Treatment Efficacy of Voice Therapy for Vocal Fold Polyps and Factors Predictive of Its Efficacy

Pre- and post-operative voice therapy for benign vocal fold lesions: protocol for a non-randomised, multicentre feasibility trial with embedded process evaluation

BACKGROUND

Management of benign vocal fold lesions (BVFLs) is variable with individuals receiving surgery, voice therapy, or a combination of these approaches. Some evidence suggests that the best outcomes may be achieved when patients are offered pre- and post-operative voice therapy in addition to phonosurgery, but what constitutes pre- and post-operative voice therapy is poorly described. The pre- and post-operative voice therapy (PAPOV) intervention has been developed and described according to the TIDieR checklist and Rehabilitation Treatment Specification System (RTSS) for voice. The PAPOV intervention is delivered by specialist speech and language therapists trained in the intervention and comprises 7 essential and 4 additional components, delivered in voice therapy sessions with patients who are having surgery on their vocal folds for removal of BVFLs.

STUDY DESIGN

Non-randomised, multicentre feasibility trial with embedded process evaluation.

METHOD

Forty patients from two sites who are due to undergo phonosurgery will be recruited to receive the PAPOV intervention. Measures of feasibility, including recruitment, retention, and adherence, will be assessed. The feasibility of gathering clinical and cost effectiveness data will be measured pre-treatment, then at 3 and 6 months post-operatively. An embedded process evaluation will be undertaken to explain feasibility findings.

DISCUSSION

This study will assess the feasibility of delivering a described voice therapy intervention protocol to patients who are undergoing surgery for removal of BVFLs. Findings will be used to inform the development and implementation of a subsequent effectiveness trial, should this be feasible.

TRIAL REGISTRATION

This trial has been prospectively registered on ISRCTN (date 4th January 2023), registration number 17438192, and can be viewed here: https://www.isrctn.com/ISRCTN17438192 .

Voice Outcome After Cold Knife Surgery According to the Characteristics of Vocal Fold Polyp

PURPOSE

Voice change is one of the major symptoms in patients with vocal fold polyp. As a result, phonomicrosurgery is commonly required in these patients. Since voice outcomes after polyp treatment can be variable according to polyp characteristics, we aimed to investigate the predicting factors of postoperative voice improvements in terms of polyp characteristics in patients with vocal fold polyp who underwent cold knife surgery.

MATERIALS AND METHODS

A total of 77 patients who were diagnosed with vocal fold polyp and underwent phonomicrosurgery with cold knife instruments. The polyp characteristics of color, size, shape, and location were evaluated at baseline. Acoustic and aerodynamic analyses, voice handicap index questionnaire and grade, roughness, breathiness, asthenia, strain scale were evaluated at baseline and 6 weeks after surgery.

RESULTS

All values of postoperative voice parameters improved after cold knife surgery. (P < 0.05) In patient with an organized vocal fold polyp, less improvement in postoperative values of maximum phonation time were observed. (P < 0.05) Likewise, less improvement of voice handicap index questionnaire score and grade, roughness, breathiness, asthenia, strain scale after surgery was shown in organized vocal fold polyp. (P < 0.05) CONCLUSIONS: Among the various polyp characteristics, the organized polyp was significantly related to relatively less improvement of objective and subjective voice parameters after surgery. These polyp characteristics would help to predict postoperative voice improvement and plan for personalized treatment in patients with vocal fold polyp.

Effectiveness and Feasibility of Telepractice on Voice Therapy for Female Teachers in Elementary Schools with Self-Reported Voice Disorders

PURPOSE

The purpose of this study is to explore the effectiveness of telepractice in voice intervention for female teachers in elementary schools with self-reported voice disorders.

METHODS

Thirty-five female elementary school teachers with self-reported voice disorders volunteered to participate in the study. They were divided into a telepractice voice intervention group (experimental group N=18) and a face-to-face voice intervention group (control group N=17) based on their employment setting. The exact same treatment protocol was applied to both groups of subjects, except that the intervention group was seen through telepractice, and the control group was seen face-to-face. The treatment protocol includes vocal hygiene education and resonant voice therapy twice a week for a total of eight sessions. Auditory perceptual analysis, acoustic assessment, aerodynamic assessment and self-assessment protocol were conducted before the intervention and one week after the last intervention, and the differences before and after interventions within each group and between groups were compared.

RESULTS

There was no significant difference in baseline data including age, working years, and voice symptoms between the two groups. Both groups showed significant improvement (P<0.05) in all voice assessment before and after the treatment sessions, except for the Voice Handicap Index-10 (VHI-10) assessment. No statistical difference was found in other pre- and post-intervention voice assessment changes between the two study groups. The control group presented higher improvement in the total score, and the two subdomain assessments of physiology and emotion.

CONCLUSIONS

Telepractice voice intervention can effectively improve the voice quality of female teachers in elementary schools, and telepractice therapy can be an effective alternative to face-to-face voice intervention.

An eclectic Voice Therapy Program for the Treatment of Hyperfunctional Voice Disorders (HFVD)

PURPOSE

An eclectic voice therapy program includes sequenced and structured set of exercises combining direct and indirect intervention methods. Tailor-made exercise prescription with specific cultural adaptations are needed to provide a holistic change to voice quality.1 This study detailed the construction of an exercise prescription for participants with hyperfunctional voice disorder [HFVD] in the Indian context.

METHOD

The exercise program was developed based on literature related to vocal therapy approaches and delivery methods. Adaptations were introduced to a selected set of exercises. Five voice experts verified the exercises and their prescription for content and feasibility of use in the Indian context. Modification suggested by the experts were included for framing the final version of the exercise program. This structured therapy program was planned for 6 weeks (30 minutes duration/session offered individually twice per week, with a gap of two days between sessions in a week) with the goals to improve voice quality, flexibility, and endurance while speaking. Five participants with HFVD partook in the study for pilot testing. Stroboscopy, perceptual voice analysis, Dysphonia Severity Index (DSI) and Vocal Fatigue Index in Tamil (VFI-T) were used to report the therapy outcomes. Participants' report on the learning process and generalization of the program were documented. Wilcoxon-signed rank test was used to test the pre-post outcome measures.

RESULTS

An eclectic voice therapy program, i.e., Comprehensive Voice Habilitation Program [CVHP] was constructed and it included vocal hygiene instructions, warm-up & cool-down, easy onset, resonant voice, and carry over exercises. Participants completed the program in 14-18 sessions (over 7 to 9 weeks of therapy). All participants showed significant changes in vocal fold movement patterns, reduction in ventricular hyperadduction, overall grade of voice quality, DSI and VFI-T. Participants reported that pictorial illustrations, feedback, and monitoring sheets were useful in learning the exercises.

CONCLUSION

CVHP showed significant change in the voice-related outcome measures and was a viable program for treating HFVD.

Pre and Post-operative Voice Therapy Intervention for Benign Vocal Fold Lesions: A Systematic Review

Benign vocal fold lesions cause dysphonia by preventing vocal fold closure, causing irregular vibration and increasing compensatory muscle tension. Voice therapy delivered in addition to phonosurgery may improve voice and quality of life outcomes but the evidence base is lacking and what constitutes voice therapy for this population is not defined. The purpose of this systematic review is to critically evaluate the evidence for pre and post-operative voice therapy to inform the development of an evidence based intervention.

STUDY DESIGN

Systematic Review.

METHODS

Electronic databases were searched using key terms including dysphonia, phonosurgery, voice therapy and outcomes. Eligible articles were extracted and reviewed by the authors for risk of bias and for information regarding the content, timing and intensity of any pre and post-operative voice therapy intervention.

RESULTS

Of the 432 articles identified, 35 met the inclusion criteria and were included in the review. 5 were RCTs, 2 were individual cohort studies, 1 was a case control study and 26 were case series. There was considerable heterogeneity in participant characteristics. Information was frequently lacking regarding the content timing and intensity of the reported voice therapy intervention, and where present, interventions were highly variable.

CONCLUSION

Reporting in relevant literature is limited in all aspects of content, timing and intensity of intervention. Further intervention development work is required to develop a robust voice therapy treatment intervention for this population, before effectiveness work can commence.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Non-intubated deep paralysis: a new anaesthesia strategy for vocal cord polypectomy

BACKGROUND

Vocal cord polyp is common otorhinolaryngological disease, traditionally treated by vocal cord polypectomy under a supporting laryngoscope with general anaesthesia. Although it is safe and controllable, it would cause some anaesthesia complications. Moreover, the complex process of general anaesthesia may significantly reduce surgical efficiency. Avoiding these problems remains an important issue.

METHODS

All patients were subjected to the standard non-intubated deep paralysis (NIDP) protocol consisting of four phases. An emergency plan was launched when NIDP cannot be implemented successfully. Patient characteristics, blood gas and monitoring data were collected during NIDP. Data concerning satisfaction, complications and duration of anaesthesia and recovery were collected to assess its effectiveness.

RESULT

Among 20 enrolled patients, the success rate of NIDP was 95%. Only one patient failed in completing NIDP. Blood gas analysis revealed that the partial pressure of oxygen and carbon dioxide was maintained at safe levels. Monitoring during NIDP revealed fluctuations in mean arterial pressure between 110 and 70 mmHg, and the heart rate was stable at 60-100 beats per minute. The duration of anaesthesia and postoperative recovery were 13.0 ± 2.84 and 5.47 ± 1.97 min, respectively. All patients and surgeons were satisfied with NIDP, and no complications were detected before discharge.

CONCLUSION

NIDP can be safely applied to patients and can replace general anaesthesia in vocal cord polypectomy. It can significantly reduce the duration of anaesthesia and postoperative recovery. No anaesthesia complications occurred without intubation, and patients and surgeons were satisfied with NIDP.

TRIAL REGISTRATIONS

This single-centre, prospective study was registered on clinicaltrial.gov (NCT04247412) on 30^th July 2020.

Office-Based Laser Therapy in Vocal Fold Polyps: A Systematic Review and Meta-Analysis

OBJECTIVES

To analyze voice outcomes and lesion regression in patients with vocal fold polyps treated in-office using lasers.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The search was performed in the Medline, Embase, and Cochrane databases using the preferred reporting items for systematic review and meta-analyses framework. There were no limitations to the year of publication and the search included studies looking at voice outcomes and lesion evolution of in-office laser treatment for vocal fold polyps measured through voice-handicap index, GRB, acoustic analysis or aerodynamics measures. Risk of bias was assessed using Cochrane's ROBINS-I tool for observational studies. Data analysis was performed SPSS software with a significance level of 5%.

RESULTS

We identified 167 articles, 10 of which met the inclusion criteria and were analyzed. The total number of participants was 242. Meta-analysis showed significant improvement in voice handicap index-10 scores (95% CI, [0.86; 1.45]) and decrease in GRB score (95% CI, [1.09; 4.13]) after in-office laser therapy. It also showed significant improvement in percent shimmer (95% CI, [0.26; 1.01]), and significant increase in maximum phonation time (95% CI, [-0.92; -0.18]).

CONCLUSIONS

Laser therapy an outpatient office setting is a reliable alternative to classical phono-microsurgery. Results show Office-based laser therapy of vocal fold polyps results in a significant improvement in subjective voice outcomes measures. This subjective improvement in voice quality is associated with partial or complete disease regression on laryngeal examination and an increase in maximum phonation time. Ovlaryngeal examination in patients with polyps treated with in-office laser.

Pre- and Postoperative Voice Therapy for Benign Vocal Fold Lesions: An International Electronic Delphi Consensus Study

INTRODUCTION

Voice therapy management of benign vocal fold lesions (BVFLs) is variable and there are currently no clinical guidelines. Poor descriptions of voice therapy interventions lead to unwarranted variation in treatment. Triangulation of the current evidence identifies a number of potential best practice elements, but also a number of outstanding questions to be explored. The aim of this study was to refine and gain global consensus on "best practice" for a pre- and postoperative voice therapy intervention for adults with BVFLs.

METHODS

An international sample of expert voice therapists (n = 42) were recruited to take part in this three-round electronic modified Delphi study. Participants were presented with statements concerning a pre- and postoperative voice therapy intervention. Statements were developed from previous research and based on the TIDieR checklist (eg, why, when, what, how?) Participants rated the extent to which they agreed or disagreed with a statement and gave comments to support their response. Consensus was defined as >75% of participants agreeing or strongly agreeing with a given statement. If consensus was not reached, participant comments were used to generate new statements and were rated in the next round. Stability of consensus between rounds was assessed.

RESULTS

The 42 international experts achieved consensus on 33 statements relating to components of a best practice pre- and postoperative voice therapy intervention for patients with BVFLs. Consensus on statements ranged from 81% to 100%. These statements were explicitly mapped to the TIDieR checklist to ensure that all aspects of the intervention were considered and the questions of "why, what, how, when and individual tailoring" were addressed.

CONCLUSIONS

This study has significantly enhanced our understanding of what should be in a best practice pre- and postoperative voice therapy intervention. It is important to now test these findings for acceptability and feasibility, prior to considering effectiveness research.

Outcomes of Cricothyroid Visor Maneuver (CVM) for Treatment of Vocal Polyp: A Case Report

OBJECTIVE

The aim of the study is the clinical investigation of a patient with a vocal fold polyp, and the visual, acoustical, perceptual, and self-report changes before and after using the cricothyroid visor manoeuvre (CVM).

DESIGN

A 48-year-old female university professor, gynecologist, and obstetrician with a history of laryngopharyngeal reflux and a left vocal polyp participated. Treatment was provided in 10 sessions. Pre- and post-treatment audio recordings of sustained vowels, selected sentences, and connected speech samples were submitted to auditory-perceptual and acoustical analysis to assess the effects of the two-treatment program. Also, laryngoscopic images, perceptions by the patient about her voice quality and quality of life before and after therapy were assessed.

RESULTS

Improvements in acoustic parameters were obtained especially in perturbation and CCPS parameters. The overall voice quality scores on the CAPE-V were moderate before therapy and became mild after therapy. Laryngoscopy images demonstrated improvement in the glottis closure configuration in two phases (open and close) in pre- and post- CVM therapy and a decrease in polyp size. The patient had improvement in VAS, IVQLP, and VRQOL scores.

CONCLUSION

The CVM therapy used in the study resulted in positive changes in acoustic and perceptual-auditory aspects of voice production, self-report, and QOL for the patient. The CVM approach appears to have been effective for this case in decreasing the polyp size or its regression or for vocal adaptation.

Voice Therapy Expectations for Injured Singers

OBJECTIVES/HYPOTHESIS

Voice therapy is a mainstay treatment modality in the management of phonotrauma in singers. However, the typical duration of therapy an injured singer undergoes is unknown. The primary aims of the study were to determine (1) the number of therapy sessions preceding a decision for surgery and (2) the number of sessions and length of time to achieve improvement in singers who did not undergo surgery. Whether specific singer factors were associated with the length of therapy was also investigated.

STUDY DESIGN

Retrospective.

METHODS

Records of singers with phonotraumatic vocal fold lesions seen over a 9-year period at a tertiary care voice center were reviewed.

RESULTS

Sixty singers who underwent surgery and 183 singers who did not undergo surgery were included in the final analysis. In nearly ¾ of the surgical patients, five or fewer voice therapy sessions were completed prior to the decision for surgery. Singers who did not undergo surgery required on average 3-4 sessions before noting improvement. Over 60% of the non-surgical singers improved within 3 months and 84% were judged to be improved by 6 months. Lesion type, professional/amateur status, formal voice training, and having a current voice teacher/coach were not associated with the length of voice therapy.

CONCLUSIONS

The length of voice therapy prior to decision for surgery was limited, and so was the length of therapy leading to initial improvement in singers who did not require surgery. These findings provide a framework for voice therapy expectations and could be reassuring for this unique population.

The Immediate Impact of Targeted Exercises on Voice Characteristics in Female Speakers With Phonotraumatic Vocal Fold Lesions

OBJECTIVE

To examine the immediate impact of 30 minutes of targeted voice exercises on measures of vocal function and lesion characteristics in female speakers with phonotraumatic vocal fold lesions (PVFLs).

STUDY DESIGN

Prospective cohort study.

METHOD

Twenty-nine (n = 29) female subjects with PVFLs completed a 30 minutes targeted voice exercise protocol and a multidimensional voice analysis was conducted immediately pre and post-exercise. Analysis included expert perceptual evaluation of connected speech and stroboscopy recordings, instrumental analysis by selected aerodynamic and acoustic parameters, and self-ratings of effort and vocal function by participants. The direction and magnitude of the change from pre- to post-exercise for each individual across parameters was assessed against a Minimal Clinically Important Difference criteria.

RESULTS

Variability was observed among participants in their response to exercise and across parameters. Multidirectional change in function was demonstrated across instrumental parameters, with observations of both improvement and decline. The most consistent change observed was a reduced PTP post-exercises for 38% of participants (n = 11), and the greatest magnitude of change was observed in aerodynamic measures of airflow and pressure, and the acoustic parameter semitone range. Variability in the direction of change across instrumental measures was observed for 24% of participants (n = 7), while consistent improved function was seen for 45% (n = 13), declined function for 17% (n = 5) and no change for 14% (n = 4). Participant's self-reported effort and function post-exercise was also multidirectional, with the greatest number reporting improvement. Comparatively little change was observed in perceptual evaluation of speech and stroboscopy recordings. Findings suggest that individuals with all lesion types, sizes and liabilities have the potential to improve vocal function immediately post-exercises according to instrumental measures, with the greatest magnitude of change observed in participants with large lesions. Although participants' characteristics did not differentiate, those with nodules or polyps tended to report improvement in function and reduced effort post-exercise, whereas those with a diagnosis of pseudocyst/s or a unilateral lesion appeared to report no change or declined function.

CONCLUSION

Change in measures of vocal function was observed in female speakers with PVFLs immediately following a 30 minutes targeted exercises protocol. Many demonstrated improvement but a high degree of variability was observed in the way speakers respond, and it is likely an individual's response is influenced by a range of factors. Self-rating scales, along with key instrumental parameters sensitive to the presence of PVFLs, may prove most useful in tracking initial change in the immediate and short-term duration in this population, and in assessing stimulability and candidacy for therapy. Further exploration is warranted of stimulability for immediate and cumulative change to achieve sustained improvement in function and efficiency across time.

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.

Spontaneous Vocal Fold Polyps Remission after Lockdown for Covid-19 Pandemic: Does Vocal Load Matter?

Objective

During the Italian lockdown for Covid-19 emergency, due to stay-at-home orders, many people experienced an unusual period of voice rest. The present case series aims at reporting the spontaneous regression of some vocal fold polyps during the Italian lockdown for SARS-CoV2 pandemic.

Methods

Five patients with voice complaints presenting to a tertiary referral center and diagnosed with vocal fold polyps before the lockdown were included. Because of the lockdown restrictive measures, planned elective surgical procedures were suspended. The patients were re-assessed immediately after lockdown. Multidimensional voice assessments were conducted before and after the lockdown period through laryngostroboscopies, perceptual voice evaluations, electroacoustic analysis and self assessments.

Results

The patients included in the present case series experienced a complete or nearly complete remission of symptoms. Videolaryngostroboscopies documented a complete or nearly complete regression of the polyps. Voices considerably improved both perceptually and electroacoustically. Self assessments showed a reduction of voice-related complaints.

Conclusions

The present study suggests that daily vocal load reduction may play a critical role in the conservative management of vocal fold polyps.

A 532-nm KTP Laser for Vocal Fold Polyps: Efficacy and Relative Factors

OBJECTIVE

We retrospectively analyzed the laryngoscopy results and voice outcomes of patients with vocal polyps who received potassium titanyl phosphate (KTP) laser treatments in a clinician's office, in order to establish the effectiveness and relative factors affecting the efficacy of this treatment.

MATERIAL AND METHODS

We enrolled 25 patients with vocal polyps who had undergone KTP laser treatment in the Department of Otorhinolaryngology at our hospital between July 2017 and November 2019. Pre- and postoperative evaluations were measured using laryngovideostroboscopy (LVS), the Voice Handicap Index questionnaire (VHI-30), the GRBAS scale (G hoarseness, R roughness, B breathiness, A asthenia, S strain), and objective acoustic parameters. The reduction rate of lesions was calculated and relative factors affecting efficacy (size, side, location, the position of lesions, type, gender, and occupation) were tested.

RESULTS

Areas of lesions decreased from 101.95 ± 70.16 before surgery to 30.49 ± 35.80 after surgery (Z = 5.234, P < .001). The LVS data showed that the postoperative proportions of normal to mild conditions were the same or higher than the preoperative data in 3 instances: glottal closure (100% vs 100%), amplitude (90.91% vs 63.64%), and mucosal wave (81.82% vs 54.55%). A significant improvement was observed in VHI-30 scores, GRBAS scores, and acoustic parameters (P < .05). The size of lesions had an effect on the GRBAS scores (P < .001) but not on VHI-30 scores and objective acoustic parameters (P > .05). Other factors we tested did not affect voice outcomes.

CONCLUSION

Potassium titanyl phosphate laser treatment can effectively reduce the lesion area of vocal polyps and improve the voice quality. The presence of small lesions seems to predict good subjective assessments of voice quality, but it remains to be seen whether this correlates with true voice quality.

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.

The Therapeutic Effects of Straw Phonation on Vocal Fatigue

OBJECTIVES

Straw phonation has been investigated for its vocal warm-up effects on healthy populations and therapeutic effects on voice patients. The purpose of this article was to determine whether it is beneficial for vocal fatigue.

STUDY DESIGN

Prospective cohort study METHODS: Twenty-five healthy participants were recruited into 1-hour vocal loading tasks followed by 10-minute vocal rest or straw phonation on 2 different days. Various parameters including phonation threshold pressure (PTP), mean airflow, closed quotient (CQ), current speaking effort level (EFFT), and laryngeal discomfort (DISC) were acquired at baseline, after vocal load, and after the intervention.

RESULTS

Increased PTP, EFFT, and DISC were observed after vocal load. Decreased PTP, EFFT, and DISC were then acquired after both vocal rest or straw phonation. More significant improvements were obtained in straw phonation when compared with vocal rest. Additionally, significantly increased mean flow and decreased CQ were obtained after straw phonation when compared to vocal rest.

CONCLUSIONS

Straw phonation has the potential to adjust aerodynamics within the vocal tract leading to improved vocal efficiency, optimized vibration mode, and attenuated vocal fatigue. This study provided a promising treatment for vocal fatigue that could have wide clinical relevance to voice users with high voice demands.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:E674-E679, 2020.

Management of benign vocal fold lesions: current perspectives on the role for voice therapy

PURPOSE OF REVIEW

Benign vocal fold lesions (BVFLs) cause dysphonia by preventing full vocal fold closure, interrupting vibratory characteristics and increasing compensatory muscle tension. Management includes phonosurgery, voice therapy, pharmacological treatment or more commonly a combination of these interventions. This review aims to present current perspectives on the management of BVFLs, particularly exploring the role of voice therapy.

RECENT FINDINGS

The review highlights variation in the management of BVFLs. There is evidence that phonosurgery is a well tolerated and effective intervention for BVFLs. Primary voice therapy can frequently prevent surgery in vocal fold nodules and some types of polyps. Used as an adjunct to phonosurgery, preoperative and postoperative voice therapy can improve patient-reported outcomes and acoustic parameters of the voice. However, heterogeneity of studies and poor descriptions of intervention components prevent a robust analysis of the impact of voice therapy.

SUMMARY

The current evidence consists of low-level studies using mixed aetiology groups, which compromises internal and external validity. There are a few exceptions to this. Poor reporting and heterogeneous methodologies lead to difficulties determining the components of a voice therapy intervention for this population. Consequently, we are unable to evaluate, which intervention elements are beneficial to patients.

Treatment Outcomes and Adverse Events Following In-Office Angiolytic Laser With or Without Concurrent Polypectomy for Vocal Fold Polyps

Importance

In-office angiolytic laser procedures have been used successfully as an alternative treatment for vocal fold polyps; little is known in detail about the treatment outcomes and adverse events.

Objective

To examine the outcomes and incidence rates of adverse events associated with in-office angiolytic laser procedures with or without concurrent polypectomy as an alternative treatment for vocal fold polyps.

Design, Setting, and Participants

Retrospective cohort study at a tertiary medical center. We identified 114 consecutive patients with vocal polyps who underwent in-office angiolytic laser treatments between January 1, 2014, and August 31, 2016. After the exclusion of 17 with missing or incomplete data, 97 were enrolled.

Interventions

In-office 532-nm laser procedures with or without concurrent polypectomy.

Main Outcomes and Measures

Between 1 and 2 months after the surgical procedures, we collected the following outcome data: videolaryngostroboscopy, perceptual rating of voice quality, acoustic analysis, maximal phonation time, and subjective rating of voice quality using a visual analogue scale and 10-item voice handicap index.

Results

This study enrolled 97 patients (mean [SD] age, 45.6 [11.3] years; 48 [49%] male). The mean duration of symptoms was 10.1 months (range, 1-60 months). Twenty-nine patients (30%) had angiolytic laser procedures only, while 68 (70%) received laser with concurrent polypectomy. Both treatment modalities offered significant improvements. Only 1 patient (1%) receiving angiolytic laser with concurrent polypectomy underwent another treatment session, so this group had significantly less need for multiple treatments than those receiving laser treatment alone (6 [21%]; effect size, -1.57; 95% CI, -2.77 to -0.36). We identified 8 adverse events (8% of the cases): vocal fold edema (n = 5), vocal hematoma (n = 2), and vocal ulceration (n = 1). Patients treated with laser plus concurrent polypectomy had significantly fewer adverse events than those treated with angiolytic laser alone (2 [3%] vs 6 [21%]; effect size, 1.20; 95% CI, 0.26 to 2.13).

Conclusions and Relevance

In-office angiolytic laser procedures can be an effective alternative treatment for vocal polyps, although with possible need for multiple treatment sessions and occasional occurrence of minor postoperative adverse events. Concurrent polypectomy following laser coagulation allows less laser energy delivery and reduces the risk of postoperative adverse events and the need for additional treatment sessions.

Relationship between socio-demographic characteristics and vocal fold nodules, polyps and oedema

The aim of our study was to compare socio-demographic characteristics of vocal fold nodules, polyps and oedema. The study included patients diagnosed for the first time with vocal fold nodules, polyps and oedema at the Communication Disorders Care Center of Clinic for Otorhinolaryngology and Maxillofacial Surgery in Clinical Center of Serbia, Belgrade. Diagnosis was made on the basis of symptoms, clinical otorhinolaryngological and phoniatric examination and endovideolaryngostroboscopic findings. A self-administered questionnaire was used to collect the following data: socio-demographic status, exposure to occupational noise and air pollution, occupational voice demands, health habits, symptoms of the present voice problems and voice problems in the family. By multivariate logistic regression analyses, nodules and oedema were more frequent in women than men in comparison with polyps (p < 0.001). Patients with nodules and polyps were younger than those with oedema (p < 0.001). Patients with nodules were more frequently lecturers, singers and actors compared with polyp patients (p = 0.006), had occupational voice demands more frequently than patients with oedema (p = 0.037) and were less frequently smokers than patients with polyps (p = 0.043) and those with oedema (p < 0.001). Patients with oedema were more frequently current smokers than patients with nodules and those with polyps (p < 0.001). Hoarseness as the main symptom was more frequent among patients with nodules than among patients with polyps (p = 0.040) and those with oedema (p = 0.001).Voice problems in the family was more frequently reported by oedema patients than by patients with polyps (p = 0.005). These findings are in agreement with majority of previous studies and may be of help in investigations on the aetiology of the disease.

Evaluation of Voice Quality in Patients With Vocal Fold Polyps: The Size of a Polyp Matters or Does it?

OBJECTIVE

This study aimed to investigate the correlation between morphological features of vocal fold polyps (VFPs) and subjective/objective voice parameters.

METHODS

Perceptual evaluations, aerodynamic and acoustic tests were performed on 47 patients with VFPs. Still images were captured from video and the morphological features associated with the size of VFP were quantified. To reveal the correlation between size-related morphological features (length of polyp base, the ratio of polyp base to vocal fold length, glottal gap area) and objective/subjective parameters of voice, Pearson's and Spearman's tests were carried out.

RESULTS

This cohort was composed of 30 (63.8 %) male and 17 (36.2%) female patients with the mean age of 45.2 years and 41.3 years, respectively. No correlation was found between the morphological features of VFPs and any of perceptual, aerodynamic and acoustic voice parameters.

CONCLUSIONS

Our findings indicated that controversies still exist regarding the role of vocal fold polyp morphology in clinical decision making.

Vocal Fold Polyps: Literature Review

Introduction  Vocal fold polyps are one of the most frequent benign laryngeal lesions, impacting the quality of life of those affected by them, primarily the vocal production. Despite being a well-established therapy in conjunction with surgery, speech therapy alone may also be effective in treating these lesions. As such, otolaryngologists and speech therapists need updated bibliographic knowledge on the issue. Objective  To describe the literature findings on vocal fold polyps that discuss prevalence, etiology, histology, physiopathology, vocal characteristics or treatment. Data Synthesis  The present study is a review article based on a bibliographic search using platforms, databases and search engines, with no restrictions on means of publication, methodological quality or language. All the articles on vocal fold polyps pertaining to the object of study published in the past 15 years were included. Among the characteristics investigated, the most discussed were prevalence of men, smoking as an etiological cofactor, the possibility of histological differentiation from vocal nodules, the relationship with cover minor structural alterations, and the indication and effectiveness of different treatment options. Conclusion  Despite the discrepancies found in the present literature review on vocal fold polyps, there has been a notable scientific progress in the otolaryngologic techniques and in the effectiveness of speech therapy as initial treatment, with direct and indirect techniques, corroborating the need for scientific investigation of the issue.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

Objective

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

Purpose

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

Action Statements

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

Disclaimer

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