Seven Days of Voice Rest Post-phonosurgery Is Not Better than 3 days: A Prospective Randomized Short-term Outcome Study

OBJECTIVE

The aim of the study is to compare the short-term effect of 7 versus 3 days of voice rest (VR) on objective vocal (acoustic) parameters following phonosurgery.

METHODS

A prospective randomized study conducted at a tertiary referral medical center. Patients with vocal fold nodules, polyps, or cysts and scheduled for phonosurgery were recruited from the Voice Clinic. They were randomized into groups of 7- or 3-day postoperative VR periods and their voices were recorded preoperatively and at 4-week postoperatively. A mixed linear model statistical analysis (MLMSA) was used to compare pre- and postoperative jitter, shimmer, harmonic-to-noise ratio, and maximum phonation time between the two groups.

RESULTS

Sixty-five patients were recruited, but only 34 fully complied with the study protocol, and their data were included in the final analysis (19 males, 20 females; mean age: 40.6 years; 17 patients in the 7-day VR group and 16 in the 3-day VR group). The groups were comparable in age, sex, and type of vocal lesion distribution. The preoperative MLMSA showed no significant group differences in the tested vocal parameters. Both groups exhibited significant (p < 0.05) and comparable improvement in all vocal parameters at postoperative week 4.

CONCLUSIONS

A VR duration of 7 days showed no greater benefit on the examined vocal parameters than the 3-day protocol 4-week postoperatively. Our results suggest that a 3-day VR regimen can be followed by patients who undergo phonosurgery without compromising the vocal results. Larger-scale and longer-duration studies are needed to confirm our findings.

LEVEL OF EVIDENCE

2 Laryngoscope, 134:4661-4666, 2024.

Clinical Voice Outcomes for Two Voice Rest Protocols after Phonomicrosurgery

OBJECTIVES

Voice rest is commonly recommended for patients with benign vocal fold lesions (BVFLs) after phonomicrosurgery. The study compares the clinical voice outcomes of two protocols, 7-day complete voice rest (CVR) and 3-day CVR followed by 4-day relative voice rest (CVR + RVR), for patients with BVFLs after phonomicrosurgery.

STUDY DESIGN

Prospective, randomized controlled trial.

METHOD

Patients with BVFLs undergoing phonomicrosurgery were recruited prospectively and randomly assigned to either protocol. Outcomes were assessed on objective measures of acoustics (fundamental frequency, frequency range, mean intensity, cepstral peak analysis) and aerodynamics (vital capacity, airflow rate, subglottal pressure, phonation threshold pressure), as well as subjective measures, both provider-reported through the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and patient-reported through the Voice Handicap Index (VHI). Clinical measures were collected at three-time points: preoperatively, 1-week postoperatively (on voice rest), and 1-month postoperatively. In addition, adherence was estimated using a vocal dosimeter.

RESULTS

Twenty-five patients were recruited and randomized to 7-day CVR (n = 13) and CVR + RVR regimen (n = 12). Statistically significant changes were found within both groups for subglottal pressure (p = 0.03) and VHI score (p < 0.001) comparing pre-operative baseline to 1-month postoperative follow-up. There were no statistically significant differences between the groups. Regardless of group assignment, a significant decrease in overall severity ratings for the CAPE-V was found by comparing the preoperative scores to postoperative scores at 1-week (p < 0.001) and 1-month (p < 0.001).

CONCLUSION

Both groups improved their overall voice quality comparably 1 month after undergoing phonomicrosurgery as measured by objective and subjective parameters.

LEVELS OF EVIDENCE

2. Laryngoscope, 134:2812-2818, 2024.

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Level of evidence

3.

Exploring Personality and Perceived Present Control as Factors in Postsurgical Voice Rest: A Case Comparison

OBJECTIVE

This case comparison explored the relation between personality, perceived present control, and postoperative voice rest (as estimated by self-report and objective voice use) following surgery for benign vocal fold lesions.

METHOD

Two participants were included. Both participants were diagnosed with benign vocal fold pathology, underwent phonosurgery, and were assigned to either complete voice rest (CVR) or relative voice rest (RVR) postoperatively. During voice rest (VR), a visual analog scale (VAS) and a dosimeter (the Vocalog2) were used daily to estimate self-perceived and objective voice use, respectively. The participants also completed questionnaires on voice-related demographics, the Voice Handicap Index (VHI), Ten-Item Personality Inventory (TIPI), and Perceived Present Control (PPC). After 7 days of CVR or RVR, participants completed a postoperative questionnaire and a final VAS for overall voice use.

RESULTS

A wide discrepancy was observed in one of two participant's subjective perception of voice use (using the VAS) versus objective dosimetry data wherein she reported significantly more voice use than was observed objectively. Differences in personality and PPC between the participants did not appear to affect their voice use following the VR protocols.

CONCLUSION

The amount of voice use in both VR protocols for these two participants suggests that personality and PPC did not affect their adherence to recommendations of VR. Patients may perceive their voice use differently across time, which might play a role in their adherence to voice rest recommendations: voice use measured as instances versus a unit of time (seconds).

Effects of Different Voice Rest on Vocal Function After Microlaryngeal Surgery: A Systematic Review and Meta-Analysis

OBJECTIVES

To compare the results of a voice handicap index (VHI) scale and acoustic parameters in patients who underwent microlaryngeal surgery followed by either short-duration (voice rest for <7 days) or long-duration (≥7 days) voice rest.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched for articles published before March 1, 2021. Randomized controlled trials (RCTs) that measured the voice outcomes of patients after different durations and extents of postoperative voice restriction were included in the meta-analysis.

RESULTS

Four RCTs comprising 112 patients were included in the quantitative meta-analysis. Compared with the long-duration voice rest group, the short-duration group exhibited comparable VHI scores (mean difference [MD], -7.01; 95% CI, -16.12 to 2.09; p = 0.13), maximum phonation time (MD, -2.58; 95% CI, -5.42 to 0.26; p = 0.07), and acoustic variables of jitter (MD, -1.25; 95% CI, -3.43 to 0.94; p = 0.26) and shimmer (MD, -0.79; 95% CI, -2.08 to 0.51; p = 0.24). Subgroup analysis for benign pathology and cold instruments studies demonstrated significantly better VHI scores (MD, -14.45; 95% CI, -26.19 to -2.72; p = 0.02 and MD, -15.98; 95% CI, -28.52 to -3.44; p = 0.01, respectively) in the short-duration group.

CONCLUSIONS

The limited evidence does not demonstrate benefit in voice outcomes from long-duration voice rest and suggests potential unfavorable effects on compliance and quality of life, providing a rationale for short-duration voice rest after microlaryngeal surgery. More studies are required to determine the optimal duration and extent of postoperative voice rest.

LEVEL OF EVIDENCE

1 Laryngoscope, 133:154-161, 2023.

The recurrent factors of idiopathic vocal process granulomas after cold steel excision

OBJECTIVE

To identify the factors predicting postoperative recurrence after cold steel excision for the market trader with idiopathic vocal process granulomas (VPGs).

MATERIAL AND METHODS

The market traders with idiopathic VPGs who do not respond to medical treatment were treated by cold steel excision. The factors considered likely to affect the recurrence were evaluated by univariate and multivariate logistic regression.

RESULTS

The total of 80 idiopathic VPGs underwent the cold steel excision. All postoperative 6 months, the complete remission rate was 37.5% (30 VPGs) and 50 recurrences developed (62.5%). The recurrence rate was not significantly associated with sex (P = 0.119), side (P = 0.468), VPG size (P = 0.726), LPR (P = 0.293), diabetes mellitus (P = 0.5611), cerebrovascular disease (P = 0.129), or chronic pulmonary disease (P = 0.190). Multivariate logistic regression showed that only vocalization frequency (P = 0.006) and smoking and alcohol consumption (P = 0.001) were independent predictors of recurrence. There was no significant correlation between age and recurrence (P = 0.59). However, recurrence was more common in those aged 51-60 years than those aged ≥61 years (P = 0.019). Of the recurrent 49 VPGs treated conservatively via behavioural modification and oral deanxit, the granulomas disappeared spontaneously in 38 (77.6%) within 6-10 months and in 11 (22.4%) within 2-3 years.

CONCLUSIONS

The market traders with VPG would be a high recurrence rate after cold steel excision, the frequency of voice use and smoking and alcohol consumption were significant independent predictors of recurrence. Antidepressant medications and behavioural modification could effectively improve the outcome of VPG.

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

Objective

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

Methods

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

Results

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

Conclusion

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

Level of evidence: 4

Voice Handicap Index Changes After Microflap Surgery for Benign Vocal Fold Lesions Are Not Associated With Recommended Absolute Voice Rest Duration

PURPOSE

Voice rest is frequently prescribed after phonosurgery, but optimal type and duration for voice outcomes have not been demonstrated. Studies to date have been characterized by heterogeneity in surgical procedures and laryngeal diagnoses. We sought to analyze the effect of recommended absolute voice rest duration on outcomes of microflap surgery for benign vocal fold lesions. A secondary purpose was to identify patient factors associated with postoperative voice outcomes.

METHOD

Forty-three patients were included in this retrospective review of patients aged 18 years and above who underwent direct microlaryngoscopy with microflap for vocal fold polyp or cyst over a 5-year period at a multidisciplinary voice center. Duration of recommended postoperative absolute voice rest was classified as less than 7 days, 7 days, and more than 7 days. Demographic and vocal hygiene data and voice treatment history were collected. Outcome measures consisted of one pre- and two postoperative Voice Handicap Index (VHI) scores. Effects of recommended voice rest on outcomes were analyzed using mixed models for repeated measures. Effects of patient factors on outcomes were analyzed as exploratory measures. Stroboscopy ratings were analyzed descriptively.

RESULTS

Thirteen patients were recommended 7 days of absolute voice rest, 15 were recommended less than 7 days, and 15 were recommended more than 7 days. Postoperatively, VHI scores significantly improved for all patients. Voice rest as a continuous variable was associated with the Functional subscale score in the short term, but there was no effect on VHI total score and no longer term effect of voice rest on any outcome. Age, sex, and preoperative voice therapy were associated with at least one VHI subscale score on at least one time point.

CONCLUSION

VHI outcomes of microflap surgery for polyps and cysts do not differ by duration of recommended absolute postoperative voice rest.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19178459.

Role of Voice Therapy in Adherence to Voice Rest After Office-Based Vocal Fold Procedures

Purpose Patients undergoing vocal fold procedures significantly reduce but often do not cease voice use during absolute postprocedure voice rest. We hypothesized that patients who completed preprocedure voice therapy would increase adherence to postprocedure voice rest. Method Eighty-six participants completed this prospective cohort study. Patients scheduled for office-based vocal fold procedures, 1-3 days of absolute postprocedure voice rest, and preprocedure speech-language pathology (SLP) care were recruited. SLP care consisted of either (a) multiple voice therapy sessions, (b) one counseling/therapy session, or (c) voice evaluation only. Participants reported talking and other specific voice behaviors on 100-mm visual analog scales for up to 3 days pre- and postprocedure as well as changes in overall voice use at follow-up at least 1 week postprocedure. Results Talking decreased postprocedure by 63% in the therapy group and 65% in the counseling group, both significantly more than the 35% decrease measured in the evaluation group. There were group differences in talking at baseline but not during voice rest. Coughing and throat clearing were highest in the voice evaluation group and decreased less than talking during voice rest. At follow-up, 84% of participants reported that they completed voice rest for at least as long as recommended and 39.5% reported that they never used their voices during voice rest. Participants estimated a 98% overall reduction in voice use during voice rest at follow-up. Conclusions Voice use before and after vocal fold procedures varies by participation in preprocedure voice therapy. Patients significantly decrease talking during postprocedure voice rest but are not perfectly adherent. Communicative voice use decreases more than noncommunicative voice use during voice rest. Patients may overestimate adherence to voice rest at follow-up. Supplemental Material https://doi.org/10.23641/asha.16589864.

Hoarseness

Hoarseness is a common problem, typically of transient nature. When hoarseness does not resolve, or when it is associated with concerning symptoms, it is important to consider a wide differential and refer to an otolaryngologist. This article discusses the physiology of the voice and possible causes of dysphonia, and explores when it warrants further work-up by ENT. A discussion of diagnostic techniques and the myriad of tools to treat hoarseness follows. Additionally, the role of reflux in dysphonia is examined with a critical eye to aid in accurate assessment of the patient's complaint.

Restoration Strategies Following Short-Term Vocal Exertion in Healthy Young Adults

Purpose This study aims to investigate the effects of a 10-min vocal exertion task on voice and respiratory measures, to determine whether restorative strategies can mitigate these effects after cessation of exertion, and to assess whether these strategies continue to reduce these detrimental effects when vocal exertion is resumed. Method A prospective, repeated-measures design was used. On consecutive days, 20 participants (equal men and women) completed two vocal exertion tasks separated by 10 min of restoration strategies: vocal rest or controlled phonation (low-level tissue mobilization using straw phonation). Voice and respiratory data were collected at baseline, following the first exertion task, after restoration strategies, and after the second exertion task. Outcome measures included (a) vocal effort, (b) phonation threshold pressure, (c) maximum and minimum fundamental frequencies, (d) cepstral peak prominence of connected speech, (e) lung volume initiation and termination, (f) percent vital capacity expended per syllable, and (g) number of syllables per breath group. Results A worsening of phonation threshold pressure (p < .001), vocal effort (p < .001), and increase of minimum fundamental frequency (p = .007) were observed after vocal exertion. Lung volume initiation (p < .001) and lung volume termination (p < .001) increased. These changes were largely reversed by restoration strategies, but only controlled phonation prevented exertion-induced changes in respiratory kinematic measures on a subsequent vocal exertion task. Conclusions Exertion-induced voice changes occur rapidly and may be mitigated by either controlled phonation or vocal rest. Controlled phonation is recommended as a superior strategy due to evidence of a protective effect on a successive vocal exertion task.

In vitro mechanical vibration down-regulates pro-inflammatory and pro-fibrotic signaling in human vocal fold fibroblasts

INTRODUCTION

Voice rest following phonotrauma or phonosurgery has a considerable clinical impact, but clinical recommendations are inconsistent due to inconclusive data. As biopsies of the vocal folds (VF) for molecular biology studies in humans are unethical, we established a new in vitro model to explore the effects of vibration on human vocal fold fibroblasts (hVFF) in an inflammatory and normal state, which is based on previously published models.

METHODS

By using a phonomimetic bioreactor we were able to apply predefined vibrational stress patterns on hVFF cultured under inflammatory or normal conditions. Inflammatory and pro-fibrotic stimuli were induced by interleukin (IL)1β and transforming growth factor (TGF)β1, respectively. Mechanical stimulation was applied four hours daily, over a period of 72 hours. Outcome measurements comprised assessment of extracellular matrix (ECM)-related components, angiogenic factors, and inflammatory and fibrogenic markers on gene expression and protein levels.

RESULTS

Under inflammatory conditions, the inflammatory cytokine IL11, as well as the myofibroblast marker alpha smooth muscle actin (α-SMA) were significantly reduced when additional vibration was applied. The desirable anti-fibrotic ECM component hyaluronic acid was increased following cytokine treatment, but was not diminished following vibration.

CONCLUSION

Our experiments revealed the effect of vibrational stress on hVFF in an inflammatory state. Elevated levels of certain pro-inflammatory/pro-fibrotic factors could be mitigated by additional vibrational excitation in an in vitro setting. These findings corroborate clinical studies which recommend early voice activation following an acute event.

Outcomes of voice therapy in children with benign vocal fold lesions

OBJECTIVE

This study aims to examine the effect of voice therapy on dysphonia on children with benign vocal fold lesions, as measured by perceptual evaluation using the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V) and acoustic and aerodynamic measures (jitter, shimmer, noise-to-harmonic ratio, phonation threshold pressure, mean airflow during voicing, subglottic pressure during comfortable phonation).

STUDY DESIGN

Prospective disease-specific outcomes database.

METHODS

Subjects identified in the database consisted of 28 children (14 male, 14 female) between the ages of three and eighteen. Pre- and post-therapy perceptual, acoustic and aerodynamic measures were compared using two-sided paired t-test.

RESULTS

There was a statistically significant difference in perceptual ratings of voice quality (p < .001) and in phonation threshold pressure before and after therapy (p = .034). While acoustic measures improved after therapy, changes were not statistically significant.

CONCLUSIONS

Children with dysphonia secondary to benign vocal fold lesions showed positive change in perceptual ratings of voice quality and in phonation threshold pressure after voice therapy.

Role of voice rest following laser resection of vocal fold lesions: A randomized controlled trial

OBJECTIVES/HYPOTHESIS

Voice rest is often prescribed following phonosurgery by most surgeons despite limited empiric evidence to support its practice. This study assessed the effect of postphonosurgery voice rest on vocal outcomes.

STUDY DESIGN

Prospective, randomized controlled trial.

METHODS

Patients with unilateral vocal fold lesions undergoing CO₂ laser excision were recruited in a prospective manner and randomized into one of two groups: 1) an experimental arm consisting of 7 days of absolute voice rest, or 2) a control arm consisting of no voice rest. The primary outcome measure was the Voice Handicap Index-10 (VHI-10) questionnaire. Secondary outcomes included aerodynamic measurements (maximum phonation time), acoustic measures (fundamental frequency, jitter, shimmer, and harmonic-to-noise ratio), and auditory-perceptual measures. Primary and secondary outcomes were assessed preoperatively and reassessed postoperatively at the 1- and 3-month follow-up. Patient compliance to voice rest instructions were controlled for using subjective and objective parameters.

RESULTS

Thirty patients were enrolled with 15 randomized to each arm of the study. Statistical analysis for the entire cohort showed a significant improvement in the mean preoperative VHI-10 compared to postoperative assessments at 1-month (19.0 vs. 7.3, P < .05) and 3-month (19.0 vs. 6.2, P < .05) follow-up. However, between-group comparisons showed no significant difference in postoperative VHI-10 at either time point. Similarly, secondary outcome measures yielded no significant difference in between-group comparisons.

CONCLUSIONS

Our study shows no significant benefit to voice rest on postoperative voice outcomes as determined by patient self-perception, acoustic variables, and auditory-perceptual analysis.

LEVEL OF EVIDENCE

1b CLINICAL TRIAL NUMBER: NCT02788435 (clinicaltrials.gov) Laryngoscope, 130:1750-1755, 2020.

Speech Language Pathology Rehabilitation

The speech language pathologist has a vital management role in patients with voice and swallow concerns, as well as stroke patients and patients with fluency problems. This article summarizes the variety of speech and swallow rehabilitation that adult patients may require or seek. The case examples allow the reader to base the clinical decision-making process within the context of a patient presentation and elucidate the role of speech and language pathology services for the primary care provider in order to refer patients with symptoms and concerns to the right provider early in their medical care.