Minimal clinically important difference of voice handicap index‐10 in vocal fold paralysis

Online Intervention for Muscle Tension Dysphonia: A Pilot Randomized Clinical Trial

Importance

Voice-related perceived control is the extent to which a person feels they can control their voice condition and/or their response to it. Given the interaction of psychological factors and voice outcomes, an intervention targeting psychological factors may be a helpful adjunct to clinical voice care.

Objective

To investigate the feasibility, acceptability, and potential efficacy of a perceived control intervention adapted for adult patients with muscle tension dysphonia and to compare its outcomes with those of a voice education program.

Design, Settings, and Participants

This was a pilot randomized clinical trial using mixed methods and including adults with muscle tension dysphonia from academic otolaryngology clinics from July 8, 2018, to December 8, 2019. Participants were randomized to the voice education program or the perceived control intervention, and feasibility and acceptability of both were assessed using quantitative and qualitative measures. Data analyses were performed from October 1, 2023, to March 5, 2024.

Main Outcomes and Measures

Voice-related impairment was measured using the Voice Handicap Index-10 (VHI-10). Psychological factors were measured using the voice-related Perceived Present Control Scale, Brief Symptom Inventory-18 (BSI), and Perceived Stress Scale-4. Open-ended participant responses were analyzed following consensual qualitative research methods.

Results

In all, 50 participants (mean [SD] age, 51.0 [15.9] years; 34 women [68%]); 27 were randomly assigned to receive the voice education program and 23 were randomly assigned to the perceived control intervention. Forty participants (80%) completed the study, which demonstrated the feasibility of both options. Outcomes of both the perceived control intervention and the voice education program were acceptable. Change in VHI-10 was heterogeneous, modest overall, and similar in the perceived control (-2.44; 95% CI, -4.25 to -0.63) and education (-2.94; 95% CI, -4.12 to -1.76) arms. Perceived control (secondary outcome) was higher, and exploratory outcomes (ie, somatic concerns, depression, anxiety, and perceived stress) were lower overall between pretest and posttest assessments. Qualitative analyses showed an overall decrease in negative voice-related emotions, fatigue, and negative self-image over the course of the perceived control intervention, and an interest in curated information in the voice education program.

Conclusions and Relevance

This pilot randomized clinical trial indicates that both the perceived control intervention and voice education program appear promising for further development. Online interventions are of interest to people with voice disorders, and future work may benefit from taking individual differences into account.

Trial Registration

ClinicalTrials.gov Identifier: NCT03576365.

Singing Voice Handicap Index-10 Minimal Clinically Important Difference: A Prospective Determination

BACKGROUND/OBJECTIVES

The Singing Voice Handicap Index-10 (SVHI-10) is a validated patient-reported outcome measure (PROM) that assesses patients' perception of handicap related to singing voice. A normative value has been established with a score ≥20 being abnormal. However, there is no defined minimal clinically important difference (MCID). This study prospectively determines the MCID of SVHI-10 among a diverse group of singers.

METHODS

103 adult singers with and without voice complaints completed SVHI-10 twice, 30 days apart. MCID for the SVHI-10 was determined using distribution-based receiver-operating characteristic (ROC) curve analysis.

RESULTS

Twenty-two men (1 transgender), 75 women (1 transgender), and 6 nonbinary individuals participated. The most frequently reported singing genres were classical (44.7%), musical theater (17.5%), and pop (10.7%). Mean initial SVHI-10 score was 13.05 (standard deviation 7.397), and mean follow-up SVHI-10 was 13.13 (7.994). There was a significant positive correlation between initial and follow-up SVHI-10 scores (r = 0.879, p < 0.001). SVHI-10 scores were significantly higher among participants who reported voice changes in the past year (p < 0.001) or sought voice treatment (p = 0.001) compared with participants who did not. SVHI-10 scores varied significantly based on singing type. The area under the ROC curve for SVHI-10 was 0.700 (p = 0.003). The SVHI-10 MCID was determined to be 9.5.

CONCLUSIONS

An SVHI-10 score change ≥10 should be considered clinically meaningful. This definition has been missing from the literature and will improve understanding of patients' responses to treatment, which will help advance clinical care and track research outcomes.

LEVEL OF EVIDENCE

4 Laryngoscope, 135:752-757, 2025.

Efficacy of Posterior Pharyngeal Wall Injection for Velopharyngeal Dysfunction in Adults

OBJECTIVE(S)

Posterior pharyngeal wall (PPW) injection is often employed to treat velopharyngeal deficiency (VPD). We sought to analyze the impact of PPW injection on severity of dysphagia and dysphonia.

METHODS

Retrospective chart review was conducted of patients undergoing PPW injection from 2018 to 2023 at a tertiary laryngology center. Effects on Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), soft palate closure on modified barium swallow, and auditory-perceptual measures of hypernasality and audible nasal air emission were analyzed.

RESULTS

67 PPW injections were performed in 29 patients (11 female). Mean age was 59.4 ± 17.0 years. Etiologies were head and neck cancer (n = 23) and neurologic conditions (n = 6). 30 PPW injections were performed concurrent with intervention on the upper esophageal sphincter (25 dilations, 3 myotomies, 2 botulinum toxin injections), and 8 with a glottic procedure (6 vocal fold injections, 2 thyroplasties). Change scores were 3.87 (-6.85 to -0.89, p = .012) for VHI-10 and -3.00 (-4.75 to -1.25, p = 0.001) for EAT-10. These were statistically different from 0 for the whole cohort but not in the subset of patients undergoing concurrent voice and/or swallow surgery. Soft palate closure scores tended to be better (but not statistically significant) on MBS after PPW injection. Hypernasality and audible nasal air emission both improved after injection.

CONCLUSION

PPW injection appears to have a therapeutic effect on dysphagia/dysphonia in patients with VPD; however, many patients have multifactorial impairment. Additional study is needed to determine benefit of PPW when performed in conjunction with other procedures in this complex patient population.

LEVEL OF EVIDENCE

4 (Case series) Laryngoscope, 135:605-613, 2025.

Prospective Outcomes After Serial Platelet-Rich Plasma (PRP) Injection in Vocal Fold Scar and Sulcus

OBJECTIVE

Vocal fold scar and sulcus pose significant treatment challenges with no current optimal treatment. Platelet-rich plasma (PRP), an autologous concentration of growth factors, holds promise for regenerating the superficial lamina propria. This study aims to evaluate the potential benefits of serial PRP injections on mucosal wave restoration and vocal function.

METHODS

In a prospective clinical trial across two institutions, patients with vocal fold scar underwent four serial PRP injections, one month apart. Blinded independent laryngologists and expert listeners used pretreatment and one-month post-fourth injection videostroboscopy and CAPE-V assessments to evaluate mucosal wave and voice quality changes, respectively. Additionally, patient reported outcome measures (PROMs) were evaluated.

RESULTS

In the study, 15 patients received 55 PRP injections without adverse effects. Eight patients (53.3%) had mild, three patients (20%) had moderate, and four patients (26.7%) had severe scar. There was an average reduction of 8.7 points in post-treatment VHI-10 scores (p = 0.007). The raters observed an improvement in post-treatment voice in 73.4% of cases, and CAPE-V scores showed a reduction of 18.8 points on average (p = 0.036). The videostroboscopic VALI ratings showed an improvement in mucosal wave rating from 2.0 to 4.0. On average, the raters perceived the post-PRP exams to be better in 56.7% of cases.

CONCLUSIONS

PRP has been validated as a safe autologous option for treatment of vocal fold scar. While results for mucosal wave and voice quality varied, there was a consistent improvement in PROMs.

LEVEL OF EVIDENCE

3: Prospective cohort study, with blinded analysis Laryngoscope, 134:5021-5027, 2024.

Voice and Airway Outcomes of Montgomery T-tube Placement in Laryngotracheal Stenosis

OBJECTIVES

To describe voice and airway outcomes and complications experienced by patients with laryngotracheal stenosis following Montgomery T-tube placement.

METHODS

Retrospective chart review of all patients with laryngotracheal stenosis and Montgomery T-tube placement treated at a tertiary referral center from 2012 to 2021.

RESULTS

Eighteen patients met criteria with laryngotracheal stenosis, seven including the level of the glottis and 11 without glottal involvement. Eleven were completely aphonic before T-tube placement and the remainder had severe dysphonia. There was improvement of Voice Handicap Index-10, Reflux Symptom Index, and GRBAS grade following T-tube placement in patients compared to their preoperative values. Improvement of grade was greater in patients without glottal involvement. Complications of chronic indwelling T-tube included granulation in 14 patients (78%), tracheitis in two patients (11%), and mucus plugging in three patients (17%) with one T-tube related mortality. Five patients were eventually decannulated, six returned to tracheostomy tube, and seven retained the T-tube at last follow-up (average: 30 months, range: 4-80 months).

CONCLUSIONS

Montgomery T-tube placement improves voice in patients with severe dysphonia secondary to laryngotracheal stenosis with and without glottal involvement though the degree of improvement is greater in patients without glottal involvement. T-tube can help reestablish long-term laryngotracheal continuity in patients with no other surgical options. The potential benefits in phonation should be weighed against the possibility of rare but serious adverse events.

Progress Toward Estimating the Minimal Clinically Important Difference of Intelligibility: A Crowdsourced Perceptual Experiment

PURPOSE

The purpose of the current study was to estimate the minimal clinically important difference (MCID) of sentence intelligibility in control speakers and in speakers with dysarthria due to multiple sclerosis (MS) and Parkinson's disease (PD).

METHOD

Sixteen control speakers, 16 speakers with MS, and 16 speakers with PD were audio-recorded reading aloud sentences in habitual, clear, fast, loud, and slow speaking conditions. Two hundred forty nonexpert crowdsourced listeners heard paired conditions of the same sentence content from a speaker and indicated if one condition was more understandable than another. Listeners then used the Global Ratings of Change (GROC) Scale to indicate how much more understandable that condition was than the other. Listener ratings were compared with objective intelligibility scores obtained previously via orthographic transcriptions from nonexpert listeners. Receiver operating characteristic (ROC) curves and average magnitude of intelligibility difference per level of the GROC Scale were evaluated to determine the sensitivity, specificity, and accuracy of potential cutoff scores in intelligibility for establishing thresholds of important change.

RESULTS

MCIDs derived from the ROC curves were invalid. However, the average magnitude of intelligibility difference derived valid and useful thresholds. The MCID of intelligibility was determined to be about 7% for a small amount of difference and about 15% for a large amount of difference.

CONCLUSIONS

This work demonstrates the feasibility of the novel experimental paradigm for collecting crowdsourced perceptual data to estimate MCIDs. Results provide empirical evidence that clinical tools for the perception of intelligibility by nonexpert listeners could consist of three categories, which emerged from the data ("no difference," "a little bit of difference," "a lot of difference"). The current work is a critical step toward development of a universal language with which to evaluate changes in intelligibility as a result of neurological injury, disease progression, and speech-language therapy.

Glottic insufficiency caused by vocal fold atrophy with or without sulcus: systematic review of outcome measurements

PURPOSE

Identifying outcome measurements instruments (OMIs) to evaluate treatment efficacy in patients with vocal fold atrophy and/or sulcus.

METHODS

Systematic review of records published before March 2021 by searching Pubmed and EMBASE. Included studies reported on adults (> 18 year) with dysphonia caused by glottic insufficiency due to vocal fold atrophy with or without sulcus, who were enrolled into a randomized controlled trial, a non-randomized controlled trial, a case-controlled study or a cohort study. All included studies described an intervention with at least one outcome measurement.

RESULTS

A total of 5456 studies were identified. After removing duplicates, screening title and abstract and full text screening of selected records, 34 publications were included in final analysis. From these 50 separate OMIs were recorded and categorized according to the ELS protocol by DeJonckere et al. (Eur Arch Otorhinolaryngol 258: 77-82, 2001). With most OMIs being used in multiple studies the total number of OMIs reported was 265. Nineteen (19) individual OMIs accounted for 80% of reports. The most frequently used OMIs according to category were: VHI and VHI-10 (subjective evaluation); G of GRBAS (perceptual evaluation); F0, Jitter and Shimmer (acoustic evaluation); MPT and MFR (aerodynamic evaluation) and glottic closure and mucosal wave (endoscopic evaluation). Of these OMIs VHI had a high percentage of significance of 90%.

CONCLUSION

This systematic review identifies the most used OMIs in patients with glottic incompetency due to vocal fold atrophy and/or sulcus as a step toward defining a Core Outcome Set (COS) for this population.

PROSPERO REGISTRATION

238274.

Platelet Rich plasma injection of the vocal folds in benign vocal pathologies

PURPOSE

There are few options for treatment of dysphonia secondary to vocal pathology related to lamina propria scar, atrophy, sulcus, or inflammatory disorders. Platelet rich plasma (PRP) may provide anti-inflammatory and regenerative properties seen with other tissue engineering therapies without the risks associated with these treatments. We evaluated vocal fold (VF) injection of PRP for feasibility, phonatory effects, patient satisfaction and durability.

METHODS

Patients with dysphonia secondary to vocal fold scar, atrophy, sulcus and inflammatory lesions were included. PRP injections were administered in office, to bilateral vocal folds. Patients were followed up at 1 week, 1 month, 3 months and 6 months to assess outcomes (GRBAS scale, maximum phonation time, vocal fatigue index (VFI), voice handicap index (VHI-10) and stroboscopy).

RESULTS

75 intracordal PRP injections were administered to 48 patients. All injections were completed, and no adverse reactions were experienced. Improvements in VHI-10 scores at 1,3,6 months were seen (mean VHI 21.73 at baseline, 15.62 at six months, p < 0.001). 72.3% rated improvement at 7 or above on Likert scale. 95.7% of patients would consider a future PRP injection. Secondary outcomes VFI, MPT, and GRBAS also demonstrated significant improvements over time. Patients receiving a single PRP injection (n = 26) still demonstrated significant VHI-10 improvements at 1,3 and 6 months.

CONCLUSIONS

VF office PRP injections are feasible and safe and can provide phonatory benefit and reduce vocal effort in benign VF disorders. A single PRP injection is sufficient to provide sustained benefit in some cases.

LEVEL OF EVIDENCE

Level III: prospective cohort study.

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

OBJECTIVE(S)

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

3 Laryngoscope, 134:S1-S20, 2024.

Prospective >12 Months Outcomes After Vocal Fold Injection Medialization With Silk Microparticle-Hyaluronic Acid Material

OBJECTIVE

Vocal fold injection medialization (VFIM) is widely used as an initial treatment for unilateral vocal fold paralysis (UVFP). Current practices employ materials that share the limitation of temporary clinical effect from variable resorption rates. A novel silk protein microparticle-hyaluronic acid-based material (silk-HA) has demonstrated cellular infiltration and tissue deposition that may portend a durable medialization effect. We report on ≥12 months outcomes after VFIM with silk-HA.

METHODS

Prospective open-label study of patients with UVFP that elected treatment with VFIM with silk-HA. Blinded experts rated laryngeal stroboscopic exams.

RESULTS

Seventeen patients with UVFP underwent VFIM with silk-HA. Twelve of the 17 patients have ≥12 months follow-up. Seven patients demonstrated durable treatment benefit ≥12 months after injection with median improvement of 19 (p = 0.0156) in VHI-10. There was no significant change in VHI-10 between 1 and 12 months for these patients. Blinded ratings indicated that 5/7 patients with sustained improvements in VHI-10 exhibited complete or touch glottal closure at 12 months. Two of the seven patients exhibited a small (<1 mm) glottal gap at 12 months. Seven patients experienced initial benefit with later regression 3-4 months after injection.

CONCLUSION

VFIM with silk-HA can offer durable improvement in voice-related outcomes for UVFP past 12 months. A subset of patients treated with silk-HA experienced early loss of effect around 3-4 months postinjection. Clinical factors predictive of sustained treatment response to silk-HA injection require further exploration.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:3679-3685, 2024.

Physical Therapy for Muscle Tension Dysphonia with Cervicalgia

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

3 Laryngoscope, 134:2805-2811, 2024.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2059-2069, 2024.

Functional Laryngectomy and Quality of Life in Survivors of Head and Neck Cancer With Intractable Aspiration

Importance

Late effects of head and neck cancer (HNC) treatment include profound dysphagia, chronic aspiration, and death. Functional laryngectomy (FL) can improve patient survival and quality of life (QoL); however, removing a failing larynx for a noncancer reason is a difficult decision. Data regarding the ability of FL to improve self-perceptions of voice, swallowing, and QOL in survivors of HNC with intractable aspiration are inconclusive.

Objective

To investigate the association of FL with changes in self-reported perceptions of voice, swallowing, oral intake, QoL, and mood in survivors of HNC experiencing profound dysphagia and intractable aspiration.

Design, Settings, and Participants

This cohort study was conducted at a single academic institution and included survivors of HNC with profound swallowing dysfunction and intractable aspiration who underwent FL from July 2016 through March 2022. Of the initial 22 patients enrolled, 2 patients (15%) died of aspiration pneumonia before receiving FL. Data analyses were performed from July 2016 through March 2023.

Main Outcomes and Measures

Self-reported measures of voice using the VHI (30-item Voice Handicap Index), swallowing using the EAT-10 (10-item Eating Assessment Tool), functional oral intake scale using the FOIS (Functional Oral Intake Scale), and quality of life using the FACT-H&N (Functional Assessment of Cancer Therapy-Head & Neck) were assessed before FL and at 1, 3, and 6 months after FL. Mood states were evaluated using the POMS (Profile of Mood States, second edition), before FL and at 6 months after FL.

Results

The study analyses included 20 patients (mean [SD] age, 72.4 (7.0) years; 19 [95%] males and 1 [5%] female) who underwent FL and had complete data across all time points. Among these, 12 patients (60%) had received chemoradiation for oropharyngeal, 7 (35%) for laryngeal, or 1 (5%) for nasopharyngeal cancer. The mean (SD) time from completion of oncologic treatment to FL was 15.5 (5.5) years. Mean (SD) score on the EAT-10 improved from 33.2 (7.4) to 23.1 (10.8) at 1 month; 12.1 (9.1) at 3 months; and 8.3 (7.4) at 6 months, with a large effect size (η2 = 0.72; 95% CI, 0.54-0.80). Mean (SD) score on the FOIS improved from 2.0 (1.5) to 2.9 (1.7) at 1 month; 4.8 (2.5) at 3 months; and 5.2 (1.7) at 6 months, with a large effect size (η2 = 0.6; 95% CI, 0.38-0.71). Improvement in oral intake was achieved in 19 patients (95%), and feeding tubes were removed in 10 of 16 patients (63%) who were feeding tube-dependent; 6 patients (27%) continued to require supplemental tube feedings. Mean (SD) score on the VHI improved from 63.6 (34.0) to 86.9 (33.7) at 1 month; 71.3 (36.1) at 3 months; and 39.7 (26.9) at 6 months, with a large effect size (η2 = 0.42; 95% CI, 0.19-0.56). Seventeen patients (85%) were able to use a tracheoesophageal voice prosthesis for alaryngeal communication. Mean (SD) score on the FACT-H&N improved from 86.2 (17.8) to 93.6 (18.4) at 1 month; 109.0 (18.4) at 3 months; and 121.0 (16.8) at 6 months, with a large effect size (η2 = 0.64; 95% CI, 0.42-0.74). Mean (SD) score on the POMS improved from 58.9 (13.2) at baseline to 44.5 (9.9) at 6 months, with a large effect size (Cohen d = 1.04; 95% CI, 0.48-1.57). None of the patients experienced major complications of FL; 1 patient (5%) had a postoperative pharyngocutaneous fistula.

Conclusions and Relevance

The findings of this cohort study indicate that FL was associated with marked improvements in self-perception of voice and swallowing, functional oral intake, QoL, and mood state among survivors of HNC. These findings can serve as a framework for FL counseling among HNC survivors experiencing profound dysphagia and intractable aspiration.

Silk-Hyaluronic Acid for Vocal Fold Augmentation: Safety Profile and Long-Term Voice Outcomes

OBJECTIVES

Silk-hyaluronic acid (silk-HA) is a novel vocal fold augmentation material used in humans since July 2020. We aim to describe indications, voice outcomes, and longevity data for silk-HA injectable when used for vocal fold injection (VFI) augmentation in a large cohort of patients with longer-term follow-up than preliminary clinical studies.

METHODS

Retrospective chart review of Silk-HA injections for glottic insufficiency (GI) and follow-up between July 2020 and November 2023. Subject demographics, diagnoses, volume of material injected, VHI-10 data, time from injection, need for reinjection, and complications were collected. Blinded perceptual voice analysis of randomly selected pre- and post-intervention voice samples for unilateral vocal fold paralysis patients was performed by three voice-specialized speech-language pathologists, and changes in VHI-10 determined at various time intervals up to 1year and beyond.

RESULTS

A total of 160 silk-HA injection procedures were performed: 59% female, with a mean age of 66± 13 (range 21-90) years. Ninety-four subjects had unilateral paralysis (58.4%); the remainder had scar, atrophy, paresis, or a combination thereof. Mean volume of silk-HA injected was 0.24± 0.14 cc. Major complications were rare, most notable for laryngoscopic evidence of hemilaryngeal edema (n = 6, 3.8%), with a readmission rate to hospital of 1.3% (n = 2). There was a statistically significant decrease in paired ΔVHI-10 and CAPE-V ratings for each of the postoperative follow-up intervals. A total of 24 (27.2%) repeat medialization procedures were recommended following silk-HA injection for unilateral paralysis.

CONCLUSIONS

This study demonstrates that silk-HA is a safe product for VFI augmentation, and effective injectable for the treatment of GI due to unilateral vocal fold paralysis. Based on the current data, it is reasonable to counsel patients that they should expect benefit for several months following the injection. If patients reach 1year from their injection with a stable and satisfactory outcome, the majority experience ongoing benefit without need for additional procedures, however, the final duration of clinical effect appears to be years, but it is yet to be determined.

Improvement in swallowing safety after injection laryngoplasty in patients with unilateral vocal paralysis complicated with aspiration

BACKGROUND

The benefit of injection laryngoplasty (IL) on voice for unilateral vocal fold paralysis (UVFP) is supported increasingly in literatures, yet less is known for swallowing. Also, prevalence of patient-reported dysphagia is substantially higher than instrumental studies. This prospective study focused on swallowing outcomes, with predetermined flexible endoscopic evaluation of swallowing (FEES) protocol that simulates daily life situation.

METHODS

Adult patients with UVFP and aspiration receiving IL were recruited. Voice outcome measurements, as well as swallowing outcomes including Eating Assessment Tool (EAT-10) and FEES, which challenged patients with different fluid volumes: 10 mL, 20 mL, and 90 mL cup sipping were evaluated.

RESULTS

Significant improvements were demonstrated in all voice outcomes. Significant changes were also presented inEAT-10 (P < 0.01). Pre-operatively, penetration-aspiration scale (PAS) was 1.5 ± 1.3, 1.9 ± 1.7 and 2.3 ± 1.8 for 10 mL, 20 mL and 90 mL serial sipping, and improved to 1.1 ± 0.3, 1.1 ± 0.4 and 1.4 ± 0.7 post-operatively (P < 0.01). Safe swallowing (PAS ≤ 2) was achieved in all, except for one patient, who presented with a post-injection PAS of 4 (material enters the airway, contacts the vocal folds, and is ejected from the airway) on 90 mL cup sipping, whose pre-injection PAS was 7 (residue in trachea).

CONCLUSION

Maintaining swallowing function suitable for social environment is important. Our results demonstrated the feasibility of the predetermined FEES protocol, and positive effects of IL on both voice and swallowing outcomes.

Voice Improvement After Essential Tremor Treatment via Focused Ultrasound and Deep Brain Stimulation

OBJECTIVES

The primary objective of this study was to determine whether two neurosurgical procedures, deep brain stimulation (DBS) and focused ultrasound (FUS), to treat essential tremor (ET) of the upper limb also reduce vocal tremor (VT) in patients with comorbid dysphonia.

METHODS

Twelve patients with ET and concomitant VT scheduled for neurosurgical intervention (FUS or DBS) or returning for follow-up after DBS implantation were assessed. FUS patients were assessed pre- and post-intervention and DBS patients were assessed with the electrodes turned on and off post-implantation. Three voice recordings of a sustained /a/ were obtained for each participant condition. Percent fundamental frequency variability (FFV) was calculated for each recorded sustained vowel. Additionally, blinded expert perceptual VT rating (VTR) was performed to assess subjective changes in tremors.

RESULTS

Of the 12 patients, seven underwent unilateral FUS, and five underwent bilateral DBS. Mean FFV without neurosurgical intervention was 18.3%, SD = 7.8 and with neurosurgical intervention was 6.3%, SD = 3.0 (t (70) =8.7, p < 0.001). Mean FFV decreased in the FUS cohort from 22.0%, SD = 7.1 pre-ablation to 6.7%, SD = 2.4 post-ablation (t (40) = 7.7, p < 0.001). Mean FFV also decreased in the DBS cohort from 15.7%, SD = 7.0 to 6.0%, SD = 3.3 when stimulation was turned on (t (28)=5.7 p < 0.001). In the FUS group, mean VTR decreased from 4.0 to 1.4 post-ablation (Z = 7.8, p < 0.001). In the DBS group, mean VTR decreased from 3.3 to 2.1 with stimulation (Z = 4.1, p < 0.001).

CONCLUSION

Neurosurgical interventions for ET (bilateral DBS and unilateral FUS) demonstrate acoustic and perceptual benefits for VT.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:367-373, 2024.

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

OBJECTIVES

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

DATA SOURCES

PubMed, Cochrane, and Embase.

REVIEW METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Comparison of Outcome Measures (Subjective, Objective, and Patient-Based) in Laryngeal Dystonia Treatment With Botulinum Toxin A Injection

BACKGROUND

Outcome assessment in laryngeal dystonia is hindered by lack of consensus on a core set of outcome measures to quantify treatment effect and disease severity on quality of life. Potential outcome measure domains include objective voice, clinician reported, and patient reported outcome measures (PROMs) for determining treatment success and longitudinal disease tracking. We aim to determine correlations between a selections of outcome measure tools following Botulinum toxin injection.

METHODS

A selection of instruments were administered to assess adductor laryngeal dystonia patient outcomes before and after Botulinum toxin injection. Voice samples recorded using a cellular telephone application were used for objective acoustic measures (CPPS, acoustic voice quality index) and speech language pathologist perceptual analysis (CAPE-V). Additionally, patients completed a PROMs battery consisting of the Voice Handicap Index-10, Communicative Participation Item Bank-10, OMNI-Vocal Effort Scale, 3 visual analog scale (VAS) questions. Changes in these outcome measures pre-post treatment were compared between each other and with a global rating of change questionnaire (GRCQ) using Spearman's rank correlation coefficients.

RESULTS

Twenty six patients (20 female, mean age 57.7 years) participated. Using an anchor based GRCQ, patients reported Botox efficacy was the only outcome measure found to have significant correlation (r = 0.54, P = 0.022); all other outcome measures did not meet statistically significant correlation. Amongst the selected outcome tools, several moderate-strong correlations were identified, largely for outcome measures within the same domain. Most notable were correlations between the patient reported OMNI-VES and VAS questions (r > 0.68, P < 0.05), clinician CAPE-V strain and overall severity (r = 0.900, P < 0.001), and acoustic voice quality index with sustained vowel CPPs (r = -0.797, P = 0.002).

CONCLUSION

Correlation between outcome measures instruments used for patients with adductor laryngeal dystonia requires further attention. Weak correlations with an anchor based GRCQ were found for this study's selected outcome instruments. A select number of correlations were found between outcome instruments within each of the individual outcome measure domains (patient perception, clinical perception, objective acoustics), but there was largely a lack of correlation found for instruments between these three separate domains.

Do patients regret having in-office vocal fold injections for glottic insufficiency?

BACKGROUND

In-office vocal fold injections (VFI) are an effective treatment for glottic insufficiency. The primary objective of this study was to assess if patients reported decisional regret after VFI. Secondary objectives included determining if variables were associated with lower decisional regret.

METHODS

Case-control study of patients who underwent in-office VFIs for glottic insufficiency from August 2017 to December 2019 at a tertiary laryngology clinic. Participants completed the validated Decision Regret Scale (DRS). Demographic data, clinician's perceptual analysis with GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain), and patient's self-reported Voice Handicap Index-10 (VHI-10) were analyzed. Nonparametric tests as well as univariate and multiple logistics regression were performed.

RESULTS

Of patients eligible, 75% (136/182) completed the DRS (mean age 65.4 years (SD 13.9), 58.1% male). Eighty-three (61.0%) reported no decisional regret, thirty-three (24.3%) reported mild decisional regret, and twenty (14.7%) reported moderate to strong decisional regret. Improvement in most recent VHI-10 (Kendall correlation coefficient tau = 0.156, p = 0.029), Grade of voice (tau = 0.236, p value = 0.002) and Breathiness of voice (tau = 0.150, p = 0.044) were associated with lower DRS. Multivariate logistics regression results showed that the change in Grade of voice (OR 9.9, p < 0.01), Roughness (OR 0.2, p < 0.01) and Breathiness (OR 0.2, p < 0.03) were significantly associated with DRS.

CONCLUSION

The majority of patients had no or mild decisional regret after in-office VFI for glottic insufficiency. Both patients who reported less vocal handicap after VFI and clinician-noted improvements in perceptual evaluation of voice after VFI were associated with significantly lower decisional regret.

Transoral CO2 laser-modified posterior cordotomy combined with plasma ablation subtotal arytenoidectomy for bilateral vocal fold paralysis: A retrospective study

OBJECTIVES

To investigate the effect of transoral CO₂ laser-modified posterior cordotomy combined with plasma ablation subtotal arytenoidectomy for bilateral vocal fold paralysis (BVFP).

DESIGN

A retrospective study with medical records from 2017 to 2021 in our hospital.

SETTING

A single-centre study.

PARTICIPANTS

This retrospective study included 22 patients with BVFP. They underwent transoral CO₂ laser-modified posterior cordotomy combined with plasma ablation subtotal arytenoidectomy in our hospital from 2017 to 2021.

MAIN OUTCOME MEASURES

Preoperative and postoperative swallowing and phonation functions were evaluated in all patients.

RESULTS

All 22 patients with a tracheostomy were successfully decannulated within 6 months after surgery without subsequent revision operations, and the width of the posterior glottis was more than 3.9 mm in all patients when they inspired. The statistical analysis showed that there was no difference in vocal function and swallowing function in all patients compared to preoperative (p > .05).

CONCLUSION

Transoral CO₂ laser-modified posterior cordotomy combined with plasma ablation subtotal arytenoidectomy enlarges the posterior glottis in patients with BVFP, which maintains airway patency without significant worsening in voice and swallowing function.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

4 Laryngoscope, 133:647-653, 2023.

Preliminary Results on the Safety and Efficacy of Silk-Hyaluronic Acid for Treatment of Glottic Insufficiency

OBJECTIVES

Silk-Hyaluronic Acid (Silk-HA) is a novel vocal fold augmentation material that has been used in humans since July 2020. There is a paucity of published data on Silk-HA and its longevity remains a question. This study aimed to evaluate a single surgeon's initial experience performing Silk-HA injection laryngoplasty for the treatment of glottic insufficiency.

METHODS

Retrospective chart review of Silk-HA injections between July 2020 and December 2021. Subject demographics, diagnoses, volume of material injected, VHI-10 data, and complications were collected. A blinded perceptual voice analysis of voice samples was performed by two voice-specialized speech-language pathologists (SLP) for a subset of unilateral vocal fold paralysis patients before and 3-months following silk-HA injection. Univariate assessment of the change in VHI-10 and perceptual voice analyses at 3-month follow up was determined.

RESULTS

58 patients (43.1% female) underwent Silk-HA injection with a mean age of 64 (range 21-88). 38 subjects had unilateral paralysis (65.6%), and the remaining had scar, atrophy, paresis or a combination thereof. 49 injections were unilateral (84.5%). Mean volume of silk injected was 0.26 mL. Complications were rare, most notable though for 2 admissions for dyspnea and laryngoscopic evidence of hemi-laryngeal edema (3.4%). Mean change in CAPE-V overall severity rating was -32.9 (P<0.0001), and VHI-10 was -14.6 ± 10 (P=0.0013). 14 patients underwent a repeat silk-HA injection for ongoing glottic insufficiency (loss of augmentation vs under-augmentation).

CONCLUSIONS

Preliminary results for Silk-HA show potential for ongoing improvement of glottic insufficiency at 3 months from date of augmentation. Clinician and patient perception of voice outcomes showed overall improvement at three months, though longevity remains to be determined. While overall well tolerated and without serious complications in 96% of the cohort, patients should be counseled on the potential for airway edema and symptomatic dyspnea requiring steroid management and observation.

Office-Based Structural Autologous Fat Injection Laryngoplasty for Unilateral Vocal Fold Paralysis

Unilateral vocal fold paralysis (UVFP) is a common cause of incomplete glottic closure, leading to significant somatic and social disabilities. Office-based autologous fat injection laryngoplasty (AFIL) has been proposed as an effective treatment for glottic insufficiency but has not been well-studied for UVFP. We enrolled 23 patients who underwent office-based structural AFIL due to unilateral vocal paralysis at our institution between February 2021 and January 2022. In the procedure, autologous fat was harvested and injected into the vocal fold under the guidance of flexible digital endoscopy for structural fat grafting. The voice handicap index-10 (VHI-10) score and perceptual voice measurements were collected before the operation, 2 weeks postoperatively, and 3 months postoperatively. Twenty-two patients were followed-up for at least 3 months. The VHI-10 score improved significantly from 29.65 ± 8.52 preoperatively to 11.74 ± 7.42 at 2 weeks (p < 0.0001) and 5.36 ± 6.67 at 3 months (p < 0.0001). Significant improvements in grades of dysphonia (p < 0.0001), breathiness (p < 0.0001), and asthenia (p = 0.004) were also noted at 3 months postoperatively when perceptual measurements were investigated. Office-based structural AFIL is an effective treatment for improving voice-related disability for UVFP patients.

Injection laryngoplasty during transoral laser microsurgery for early glottic cancer: a randomized controlled trial

BACKGROUND

Transoral laser microsurgery is widely used for treating T1/T2 glottic cancers. Hyaluronic acid (HA) is commonly used in vocal cord augmentation. We investigated the impact of intra-operative injection laryngoplasty on voice outcomes in early glottic cancer.

METHODS

Twenty patients were randomized to the treatment group receiving HA injection to the vocal cord contralateral to the lesion; or the control group, receiving no injection. Patients had a Voice Handicap Index-10 (VHI-10) questionnaire and a Maximum Phonation Time (MPT) measurement preoperatively and at 3, 12 and 24 months post-operatively. Mean change in VHI-10 and MPT, compared to baseline and between time points, were compared. Survival estimates were calculated.

RESULTS

Mean VHI-10 scores improved over time amongst all patients. There were no changes in mean VHI-10 from pre-operative values to 3, 12 or 24 months post-operatively. There were no significant differences when comparing various timepoints between groups. There were no significant changes in MPT amongst the groups, or the time-points compared. Two-year overall survival was 91.7%; disease free survival was 80.9%; no difference in recurrence free survival was seen between the groups.

CONCLUSION

Subjective voice scores improved over time in both groups; there were no improvements in VHI-10 or MPT scores in the injection group, over control, at any time points. We saw no significant impact for intra-operative HA injection laryngoplasty on subjective or objective voice outcomes following surgery for early glottic cancers.

Patient reported voice handicap and auditory-perceptual voice assessment outcomes in patients with COVID-19

PURPOSE

The purpose of this study is to compare patient-reported voice handicap and auditory-perceptual measures of voice between healthy individuals and COVID-19 patients, as well as to investigate the effect of clinical factors on voice quality.

METHODS

COVID-19 patients (n = 138) and 90 healthy controls were included in the study. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was used to grade voice samples based on overall severity, roughness, breathiness, strain, pitch, and loudness. The Voice Handicap Index-10 was completed by all participants (VHI-10). Physical (pVHI), emotional (eVHI) and functional (fVHI) subscores were calculated. Clinical data were collected (disease stage, CT grade, neutrophil/lymphocyte ratio, CRP, and symptoms).

RESULTS

A statistically significant difference between patient and control groups in VHI-10 and CAPE-V scores was detected (p < 0.001). Except eVHI, total score and all subscale scores were higher in patients with COVID-19 as the pVHI was the most affected (η² = 0.324) subscale. All scores of CAPE-V were significantly worse in patients with COVID-19 as highest impact of COVID-19 was on breathiness (η² = 0.518). Pre-existing pulmonary comorbidity_, dyspnoea and N/L was significantly associated with the VHI-10 overall score (β_pc = 4.27, β_dyspnoea = 5.69 and β_nl = 0.25). The overall severity of CAPE-V was significantly dependent on dyspnoea and pulmonary comorbidity (β_dyspnoea = 11.25, β_pc = 10.12). VHI ≥4 and CAPE-V overall severity ≥11 were good indicators of COVID-19 related dysphonia.

CONCLUSIONS

COVID-19 causes patient-reported voice handicap and deteriorates auditory-perceptual measures of voice. COVID-19 related voice impairment was mainly associated with the decreased respiratory capacity.

Linguistic Relevance and Applicability of the Spanish VHI-10 in a Population Outside Spain

INTRODUCTION

The Voice Handicap Index 10 (VHI-10) has been translated to many languages. There are substantial differences between the translation methods. Translated questionnaires without appropriate linguistic validation may not capture cultural differences or be understood by the participants in the manner intended by the original developers. This also holds true between dialects within a language. There are two versions of the VHI-10 in Spanish, both translated in Spain. Considering the cultural and dialectical differences amongst Spanish speakers, it is hypothesized that these translations may not be applicable globally. The purpose of this study was to determine the linguistic relevance and applicability of the currently available versions of the VHI-10 in Spanish amongst Spanish speakers outside of Spain.

METHODS

This study used mixed methods qualitative and quantitative procedures consisting of semi-structured interviews and quantitative analysis of data. Sixty-nine participants met the inclusion criteria. Participants with and without a diagnosis of dysphonia were included. Demographic data collected included age, gender, cultural/dialectical background, level of education, and number of years residing in Southern California. Participants were provided the currently available translated versions of the VHI-10 in Spanish (V1 and V2). After reading both questionnaires, a semi-structured interview was conducted by a bilingual SLP. Semi-structured interview responses were coded to determine patterns of words marked as problematic/not understood or non-representative of the Spanish dialect spoken by the participants.

RESULTS

The majority of participants marked at least one word in both versions as problematic/not understood or non-representative of the Spanish dialect spoken (60/69, 87.0% for V1 and 63/69, 92.3%, for V2). The two words most frequently marked as problematic/not understood or non-representative of the Spanish dialect spoken were "hándicap" (marked by 51/69 participants, 73.9%) and "minusvalía" (marked by 52/69 participants, 75.4%).

CONCLUSIONS

Data analysis demonstrates that the majority of participants marked words as not understood/non-representative of their dialect on either V1 or V2. One question not understood or not answered could have an impact on how we interpret this PRO measure in clinical practice. Use of currently available Spanish translations of the VHI-10 may yield unreliable results when used amongst Spanish speakers outside Spain due to dialectal and cultural differences. Future work will include validation of a voice patient-reported outcome (PRO) measure that is culturally and linguistically appropriate for Spanish speakers outside Spain.

Autologous Lipoaugmentation Long-Term Clinical Outcomes: A Systematic Review

OBJECTIVES/HYPOTHESIS

Vocal fold (VF) lipoaugmentation can be employed to treat glottal insufficiency although variable data exist on its length of effectiveness. We aimed to review published long-term outcomes following lipoaugmentation across the literature and compile outcome data.

STUDY DESIGN

Systematic review.

METHODS

A systematic search in September 2020 of PubMed, MEDLINE, Cochrane Library, and Web of Science used the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines to identify 128 relevant articles related to VF lipoaugmentation effectiveness duration. Primary search terms included the following: vocal cord, fat, lipo, and atrophy. Forty-eight full-text articles were reviewed and 31 were included in the final analysis. Primary endpoints included the following: duration of effectiveness per patient-reported outcome measures, objective findings, and additional procedures performed. In addition, fat harvest location and processing techniques were recorded.

FINDINGS

Thirty-one studies totaling 764 patients were included in the review. Indications for augmentation were VF paralysis (N = 690) and atrophy (N = 74). Fat was harvested from the abdominal region in 21 studies (529 patients), the thigh/abdomen in 5 studies (91 patients), and buccal/submental region in 2 studies (33 patients). Processing techniques and injectable volume varied. Across included studies, only 11 of 764 patients (1.4%) reported no improvement in voice and/or swallowing. Within the first year, 71 of 608 patients (11.7%) reported a regression toward baseline. Beyond 1 year and up to 8 years, 27 of 214 patients (12.6%) reported regression from initial improvement. Thirty-three patients underwent additional procedures.

CONCLUSION

Although improvements in voice and swallowing after lipoaugmentation taper over time, most patients experienced long-term benefit. Laryngoscope, 2021.

Multi-dimensional investigation of the clinical effectiveness and prognostic factors of voice therapy for benign voice disorders

BACKGROUND/PURPOSE

Voice therapy is frequently recommended as the first-line treatment for benign voice disorders. This study investigated the clinical effectiveness of voice therapy and the prognostic factors of treatment outcomes.

METHODS

We recruited 103 consecutive patients with voice disorders, namely vocal nodules, polyps, and muscle tension dysphonia (MTD), from September 2014 to July 2016. All the patients received voice therapy as the primary treatment. Treatment outcomes were evaluated using auditory perceptual evaluation, acoustic analysis, maximum phonation time, and 10-item voice handicap index (VHI-10). Clinical effectiveness of voice therapy was defined by either 1) a posttreatment VHI-10 score ≤ 10 points or 2) decline of VHI-10 ≥ 4 points.

RESULTS

After voice therapy, VHI-10 and perceptual rating of voice quality improved significantly (p < 0.05) in the three disease categories. In patients with nodules, all the outcome parameters improved significantly (p < 0.05). Patients with good adherence to voice therapy (attending more than four sessions) had a significantly higher effectiveness than those with poor adherence (87% vs. 64%, p < 0.05). Patients with high occupational vocal demand also demonstrated a better effectiveness than those with routine vocal demand (90% vs. 70%, p < 0.05). Subsequent multivariate analyses revealed that adherence and vocal demand were independently and significantly correlated with clinical effectiveness (p = 0.03).

CONCLUSION

Voice therapy is effective for patients with vocal nodules, polyps, and MTD. Adherence to voice therapy and occupational vocal demand are significant prognostic factors for treatment outcomes.

Vocal fold injection material does not preclude interpretation of laryngeal electromyography

INTRODUCTION/AIMS

Temporary vocal fold injection (VFI) is a common treatment for acute and subacute vocal fold paralysis (VFP). Laryngeal electromyography (LEMG) is useful for diagnosing neurogenic causes of VFP. This study evaluated whether the presence of VFI material prevents interpretation of LEMG in patients with acute and subacute VFP.

METHODS

Patients with acute and subacute unilateral VFP (onset ≤6 mo) who underwent temporary VFI within 3 mo preceding LEMG were evaluated. A matched control group that did not undergo VFI was also studied. The LEMG team (laryngologist and electromyographer) performed and interpreted LEMG using a pre-specified protocol, including qualitative and quantitative motor unit analysis.

RESULTS

Eighteen patients with VFI underwent LEMG successfully with interpretation of spontaneous activity and motor unit recruitment. Fourteen patients were seen in follow-up to determine accuracy of established LEMG prognosis. Seven of seven subjects with poor LEMG prognosis did not recover vocal fold motion. Five of seven subjects with fair LEMG prognosis recovered vocal fold motion. Findings were similar for the control group.

DISCUSSION

VFI augmentation material did not prevent interpretation of meaningful LEMG data in patients with acute and subacute VFP, and accurate prognoses of vocal fold motion recovery were established.

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

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

Phonation Resistance Training Exercises (PhoRTE) With and Without Expiratory Muscle Strength Training (EMST) For Patients With Presbyphonia: A Noninferiority Randomized Clinical Trial

OBJECTIVES

Presbyphonia negatively impacts quality of life in patients with age-related voice changes. A proof-of-concept study showed promise for high vocal intensity exercise to treat presbyphonia, which became the basis for a novel intervention for age-related voice changes known as Phonation Resistance Training Exercises (PhoRTE). Expiratory Muscle Strength Training (EMST) has also been proposed as an additional intervention to target and strengthen the aging respiratory system; however, EMST has undergone limited evaluation as an adjunct treatment for elderly patients undergoing voice therapy for presbyphonia. This study determined if the addition of EMST to PhoRTE voice therapy (PhoRTE + EMST) is at least as effective at voice improvement as PhoRTE alone.

STUDY DESIGN

Prospective, randomized, controlled, single-blinded, non-inferiority.

MATERIALS AND METHODS

Participants aged 55 years or older with a diagnosis of vocal fold atrophy were randomized to complete PhoRTE therapy or PhoRTE + EMST. The primary outcome was change in Voice Handicap Index-10 (VHI-10). Secondary outcomes included the Aging Voice Index, maximum expiratory pressure, and acoustic and aerodynamic measures of voice. Repeated measures linear mixed models were constructed to analyze outcomes at a significance level of α = 0.10.

RESULTS

Twenty-six participants were recruited for the study, and 24 participants were randomized to either treatment arm. Sixteen participants completed the entire study. Both treatment arms showed statistically significant and clinically meaningful improvements in VHI-10 (PhoRTE mean [M] = -8.20, P < 0.001; PhoRTE + EMST M = -9.58, P < 0.001), and PhoRTE + EMST was noninferior to PhoRTE alone (P = 0.069). Both groups experienced a statistically significant pre-post treatment decrease (improvement) in AVI scores (PhoRTE M = -18.40, P = 0.004; PhoRTE + EMST M = -16.28, P = 0.005). PhoRTE+EMST had statistically significantly greater changes in maximum expiratory pressure compared to PhoRTE alone (PhoRTE M = 8.24 cm H₂O, PhoRTE + EMST M = 32.63 cm H₂O; P= 0.015). Some secondary acoustic and aerodynamic outcomes displayed trends toward improvement.

CONCLUSION

This study demonstrates that voice therapy targeting high vocal intensity exercise (eg, PhoRTE) and EMST can play a role in improving voice outcomes for patients with presbyphonia.

Effectiveness of Intensive Voice Therapy Versus Weekly Therapy for Muscle Tension Dysphonia: A Noninferiority Randomised Controlled Trial With Nested Focus Group

OBJECTIVES

To investigate the noninferiority of intensive voice therapy and compare its effects with weekly voice therapy on multidimensional outcomes of voice and well-being, satisfaction, and attendance in people with muscle tension dysphonia (MTD). The study further aimed to explore clinician's perceptions of barriers and enablers to implementation of intensive therapy.

STUDY DESIGN

Noninferiority randomised controlled trial with nested focus group.

METHODS

Twenty adults with MTD were randomised to receive either weekly voice therapy (1 hour per week for 8 weeks) or intensive voice therapy (1 hour, 4 days per week for 2 weeks). Participants were assessed by a blinded assessor twice before treatment, once post treatment and once at 4 weeks follow up on the primary outcome measure VHI and a range of secondary auditory-perceptual, acoustic, and patient (i.e., VoiSS, satisfaction) and clinician reported outcome measures (i.e., AusTOMs, attendance rates). Five Speech Language Pathologists also participated in a focus group to explore barriers and enablers to implementing intensive therapy, with questions and analyses guided by the Theoretical Domains Framework.

RESULTS

While noninferiority for the primary outcome measure VHI was not confirmed, secondary outcome measures revealed comparable within group clinically important improvements for VoiSS and the AusTOMs, as well as selected acoustic and auditory-perceptual measures for both groups. A trend of more improvements being maintained in the intensive group was identified. Comparably high satisfaction and attendance was also found between groups. Clinicians reported more enablers than barriers to providing intensive therapy which included beliefs that it led to greater progression and consolidation of patient learning, was supported by the local context and was associated with positive emotions. Barriers related to difficulties with booking and scheduling and the belief that intensive therapy was not for all patients.

CONCLUSIONS

While the current study was likely underpowered to establish non-inferiority of intensive therapy, secondary outcomes suggested that intensive therapy may produce comparable benefits to voice, wellbeing, satisfaction and attendance compared to weekly therapy and may be a viable therapy option for individuals with MTD. When implementing intensive therapy, clinicians should consider patient's preferences and availability, as well as systems which allow for flexible booking and therapy provision for patients. Clear recommendations for future research including the use of a larger sample and telehealth are also provided.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Interventions

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

Main Outcomes and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

ClinicalTrials.gov Identifier: NCT03437824.

The development and validation of the laryngopharyngeal measure of perceived sensation

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

NA Laryngoscope, 2019.

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

BACKGROUND AND OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Addition of Wendler Glottoplasty to Voice Therapy Improves Trans Female Voice Outcomes

OBJECTIVES/HYPOTHESIS

VT is often considered the preferred treatment for vocal feminization in transgender patients. However, Wendler glottoplasty offers a surgical option for increasing fundamental frequency and perception of vocal femininity. We aimed to determine whether the addition of glottoplasty to VT results in greater fundamental frequency elevation and improvement in quality-of-life measures.

STUDY DESIGN

Retrospective case series.

METHODS

Forty-eight trans female patients were treated for vocal feminization. Twenty-seven patients underwent VT, and 21 patients underwent VT with additional glottoplasty (VTWG). Pre- and posttreatment acoustic measures, Trans Woman Voice Questionnaire (TWVQ), and Voice Handicap Index-10 (VHI-10) data were compared.

RESULTS

Glottoplasty in combination with VT elevated average speaking fundamental frequency (SF0) to a greater extent than VT alone (P < .0001). The VTWG group achieved a 42-Hz increase in SF0, whereas the VT group achieved a 15-Hz increase in SF0. In both the VT and VTWG groups, the lower bound of physiologic range increased by 18 Hz (P = .0008 and P = .016, respectively). The addition of glottoplasty also resulted in greater improvement in voice-related quality of life. Improvement in TWVQ and VHI-10 was significantly greater in the VTWG group than the VT group (P = .007 and P = .029, respectively). TWVQ showed statistically significant improvement in the VTWG group only.

CONCLUSIONS

VT results in SF0 elevation and improvement in VHI-10. The addition of glottoplasty to VT results in further improvements in SF0 and VHI-10 and statistically significant improvement in TWVQ.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1588-1593, 2021.

Voice Therapy for Benign Voice Disorders in the Elderly: A Randomized Controlled Trial Comparing Telepractice and Conventional Face-to-Face Therapy

Purpose Previous studies have reported that voice therapy via telepractice is useful for patients with nodules and muscle tension dysphonia. Nevertheless, telepractice for elderly patients with voice disorders has not yet been investigated. We conducted this study to examine the hypothesis that voice therapy via telepractice is not inferior to conventional voice therapy. Method Eighty patients with dysphonia aged more than 55 years participated in this study from September 2016 to June 2018. After screening the inclusion and the exclusion criteria, 69 patients were randomized into telepractice (33 patients) and conventional (36 patients) groups. The outcome measurements included Voice Handicap Index-10, videolaryngostroboscopy, maximum phonation time, auditory-perceptual evaluation, and acoustic analysis. Paired t test, Wilcoxon signed-ranks test, and repeated measures analysis of variance were used to examine treatment outcomes. Results The diagnoses of voice disorders included atrophy (n = 33), unilateral vocal paralysis (n = 13), muscle tension dysphonia (n = 7), nodules (n = 6), and polyps (n = 10). No significant differences were observed in age, sex, and baseline measurements between the two groups. Twenty-five patients in the telepractice group and 24 patients in the control group completed at least four weekly sessions. Significant improvements were observed for all the outcome measures (p < .05) in both groups. Improvements in Voice Handicap Index-10 in the telepractice group (24.84 ± 5.49 to 16.80 ± 8.94) were comparable to those in the conventional group (22.17 ± 7.29 to 13.46 ± 9.95, p = .764). Other parameters also showed comparable improvements between the two groups without statistically significant differences. Conclusions This is the first randomized controlled trial comparing telepractice and conventional voice therapy in elderly patients with voice disorders. The results showed that the effectiveness of voice therapy via telepractice was not inferior to that of conventional voice therapy, indicating that telepractice can be used as an alternative to provide voice care for elderly patients with vocal disorders.

Effect of Wendler Glottoplasty on Acoustic Measures of Voice

OBJECTIVES

Voice therapy has been the primary treatment for voice feminization in transfemale patients due to concerns that surgery worsens voice quality. We aim to determine the impact of Wendler glottoplasty on acoustic measures of voice.

STUDY DESIGN

Retrospective case series.

METHODS

Transgender female patients treated for vocal feminization with Wendler glottoplasty at a single tertiary care center were identified. Pre- and postoperative measures were taken with the Kay Elemetrics Real-Time Pitch, Analysis of Dysphonia in Speech and Voice, and Multidimensional Voice Program.

RESULTS

Twenty-eight patients were included in this study. There were no statistically significant changes in fundamental frequency variation, peak amplitude variation, soft phonation index, noise-to-harmonics ratio, cepstral peak prominence, or cepstral spectral index of dysphonia at a significance level of P < .05. Average speaking fundamental frequency (SF0) increased from 143 Hz after voice therapy to 163 Hz after surgery (P = .0009). Lower range decreased in 61% and increased in 26% of patients. Upper range decreased in 52% and increased in 48% of patients.

CONCLUSIONS

Wendler glottoplasty does not worsen voice quality based on acoustic measures. Although most patients experience an increase in average SF0, effects on vocal range are variable with approximately half of patients experiencing a reduction and half experiencing an increase in upper pitch limit.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:583-586, 2021.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Incidence and Outcomes of Acute Laryngeal Injury After Prolonged Mechanical Ventilation

OBJECTIVES

Upper airway injury is a recognized complication of prolonged endotracheal intubation, yet little attention has been paid to the consequences of laryngeal injury and functional impact. The purpose of our study was to prospectively define the incidence of acute laryngeal injury and investigate the impact of injury on breathing and voice outcomes.

DESIGN

Prospective cohort study.

SETTING

Tertiary referral critical care center.

PATIENTS

Consecutive adult patients intubated greater than 12 hours in the medical ICU from August 2017 to May 2018 who underwent laryngoscopy within 36 hours of extubation.

INTERVENTIONS

Laryngoscopy following endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS

One hundred consecutive patients (62% male; median age, 58.5 yr) underwent endoscopic examination after extubation. Acute laryngeal injury (i.e., mucosal ulceration or granulation tissue in the larynx) was present in 57 patients (57%). Patients with laryngeal injury had significantly worse patient-reported breathing (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 1.05; interquartile range, 0.48-2.10) and vocal symptoms (Voice Handicap Index-10: median, 2; interquartile range, 0-6) compared with patients without injury (Clinical Chronic Obstructive Pulmonary Disease Questionnaire: median, 0.20; interquartile range, 0-0.80; p < 0.001; and Voice Handicap Index-10: median, 0; interquartile range, 0-1; p = 0.005). Multivariable logistic regression independently associated diabetes, body habitus, and endotracheal tube size greater than 7.0 with the development of laryngeal injury.

CONCLUSIONS

Acute laryngeal injury occurs in more than half of patients who receive mechanical ventilation and is associated with significantly worse breathing and voicing 10 weeks after extubation. An endotracheal tube greater than size 7.0, diabetes, and larger body habitus may predispose to injury. Our results suggest that acute laryngeal injury impacts functional recovery from critical illness.

The 22-Item Sinonasal Outcome Test as a Tool for the Assessment of Quality of Life and Symptom Control in Allergic Rhinitis

Background

The 22-item Sinonasal Outcome Test (SNOT-22) is a validated patient-reported outcome measure for chronic rhinosinusitis and in many circumstances is used in rhinology/otolaryngology clinics to assess sinonasal symptoms in general when a formal diagnosis is not established, although with little support for such usage.

Objective

To assess the utility of the SNOT-22 as a reflection of quality of life (QOL) and symptom control for patients with allergic rhinitis (AR).

Methods

Retrospective review of 353 patients with persistent AR. Each patient completed a SNOT-22, 5-item EuroQol general health-related QOL (EQ-5D) questionnaire (from which the visual analog scale [VAS] was used), and Rhinitis Control Assessment Test (RCAT). In addition, 95 patients also completed these questionnaires 1 to 12 months later.

Results

The SNOT-22 was negatively correlated with the EuroQol 5-dimensional visual analog scale (EQ-5D VAS; r = −.45, 95% confidence interval [CI]: −0.53 to −0.36, P < .001) and RCAT ( r = −.62, 95% CI: −0.68 to −0.55, P < .001), with excellent internal consistency. The SNOT-22 demonstrated responsiveness, with mean change of −5.8 (95% CI: −8.9 to −2.6, P < .001) from pre- to posttreatment. The change in SNOT-22 over the treatment period was correlated with change in EQ-5D VAS ( r = −.28, 95% CI: −0.46 to −0.07, P = .008) and RCAT ( r = −.56, 95% CI: −0.69 to −0.41, P < .001). The minimal clinically important difference was calculated to be between 6 and 11.

Conclusion

The SNOT-22 has utility to assess QOL and symptom control in AR, and it is both reliable and responsive in its application to patients with AR. The SNOT-22 may therefore be a convenient and versatile tool in the clinical assessment of patients with AR.

The minimal clinically important difference of the dyspnea index in laryngotracheal stenosis

OBJECTIVE

The Dyspnea Index (DI) is a validated patient-reported outcome (PRO) instrument that has been used in the management of laryngotracheal stenosis (LTS). The minimal clinically important difference (MCID) is an established concept to help determine the change in a PRO instrument that reflects meaningful change for the patient. It is not known what change in the DI is of clinical significance in airway surgery. This study aims to determine the MCID for the DI in patients undergoing surgical treatment for LTS.

METHODS

This is a prospective cohort study in which 26 patients with LTS completed the DI (score range 0 to 40) before and 6 to 8 weeks postoperatively, in addition to a Global Ratings Change Questionnaire (GRCQ), scored from -7 to +7, at the postoperative interval. A hypothesis test was carried out to test the association between GRCQ and change in DI. The MCID for change in DI was determined using anchor-based analysis.

RESULTS

Overall mean change in DI was -11, and mean change in GRCQ was +5. Change in DI scores were significantly different among the improvement and no improvement groups (P value <0.002). Area under the receiver operating curve was 0.92, demonstrating high discriminatory ability of the change in DI score. A change of -4 was determined to be the threshold that discriminated between significant improvement and no improvement.

CONCLUSION

A decrease of 4 in the DI can be considered as the MCID for patients with LTS after surgical treatment.

LEVEL OF EVIDENCE

2b Laryngoscope, 130:1775-1779, 2020.

Understanding the Minimal Clinically Important Difference (MCID) of Patient-Reported Outcome Measures

OBJECTIVE

The minimal clinically important difference (MCID) of a patient-reported outcome measure (PROM) represents a threshold value of change in PROM score deemed to have an implication in clinical management. The MCID is frequently used to interpret the significance of results from clinical studies that use PROMs. However, an understanding of the many caveats of the MCID, as well as its strengths and limitations, is necessary. The objective of this article is to provide a review of the calculation, interpretation, and caveats of MCID.

DATA SOURCES

MEDLINE and PubMed Central.

REVIEW METHODS

Literature search-including primary studies, review articles, and consensus statements-pertinent to the objectives of this review using PubMed.

CONCLUSIONS

The MCID of a PROM may vary depending on the patients and clinical context in which the PROM is given. The primary approaches for calculating MCID are distribution-based and anchor-based methods. Each methodology has strengths and limitations, and the ideal determination of a PROM MCID includes synthesis of results from both approaches. The MCID of a PROM is also not perfect in detecting patients experiencing a clinically important improvement, and this is reflected in its accuracy (eg, sensitivity and specificity).

IMPLICATIONS FOR PRACTICE

Interpretation or application of MCID requires consideration of all caveats underlying the MCID, including the patients in whom it was derived, the limitations of the methodologies used to calculate it, and its accuracy for identifying patients who have experienced clinically significant improvement.