Inhaled Corticosteroids and Voice Problems. What Is New?

Expert panel consensus recommendations on the utilization of nebulized budesonide for managing asthma and COPD in both stable and exacerbation stages in Thailand

OBJECTIVE

This study investigated the utilization of nebulized budesonide for acute asthma and COPD exacerbations as well as for maintenance therapy in adults.

DATA SOURCES

We conducted a search on PubMed for nebulized budesonide treatment.

SELECTED STUDIES

Selecting all English-language papers that utilize Mesh phrases "asthma," "COPD," "budesonide," "nebulized," "adult," "exacerbation," and "maintenance" without temporal restrictions, and narrowing down to clinical research such as RCTs, observational studies, and real-world studies.

RESULTS

Analysis of 25 studies was conducted to assess the effectiveness of nebulized budesonide in asthma (n = 10) and COPD (n = 15). The panel in Thailand recommended incorporating nebulized budesonide as an additional or alternative treatment option to the standard of care and systemic corticosteroids (SCS) based on the findings.

CONCLUSION

Nebulized budesonide is effective and well-tolerated in treating asthma and COPD, with less systemic adverse effects compared to systemic corticosteroids. High-dose nebulized budesonide can enhance clinical outcomes for severe and mild exacerbations with slow systemic corticosteroid response. Nebulized budesonide can substitute systemic corticosteroids in some situations.

Maximum Phonation Times as Biomarkers of Lung Function

PURPOSE

To verify whether measurements of maximal phonation times are biomarkers of forced vital capacity in patients with chronic obstructive pulmonary disease, and to characterize the vocal aspects of these patients, taking into account variables, such as age, body mass index, use of bronchodilators, presence of symptoms, and quality of life related to voice.

METHODS

Complete records of 25 subjects with chronic obstructive pulmonary disease, both sexes, aged 31 to 85 years, evaluated by forced vital capacity, maximum phonation times of /a/, and numerical count and number reached at this count, Vocal Symptom Scale, Voice Quality of Life. Data were presented descriptively and statistically analyzed using Student's t test for independent samples and Mann-Whitney U test. A significance level of 5% was accepted. The receiver operating characteristic curve was plotted and the standardized value of forced vital capacity <80% was considered as an indicator of pulmonary dysfunction.

RESULTS

Patients exhibited reduced maximum phonation times for /a/, numeric counting, and reached digits in counting; discrepancies in Vocal Signs and Symptoms and Voice Quality of Life Scale scores. Numeric counting times of up to 12.5 seconds indicated that forced vital capacity may be impaired.

CONCLUSION

The patients with chronic obstructive pulmonary disease examined in this study exhibited vocal deviations as evidenced by reduced maximum phonation times of /a/, numeric counting, and the digit reached during counting, as well as deviations in vocal self-assessment. Maximum phonation time in numerical counting was considered a biomarker of pulmonary function impairment.

Better Breathing, Tougher Speaking? A Scoping Review of the Effects of Inhaled Corticosteroids on the Voice Quality of Asthmatic Children

BACKGROUND

Inhaled corticosteroids (ICS) are a common treatment for certain lung diseases, including chronic obstructive pulmonary disorder in adults, and asthma across the lifespan. There is a link between the use of ICS and dysphonia in adults. This scoping review aims to investigate the incidence of dysphonia, in children aged under 12, who use ICS to treat asthma.

METHODS

A scoping review was conducted, in accordance with the guidelines prescribed by Arksey and O'Malley (2005). ASHAWire, Science Direct, PubMed, and ProQuest databases were searched. Out of the total yield of 1471 articles, four articles met the inclusion criteria, that is, were primary studies reporting on voice quality in children who use ICS, who present with asthma and/or allergy.

RESULTS

The majority of papers yielded from the initial search were retrieved because of the use of the term "dysphonia" in the basic definitions of asthma and descriptors of its side effects. Only four studies presented primary data about the presence of dysphonia in asthmatic children (with or without comorbid allergic conditions). None specifically investigated the relationship between ICS and dysphonia. Research questions focused on side effects associated with allergies and asthma, which included some information about medication. Only three of the four studies conducted a comprehensive review of the voice and utilized video laryngoscopy.

DISCUSSION

The evidence of a relationship, between ICS and dysphonia in children, is not conclusive, and is complicated by the connection between asthma, and breath support for phonation. There is a need for more thorough and focused investigation of the relationship between ICS, with or without bronchodilator use, and any resultant effects on children's vocal quality.

Voice Disorders Associated With the Use of Inhaled Corticosteroids

OBJECTIVE

Inhaled corticosteroids (ICS) have been demonstrated to be associated with voice changes. The goal was to determine the strength of the association between ICS use and a diagnosis of dysphonia made by an otolaryngologist and to determine whether inhaler particle type or medication type influenced this risk.

STUDY DESIGN

A case-control study from 2018 to 2020.

SETTING

Urban academic medical system.

METHODS

Adult patients with dysphonia diagnosed by an otolaryngologist, and control patients matched on age, gender, race, and health status, were included. Exposure to ICS was assessed, and the odds ratio (OR) of the association of ICS with dysphonia was calculated.

RESULTS

A total of 6551 cases and 6551 matched controls were included. We found that ICS use was significantly associated with dysphonia (OR: 5.11, 95% confidence interval: 4.23-6.17, p < .001). Subset analyses demonstrated no significant differences between inhaler particle types or specific active medications.

CONCLUSION

This study emphasizes the importance of identifying ICS use in the evaluation and treatment of patients with dysphonia.

Videostroboscopy and Voice Profile in Long-Term Combination Inhaler Users With Obstructive Lower Airway Disease

OBJECTIVE

Dysphonia is one of the most common side effects of long-term inhaler therapy containing corticosteroids in asthma or asthma-chronic obstructive pulmonary disease overlap (ACO) patients. This common, often reversible side effect is due to the structural changes in the vocal folds resulting from steroid deposition. This study determines the structural changes and voice profile of patients on long-term inhaler therapy by videostroboscopy and perceptual voice profile analysis. It also determines the duration, formulation, and drug delivery system producing the least side effects during therapy.

STUDY DESIGN

Prospective case-control study.

SETTING

Tertiary care hospital.

METHODS

In total, 196 patients diagnosed with moderate to severe asthma or ACO were divided into cases (patients on at least 6-month combination inhaler therapy) and controls (newly diagnosed patients not on inhaler therapy) and recruited in the study. They were assessed by videostroboscopy for structural changes and GRBAS (grade of hoarseness, roughness, breathiness, asthenia, and strain) perceptual scale for voice profile changes.

RESULTS

The prevalence of dysphonia was significantly higher in cases (62.2%) than controls (27.6%). Prevalence of laryngeal structural changes and voice profile changes were higher in cases. The prevalence of dysphonia and structural changes among cases was much lower when a spacer was used (P < .001).

CONCLUSION

This study adds evidence to the long-term side effects of combination inhaler therapy containing corticosteroids on the larynx as demonstrated by videostroboscopy and perceptual voice profile analysis. It also propagates the use of spacers in drug delivery to reduce the prevalence of side effects during long-term inhaler therapy.

Self-Perceived Handicap Associated With Dysphonia and Health-Related Quality of Life of Asthma and Chronic Obstructive Pulmonary Disease Patients: A Case-Control Study

Purpose The association between voice alterations, health-related quality of life (HRQL), and chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease (COPD), has previously been reported. The aim of this study was to test the hypothesis that HRQL and dysphonia-associated handicap of patients diagnosed with asthma or COPD are worse than healthy controls. Method A case-control study in which participants were recruited by a consecutive sampling method from a single institution was conducted. Three groups were created: (a) asthma (51 patients), (b) COPD (52 patients), and (c) 50 healthy controls. Self-reported handicap associated with dysphonia was assessed using the 30-item Voice Handicap Index (VHI-30); meanwhile, HRQL was tested via the European Quality of Life (EQ) Questionnaire and the EQ-visual analog scale. Also, aerodynamic assessment applied to phonation was assessed, and maximum phonation time and s/e index were registered. Results VHI scores were higher for asthma and COPD (7.19 ± 8.31 and 11.80 ± 15.18, respectively) than in the control group (3.72 ± 6.78). The EQ index was lower in asthma and COPD patients than in controls. The EQ-visual analog scale showed lower scores in asthma and COPD than in the controls. Conclusions HRQL was worse in COPD patients than in asthma patients. Even though the patient groups showed worse VHI and HRQL scores than the healthy controls, the scores fell within the normal variation range. No significant variations in the maximum phonation time index between groups were noted.

Effects of Humidification of the Vocal Tract and Respiratory Muscle Training in Women With Voice Symptoms-A Pilot Study

OBJECTIVE

The aim of this study was to determine the efficacy of a 4-week breathing exercise intervention in participants with voice symptoms.

METHODS

Six nonsmoking women (mean age 49) experiencing voice symptoms used a novel device WellO₂ for respiratory exercises that provides counter pressure during both inspiration and expiration and warms and humidifies the breathing air. Speech samples were acoustically (Acoustic Voice Quality Index) and perceptually (grade, roughness, breathiness, asthenia, and strain scale) analyzed, and perceived voice symptoms and self-reported effort in breathing and phonation were obtained. Respiratory measurements included breathing frequency and pattern, peak expiratory flow, forced vital capacity, and forced expiratory volume in 1 minute.

RESULTS

The total scores of Acoustic Voice Quality Index and some of its subcomponents (shimmer and harmonic-to-noise ratio), and the grade, roughness, and strain of the GRBAS scale indicated significantly improved voice quality. However, neither the nature or frequency of the experienced voice symptoms nor the perceived phonatory effort changed as the function of intervention. According to the participants, their breathing was significantly less effortful after the intervention, although no significant changes were observed in the objective respiratory measurements with a spirometer.

CONCLUSION

Training with the WellO₂ device has the potential to improve voice quality. The combination of inspiratory and expiratory training and warmed, humidified air is a multifaceted entity influencing several parts in the physiology of voice production. The effects of using WellO₂ need to be confirmed by further studies with a larger number of participants.

The Role of Allergy in Phonation

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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