI, 1.017-1.832) were significantly associated with dysphonia, compared to a sleep duration of 7 h. In terms of gender, males who slept for ≥9 h were at a 2-fold (OR = 2.028; 95% CI, 1.22-3.35) higher odds for dysphonia (p<0.05) compared to those who slept for 7 h. A sleep duration ≤5 h was associated with a 1.6-fold (OR = 1.574; 95% CI, 1.203-2.247) higher odds of dysphonia ≥3 weeks in duration (long-term dysphonia).

CONCLUSIONS

This is the first study to show that both short and long sleep duration were significantly associated with the development of dysphonia. The association between sleep duration and dysphonia was more marked in males than females. A sleep duration ≤5 h had a significant impact on the prevalence of long-term dysphonia.

Laryngeal Cysts in Adults: Simplifying Classification and Management

Objective

Laryngeal cysts may occur at any mucosa-lined location within the larynx and account for 5% to 10% of nonmalignant laryngeal lesions. A number of proposed classifications for laryngeal cysts exist; however, no previously published classification aims to guide management. This review analyzes contemporary laryngeal cyst management and proposes a framework for the terminology and management of cystic lesions in the larynx.

Data Sources

PubMed/Medline.

Review Methods

A primary literature search of the entire Medline database was performed for all titles of publications pertaining to laryngeal cysts and reviewed for relevance. Full manuscripts were reviewed per the relevance of their titles and abstracts, and selection into this review was according to their clinical and scientific relevance.

Conclusion

Laryngeal cysts have been associated with rapid-onset epiglottitis, dyspnea, stridor, and death; therefore, they should not be considered of little significance. Symptoms are varied and nonspecific. Laryngoscopy is the primary initial diagnostic tool. Cross-sectional imaging may be required, and future use of endolaryngeal ultrasound and optical coherence tomography may revolutionize practice. Where possible, cysts should be completely excised, and there is growing evidence that a transoral approach is superior to transcervical excision for nearly all cysts. Histology provides definitive diagnosis, and oncocytic cysts require close follow-up.

Implications for Practice

A new classification system is proposed that increases clarity in terminology, with the aim of better preparing surgeons and authors for future advances in the understanding and management of laryngeal cysts.

The prevalence and factors associate with vocal nodules in general population: Cross-sectional epidemiological study

The purpose of this study was to analyze the prevalence of vocal nodules and to identify factors related with an increased risk for vocal nodules.This study was conducted using data from the Korean National Health and Nutrition Examination Survey 2008 to 2011. The subjects consisted of 19,636 men and women aged ≥19 years. Related factors such as age, marital status, incomes, and education level were assessed in individual interviews, and health-related behaviors including smoking, alcohol, and activity were assessed with self-administered questionnaires. Also, examination survey such as laryngoscopy examination, basic physical examination, and blood sampling was conducted.The prevalence of vocal nodules was 1.31% (n = 258). Among variable factors, age, education level, and voice disorder were related with the presence of vocal nodules (P < 0.05). Other factors including sex, alcohol, smoking, physical activities, hypertension, obesity, waist circumference and metabolic syndrome, hypercholesterolemia, serum calcium, and vitamin D did not show any meaningful relationship with the presence of vocal nodules.This result may help reduce the incidence of vocal nodules and offer proper management for patients with vocal nodules, and may also facilitate efficient allocation of public health resources.

Are Vocal Alterations Caused by Smoking in Reinke's Edema in Women Entirely Reversible After Microsurgery and Smoking Cessation?

BACKGROUND

Reinke's edema is a benign lesion of the vocal folds that affects chronic smokers, especially women. The voice becomes hoarse and virilized, and the treatment is microsurgery. However, even after surgery and smoking cessation, many patients remain with a deep and hoarse voice.

OBJECTIVES

The aim of the present study was to compare pre- and postoperative acoustic and perceptual-auditory vocal analyses of women with Reinke's edema and of women in the control group, who were non-smokers.

METHODS

A total of 20 women with videolaryngoscopy diagnosis of Reinke's edema who underwent laryngeal microsurgery were evaluated pre- and postoperatively (6 months) by videolaryngoscopy, acoustic voice, and perceptual-auditory analyses (General degree of dysphonia, Roughness, Breathiness, Asthenia, Strain, and Instability [GRBASI] scale), and the maximum phonation times were calculated. The pre- and postoperative parameters of the women with Reinke's edema were compared with those of the control group of women with no laryngeal lesions, smoking habit, or vocal symptoms.

RESULTS

Acoustic vocal perceptual-auditory analyses and the maximum phonation time of women with Reinke's edema improved significantly in the postoperative evaluations; nevertheless, 6 months after surgery, their voices became worse than the voices of the women from the control group.

CONCLUSIONS

Abnormalities caused by smoking in Reinke's edema in women are not fully reversible with surgery and smoking cessation. One explanation would be the presence of possible structural alterations in fibroblasts caused by the toxicity of cigarette components, resulting in the uncontrolled production of fibrous matrix in the lamina propria, and preventing complete vocal recovery.

Association Between Obesity and Falls Among Korean Adults: A Population-Based Cross-Sectional Study

The objective of this study was to evaluate the association between falls and obesity using Asian body mass index (BMI) classifications. Using the data from the Korean community health survey in 2011, a total of 229,226 participants ranging from 19 to 106 years old were included in this study. The BMI groups were classified as underweight (<18.5), healthy (18.5 ≤ BMI < 23), overweight (23 ≤ BMI <25), and obese (≥25) using Asian BMI classifications. The associations between BMI groups and falls (≥1 time or ≥2 times per year) were analyzed using multiple logistic regression analyses with complex sampling. A subgroup analysis was conducted according to age (19-40, 41-60, and ≥61 years) and the location of the fall (indoor and outdoor). Physical activity, household income, education level, alcohol consumption, smoking, stress level, and medical comorbidities were adjusted as confounders. In total, 16.8% and 6.1% of the participants experienced falls ≥1 time and ≥2 times per year, respectively. Compared to the healthy weight group, the other BMI groups showed a significant U-shaped relationship with falls ≥1 time (AOR underweight = 1.12, 95% CI [confidence interval] = 1.05-1.19; AOR obese = 1.06, 95% CI = 1.02-1.10, P < 0.001) and ≥2 times (AOR underweight = 1.14, 95% CI = 1.04-1.26; AOR obese = 1.04, 95% CI = 0.99-1.10, P < 0.001). Obese status was significantly associated with falls (≥1 fall per year) in all age groups, whereas being underweight was significantly associated with falls in the 19 to 40 year age group only. In conclusion, both underweight and obese statuses were significantly associated with falls in this adult Korean population. However, the relationship between BMI group and falls varied according to age and the location of the falls.

Giant fibrovascular polyp on aryepiglottic fold

Polyps are common lesions in pharynx and larynx. A 46-year-old woman was transferred to our department because of the huge laryngeal mass, which was incidentally detected during routine health screening. On laryngoscopic exam, both vocal folds were not visualized due to the mass but she had no symptom such as hoarseness, dysphagia, and dyspnea. Awake intubation was safely performed using flexible bronchoscope without tracheostomy. A 4-cm sized mass on the left aryepiglottic fold was removed with trans-oral approach and discharged without complication. The pathologic diagnosis was reported as 'fibrovascular polyp'. Herein, we describe a unique case of giant fibrovascular polyp on aryepiglottic fold, which is the first report in the English literature.