Unilateral Vocal Fold Paralysis: A Systematic Review of Speech-Language Pathology Management

Noninvasive Management of Voice Disorders: An Umbrella Review

OBJECTIVES

The aim of this study was to assess published systematic reviews that discussed noninvasive management of voice disorders. An umbrella review was conducted to collect, organize, and summarize narratively all available pharmacologic and voice therapy interventions.

STUDY DESIGN

Umbrella review of systematic reviews.

METHODS

Pertinent systematic reviews were identified by searching Pubmed/Medline and Embase. A primary screen identified studies related to voice. The second round of screening focused on studies that involved noninvasive management of voice disorders such as pharmacologic or voice therapy interventions. Variables of interest included study design, number of studies included in the review, target population, method of intervention, and outcomes.

RESULTS

Forty-three systematic reviews were eligible and included in the umbrella review. Ten studies focused on pharmacologic interventions, and 33 studies focused on voice therapy. Individual studies included in the systematic reviews ranged from 2-47, with a total of 601 studies overall.

CONCLUSIONS

This study provides a detailed review of all available systematic reviews on noninvasive management of voice disorders. Explored medications included proton pump inhibitors, calcium channel blockers, tricyclic antidepressants, antibiotics, corticosteroids, and hormone replacement. Explored voice therapy techniques included hydration, vocal function exercises, laryngeal manual therapy, respiratory exercise, biofeedback, phonation, coping strategies, and others. This may be utilized to guide therapeutic decision-making and identify current gaps in the literature that may warrant future investigation.

Immediate effect of recurrent laryngeal nerve stimulation in patients with idiopathic unilateral vocal fold paralysis

BACKGROUND

There is a lack of effective treatment for idiopathic unilateral vocal fold paralysis (IUVFP). A better phonation was reported by patients after laryngeal nerve stimulation during our clinical examination.

OBJECTIVES

This study aims to investigate immediate effect of recurrent laryngeal nerve (RLN) stimulation on phonation in patients with IUVFP.

MATERIAL AND METHODS

Sixty-two patients with clinically identified IUVFP underwent RLN stimulation with needle electrodes. Laryngoscopy, acoustic analysis, and voice perception assessment were performed for quantitative comparison of vocal function and voice quality before and after the intervention.

RESULTS

Laryngoscopic images showed a larger motion range of the paralyzed vocal fold (p < .01) and better glottal closure (p < .01) after RLN stimulation. Acoustic analysis revealed that the dysphonia severity index increased significantly (p < .01) while the jitter and shimmer decreased after the intervention (p < .05). According to perceptual evaluation, RLN stimulation significantly increased RBH grades in patients with IUVFP (p < .01). Furthermore, the improvement in voice perception had a moderate positive correlation with the decrease in the glottal closure.

CONCLUSIONS AND SIGNIFICANCE

This study shows a short-term improvement of phonation in IUVFP patients after RLN stimulation, which provides proof-of-concept for trialing a controlled delivery of RLN stimulation and assessing durability of any observed responses.

Electrical Stimulation of Vocal Fold Adduction Triggered by Laryngeal Electromyography Using a Custom Implant

PURPOSE

Medialization procedures for unilateral vocal fold (VF) paralysis generally improve voice but do not fully replace dynamic VF adduction. Paralyzed VFs typically experience synkinetic reinnervation, which makes it feasible to elicit movement through electrical stimulation. We tested a novel laryngeal pacing implant capable of providing closed-loop (automatic) stimulation of a VF triggered by electromyography (EMG) potentials from the contralateral VF.

METHOD

A custom, battery-powered, microprocessor-based stimulator was tested in eight dogs with bipolar electrodes implanted for recording EMG from the left VF and stimulating adduction of the right VF. A cuff electrode on the left recurrent laryngeal nerve (RLN) stimulated unilateral VF adduction, modeling voluntary control in anesthetized animals. Closed-loop stimulation was tested in both acute and chronic experiments. Synkinetic reinnervation was created in two animals by right RLN transection and suture repair to model unilateral VF paralysis.

RESULTS

In all animals, left VF activation through RLN stimulation generated a robust EMG response that rapidly triggered stimulation of contralateral thyroarytenoid and lateral cricoarytenoid muscles, causing nearly simultaneous bilateral adduction. Optimal triggering of VF stimulation from elicited EMG was achieved using independent onset and offset thresholds. Real-time artifact blanking allowed closed-loop stimulation without self-perpetuating feedback, despite the proximity of recording and stimulation electrodes.

CONCLUSIONS

Using a custom implant system, we demonstrated real-time closed-loop stimulation of one VF triggered by the activation of the contralateral VF. This approach could potentially restore dynamic glottic closure for reflexive behaviors or phonation in cases of unilateral VF paralysis with synkinetic reinnervation.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24492133.

Effect of Practice Structure and Feedback Frequency on Voice Motor Learning in Older Adults

OBJECTIVES

The long-term goal of this research is to advance the rehabilitation of voice disorders through the study and development of efficacious treatment regimes based upon motor learning principles. This study examined the effect of contextual interference (CI) of practice structure with knowledge of results (KR) feedback on motor learning of a novel voice task, "Twang," by hypophonic, novice, and expert older adults.

STUDY DESIGN

Prospective, randomized controlled mixed design.

METHODS

A total of 92 adults, age 55-80, recruited from the following motor skill levels: 1) Hypophonic voice; 2) Novice-untrained vocalists; 3) Expert-trained vocalists were randomly assigned to four different interventions and examined during acquisition, retention, and transfer phases of motor learning. Participants from each skill-level practiced the novel task, "Twang," according to the randomly assigned Practice Structure/KR combinations: 1) Blocked practice/100%KR; 2) Blocked practice/55% KR; 3) Random practice/100%KR; 4) Random practice/55% KR.

RESULTS

During the motor performance phase, our results mirrored those reported in the limb motor learning literature for CI: A Blocked practice structure enhanced short-term effects of motor acquisition for novice, expert, and hypophonic subjects. The only significant result for KR occurred when paired with Random Practice in the hypophonic subject group: 100% KR paired with Blocked practice increased motor performance, but degraded motor learning.

CONCLUSIONS

Fundamental motor learning principles were explored within the context of a voice training paradigm. Practice with a high CI and low frequency of KR degraded performance during short-term acquisition but enhanced long-term performance effects of motor learning. Voice clinicians and teachers may benefit by implementing motor learning theory into practice during training and treatment sessions.

Clinical Experiences of Speech-Language Pathologists in the Rehabilitation of Unilateral Vocal Fold Paralysis

PURPOSE

Unilateral vocal fold paralysis (UVFP) is a neurological voice disorder that is often first treated by a speech-language pathologist (SLP). In literature, little consensus is found regarding voice therapy onset, duration, frequency, and content. The aim of the current study is to investigate the clinical practice of SLPs for treatment of UVFP regarding diagnostics and treatment characteristics. Additionally, the study examined the personal experiences of SLPs regarding UVFP care.

METHOD

An online survey was completed by 37 respondents, all SLPs with experience in treating UVFP. Demographic characteristics, experiences with voice assessments and treatment modalities were examined. Lastly, experiences and opinions of SLPs on evidence-based practice and their own clinical practice were surveyed.

RESULTS

Almost all respondents used a multidimensional voice assessment with findings from laryngovideostroboscopy to assess UVFP. Laryngeal electromyography is not yet integrated in regular clinical practices. The most commonly used vocal techniques were resonant voice exercises, laryngeal manipulation, semioccluded vocal tract exercises (SOVTEs), vocal hygiene, and Vocal Function Exercises, with SOVTEs most often considered effective. A total of 75% of the respondents feel confident treating UVFP, and 87.6% believe it is important to stay updated on evidence-based practice. Variation in therapy timing and dosage was observed, and 48.4% of SLPs usually started early voice therapy within 4 weeks after UVFP onset.

CONCLUSION

Flemish SLPs generally feel confident treating UVFP patients and show interest in improving evidence-based practice. Initiatives to train clinicians further in UVFP care and encouraging SLPs to provide practice-based evidence will enhance the knowledge base for evidence-based practice in UFVP.

Acoustic-Aerodynamic Voice Outcome Ratios Identify Changes in Vocal Function Following Vocal Fold Medialization for Unilateral Vocal Fold Paralysis

PURPOSE

This study aimed to determine whether ratio-based measures that combine acoustic (output) and aerodynamic (input) parameters detect postoperative change in vocal function following vocal fold medialization for unilateral vocal fold paralysis.

METHOD

Pre- and postoperative acoustic and aerodynamic measures were analyzed retrospectively from 149 patients who underwent vocal fold medialization for unilateral vocal fold paralysis. A 2 × 2 repeated-measures analysis of variance was conducted for each of four acoustic-aerodynamic ratios-traditional vocal efficiency (VE), sound pressure level to aerodynamic power (SPL/AP), SPL to average airflow (SPL/AFLOW), and SPL to subglottal pressure (SPL/Ps)-to investigate the main effects and interaction of treatment stage and loudness level (comfortable and loud).

RESULTS

The patient group showed significant postoperative improvements in self reports of vocal function (voice-related quality of life) and clinical auditory-perceptual judgments of dysphonia (consensus auditory-perceptual evaluation of voice). Main effects for both treatment stage and loudness level were statistically significant for all measures except SPL/Ps. There were interaction effects for VE and SPL/AP, suggesting that magnitude of the treatment effect differs based on loudness. SPL/AFLOW had medium-to-large effect sizes in both loudness conditions. There were postoperative changes in SPL/Ps that were dependent on the magnitude of the reduction in AFLOW; as expected, SPL/Ps increased postoperatively in a subgroup that had large postoperative reductions in AFLOW at the comfortable loudness level.

CONCLUSIONS

Acoustic-aerodynamic ratios can aid in tracking changes in vocal function following vocal fold medialization. SPL/AFLOW exhibited the largest effect size, which is expected since a reduction in abnormally high AFLOW typically accompanies the increased modulation of glottal air flow associated with successful vocal fold medialization. Future study is needed to model physiological changes in acoustic-aerodynamic voice outcome ratios across different types of voice disorders.

Treatment of relapsing functional and organic dysphonia: a narrative literature review

Information about failure and relapses is critical in deciding whether and how to treat a given condition, as well as during patient counselling before therapy. This paper aims to perform a non-systematic review of relapses and failure of dysphonia treatment in the adult population. Studies on failure and relapses after treatment of benign vocal fold lesions, functional dysphonia and neurogenic dysphonia were analysed. The frequency and the duration of follow-up were heterogeneous, and the management of relapses was reported in only a portion of the studies. Relapses after surgical treatment of benign vocal fold lesions ranged between 1% and 58% of cases, and their management was mainly surgical. Rates of relapse after voice therapy for functional dysphonia and spasmodic dysphonia were 12%-88% and 8%-63%, respectively. Rates of relapse after surgical treatment for unilateral and bilateral vocal fold paralysis were 10%-39% and 6%-25%, respectively; treatment was mainly represented by surgical revision. In conclusion, failure and relapses of functional and organic dysphonias after therapy are not rare, but treatment modalities are seldomly reported. The data from this non-systematic review stresses the need for further research in this area.

Brain adaptation following various unilateral vocal fold paralysis treatments: A magnetic resonance imaging based longitudinal case series

Aim

Examination of central compensatory mechanisms following peripheral vocal nerve injury and recovery is essential to build knowledge about plasticity of the neural network underlying phonation. The objective of this prospective multiple-cases longitudinal study is to describe brain activity in response to unilateral vocal fold paralysis (UVFP) management and to follow central nervous system adaptation over time in three patients with different nervous and vocal recovery profiles.

Materials and methods

Participants were enrolled within 3 months of the onset of UVFP. Within 1 year of the injury, the first patient did not recover voice or vocal fold mobility despite voice therapy, the second patient recovered voice and mobility in absence of treatment and the third patient recovered voice and vocal fold mobility following an injection augmentation with hyaluronic acid in the paralyzed vocal fold. These different evolutions allowed comparison of individual outcomes according to nervous and vocal recovery. All three patients underwent functional magnetic resonance imaging (fMRI task and resting-state) scans at three (patient 1) or four (patients 2 and 3) time points. The fMRI task included three conditions: a condition of phonation and audition of the sustained [a:] vowel for 3 s, an audition condition of this vowel and a resting condition. Acoustic and aerodynamic measures as well as laryngostroboscopic images and laryngeal electromyographic data were collected.

Results and conclusion

This study highlighted for the first time two key findings. First, hyperactivation during the fMRI phonation task was observed at the first time point following the onset of UVFP and this hyperactivation was related to an increase in resting-state connectivity between previoulsy described phonatory regions of interest. Second, for the patient who received an augmentation injection in the paralyzed vocal fold, we subsequently observed a bilateral activation of the voice-related nuclei in the brainstem. This new observation, along with the fact that for this patient the resting-state connectivity between the voice motor/sensory brainstem nuclei and other brain regions of interest correlated with an aerodynamic measure of voice, support the idea that there is a need to investigate whether the neural recovery process can be enhanced by promoting the restoration of proprioceptive feedback.

Demographic differences in the treatment of unilateral vocal fold paralysis

Objective

To determine the impact of patient demographics and social determinants of health on treatment pathways for unilateral vocal fold paralysis (UVFP) at a tertiary laryngology clinic.

Study design

Retrospective medical record review.

Methods

Patient demographics (age, gender, race, ethnicity, and insurance status) were extracted for adults diagnosed with UVFP between 2009 and 2019. Odds ratios for the associations between sociodemographic factors and UVFP treatment pathways were determined by chi-square analyses.

Results

A total of 1490 UVFP diagnoses were identified during the study period with the majority being female (58%), White (85%), non-Hispanic (97%), and publicly insured (54%). Five treatment pathways were identified: observation, injection laryngoplasty, voice therapy, laryngeal framework surgery/thyroplasty, and reinnervation surgery. There were 538 patients who underwent observation, 512 injection laryngoplasty, 366 voice therapy, 136 thyroplasty, and 26 laryngeal reinnervation surgery. Males were more likely to undergo injection laryngoplasty than females (OR 1.32; CI 1.08-1.61), whereas females were more likely to undergo voice therapy (OR 1.39; CI 1.09-1.76). Patients with public insurance (OR 1.48; CI 1.03-2.14) and Hispanics (OR 2.60; CI 1.18-5.72) were more likely to undergo thyroplasty. Patients who underwent reinnervation surgery were younger than those in other treatment pathways (median: 39.1 years vs. 50.7-56.1 years).

Conclusions

Gender, ethnicity, and insurance status were significantly associated with specific UVFP treatment pathways. Patients with public insurance were more likely to undergo surgical intervention than voice therapy. This data overall supports differences in care pathway utilization for UVFP based on social determinants of health.

Level of evidence

Level IV.

Multicenter Development and Validation of the Vocal Cord Paralysis Experience (CoPE), a Patient-Reported Outcome Measure for Unilateral Vocal Fold Paralysis-Specific Disability

Importance

Unilateral vocal fold paralysis (UVFP) is a common and life-changing complication of cancer, trauma, and an estimated 500 000 head, neck, and chest surgeries performed annually in the US, among other causes (eg, idiopathic). Consequent disabilities are profound and often permanent and can include severe voice, swallowing, and breathing dysfunction and concomitant anxiety, isolation, and fear. Physiological measures often correlate poorly with patient-reported disability. The measure described herein was designed to be a comprehensive, psychometrically sound UVFP-specific patient-reported outcome measure (PROM) for use in clinical trials or at point of care.

Objective

To evaluate the reliability and validity of the CoPE (vocal Cord Paralysis Experience) PROM in a nationally representative sample for both clinical and research use.

Design, Setting, and Participants

This survey validation study was performed at 34 tertiary care centers across the US and included English-speaking adults with unilateral vocal fold immobility confirmed via laryngoscopy.

Main Outcomes and Measures

Reliability (internal consistency, alternate form, and test-retest) and validity (convergent and known-group).

Results

In total, 613 patients (mean [SD] age, 58 [15.3] years; 394 [64.5%] women) were recruited, and 555 (92.3%) completed surveys for all time points. Internal consistency was high in the overall 22-item PROM and psychosocial, swallow, and voice subscales (Cronbach α > 0.91). Intraclass correlations for individuals between the baseline and 2-week administrations were moderate for the overall score and subscales (intraclass correlations range, 0.66-0.80). There were significant differences between the online and 2-week paper administrations for the overall score and voice and psychosocial subscales (overall scale mean: 54.4 [95% CI, 49.7-59.1] vs 48.9 [95% CI, 43.7-54.0] at 2 weeks). The confirmatory model was found to be suitably fitted based on average r2 values 0.5 or greater for subscale and overall scores. Correlations between subscales and existing PROMs (Voice-Related Quality of Life, Eating Assessment Tool, and Communication Participation Item Bank) were all greater than 0.69, and mean PROM subscale scores were significantly different across known quartiles of existing PROMs.

Conclusions and Relevance

The findings of this survey validation study suggest that the CoPE PROM could serve as a psychometrically sound, comprehensive measure of UVFP-attributed disability suitable for use in clinical and research settings to assess within-person changes. The results will inform a user manual to facilitate use in clinical trials comparing the effectiveness and durability of treatments including behavioral (speech therapy), temporary (eg, injection augmentation), and permanent surgical treatments for UVFP.

Long‐term results and safety of fibroblast growth factor injection for unilateral vocal fold paralysis

Objectives

Treatments for unilateral vocal fold paralysis (UVFP) include conservative voice rehabilitation, vocal fold injection, and laryngeal framework surgery. We proposed basic fibroblast growth factor (bFGF) injection as a potential novel treatment for UVFP and have reported the short‐term results. In this study, we present the long‐term results and safety of vocal fold bFGF injection as a treatment for UVFP.

Methods

This retrospective study included 42 patients (25 males and 17 females) with UVFP who were administered a local injection of bFGF. The injection regimen involved injecting FGF (0.5 μg/ml in 0.5 ml per side) into the bilateral vocal folds using a 23‐gauge injection needle. Phonological outcomes were evaluated 6 months and 12 months after the injection.

Results

Overall, 26 patients received a single injection of bFGF, six patients received an additional injection, and 10 patients received the additional framework surgery. Maximum phonation time, mean flow rate, pitch range, jitter and shimmer percentages, the total GRBAS (grade, roughness, breathiness, asthenia, strain) score, and voice handicap index scores improved significantly in the long term. In patients who received the additional injection or framework surgery, the effects of bFGF injection were temporary, but did not interfere with the performance of the framework surgery.

Conclusion

In total, 42 patients who underwent vocal fold bFGF injections were reviewed. The bFGF injections were effective and safe in the long‐term results for UVFP in the selected cases. Some patients with severe symptoms benefited from the additional framework surgery but not the additional bFGF injection.

Lipoinjection for Unilateral Vocal Fold Paralysis Treatment: A Systematic Review and Meta-Analysis

INTRODUCTION

Lipoinjection is one of the available treatments for unilateral vocal fold paralysis.

OBJECTIVE

To evaluate lipoinjection predictability, and analyze the differences in safety and efficacy of the different techniques.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS AND RESULTS

A systematic review on Medline, Cochrane, and Scopus databases included 49 articles analyzing the data of 1,166 patients, concerning technical details and voice parameters changes. Lipoinjection used a mean volume of 1.3 mL, 95% confidence interval (CI) (0.92, 1.69)-average overcorrection of 30%. Meta-analysis of pre- and postoperative voice parameters' means showed a significant improvement at 6 months of mean phonation time (preoperative: 5.12, 95% CI [4.48, 5.76]-6 months: 10.46, 95% CI [9.18, 11.75]), Jitter (preoperative: 2.71, 95% CI [2.08, 3.33])-6 months: 1.37, 95% CI [1.05, 1.70]), Shimmer (preoperative: 4.55, 95% CI [3.04, 6.07]-6 months: 2.57, 95% CI [1.69, 3.45]), grade (preoperative: 2.15, 95% CI [1.73, 2.57]-6 months: 0.12, 95% CI [0.97, 1.43]), breathiness (preoperative: 2.012, 95% CI [1.48, 2.55]-6 months: 0.99, 95% CI [0.58, 1.40]), and asthenia (preoperative: 1.90, 95% CI [1.33, 2.47]-6 months: 0.75, 95% CI [0.17, 1.33]) of GRBAS (Grade, Roughness, Breathiness, Asthenia and Strain), and Voice Handicap Index-30 (preoperative: 72.06, 95% CI [54.35, 89.76]-6 months: 26.24, 95% CI [19.58, 32.90]). Subgroup analysis by harvesting technique concluded in no statistically significant difference between them. Few complications were reported. Reintervention was only required for 86 patients.

CONCLUSION

Lipoinjection seems a safe therapeutic option for unilateral vocal fold paralysis, with available data showing an efficacy lasting 6 months to 1 year. Laryngoscope, 2021.

Guidelines for the Management of Unilateral Vocal Fold Paralysis From the Korean Society of Laryngology, Phoniatrics and Logopedics

The Korean Society of Laryngology, Phoniatrics and Logopedics appointed a task force to establish clinical practice guidelines for the management of unilateral vocal fold paralysis (UVFP). These guidelines cover a comprehensive range of management-related factors, including the diagnosis and treatment of UVFP, and provide in-depth information based on current, up-to-date knowledge. Detailed evidence profiles are provided for each recommendation. The CORE databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers, using a predefined search strategy. When insufficient evidence existed, expert opinions and Delphi questionnaires were used to fill the evidence gap. The committee developed 16 evidence-based recommendations in six categories: initial evaluation (R1–4), spontaneous recovery (R5), medical treatment (R6), surgical treatment (R7–14), voice therapy (R15), and aspiration prevention (R16). The goal of these guidelines is to assist general otolaryngologists and speech-language pathologists who are primarily responsible for treating patients with UVFP. These guidelines are also intended to facilitate understanding of the condition among other health-care providers, including primary care physicians, nurses, and policy-makers.

Speech Pathology Utilization and Stroboscopy Before and After Adult Medialization Laryngoplasty

OBJECTIVES

Evaluation of trends and utilization of speech-language-pathology (SLP) services, including stroboscopy, before and after medialization laryngoplasty (ML) over 11 years.

METHODS

Retrospective national US database study conducted using OptumLabs Data Warehouse. Study cohort included patients (age ≥18 years) who underwent ML between January 2007 and December 2016. Primary outcomes were rates of SLP visits in the 12 months before and 12 months after ML. Linear regression analysis was performed assessing for trends utilization across years. Secondary outcomes were predictors of utilization After-ML using multivariable logistic regression.

RESULTS

1114 patients met criteria. Services, including stroboscopy, were utilized by 774 (69%) Before-ML and 697 (63%) After-ML. SLP services, excluding stroboscopy, were utilized by 512 (46%) Before-ML and 478 (43%) After-ML. Vocal cord paralysis was the most common diagnosis, 945 (84.8%) patients. Other service billed were stroboscopy, [Before-ML 676 (60.7%); After-ML 567 (50.9%)], voice evaluation [Before-ML 431(38.7%); After-ML 366 (32.9%)], voice therapy [Before-ML 309 (27.7%); After-ML 339 (30.4%)], laryngeal function studies, [Before-ML 175 (15.7%); After-ML 164 (14.7%)], swallow evaluations [Before-ML 150 (13.5%); After-ML 90 (8.1%)], and swallow therapy [Before-ML 53 (4.8%); After-ML 47 (4.2%)]. SLP utilization Before-ML predicted SLP utilization After-ML [Odds Ratio (95% Confidence Interval): 9.31 (6.78, 12.77)]. Nearly half (49%) of visits occurred in the 6 months around ML. Of those who had voice therapy, the majority (73.7%) had a total of 1 to 5 sessions.

CONCLUSION

Based on this retrospective US national database study, SLP services and stroboscopy are a complementary component of assessment and treatment of patients who undergo ML with the majority of services occurring in the 3 months before and after ML. Future work would benefit from outcome data.

A panel of jitter/shimmer may identify functional dysphonia at risk of failure after speech therapy

BACKGROUND

There are no reliable outcome predictors for functional dysphonia (FD) patients.

OBJECTIVES

To investigate if any clinical or phoniatric characteristics could identify FD patients at risk of negative outcome after speech therapy.

METHODS

We retrospectively reviewed the results of 78 FD patients treated with the proprioceptive elastic method. Before and one-month after therapy, patients underwent endoscopy, acoustic analysis with Multi-Dimensional Voice Program, and Voice Handicap Index-10 questionnaire (VHI-10). Negative outcome was the persistence of VHI-10 ≥ 13.

RESULTS

26 FD patients had negative outcome (i.e. VHI-10 ≥ 13) after speech therapy. At univariate analysis, clinical variables (i.e. sex, age, comorbidities, dysphonia duration, and professional voice use) were not associated with the outcome. Elevated Jitter% (Jitt; p = 0.03), Shimmer% (Shim; statistical trend, p = 0.06), and Noise to Harmonics Ratio (statistical trend, p = 0.06) were found in patients with poor results. At multivariate analysis, higher Jitt was an independent negative prognostic factor (p = 0.02), while a statically trend was identified for Shim (p = 0.06). A panel of Jitt >1.5 and Shim >5.1 showed an acceptable discriminatory power (AUC [ROC] = 0.76) according to Hosmer and Lemeshow scale.

CONCLUSION

A panel of two acoustic analysis parameters could help in identifying FD patients at risk of speech therapy failure. Further studies in these patients are needed to evaluate the most efficient treatment protocol.

The effectiveness of voice therapy on voice-related handicap: A network meta-analysis

BACKGROUND

Treatment approaches for voice therapy are diverse, yet their differential effects are not well understood. Evaluations of treatment effects across approaches are important for clinical guidance and evidence-based practice.

OBJECTIVE OF REVIEW

To quantify the evidence of treatment effectiveness on the outcome measure Voice Handicap Index with the 30-items (VHI-30) from existing randomised controlled/clinical trials (RCT) of voice therapy using the statistical approach of a network meta-analysis (NMA) with a random effects model.

TYPE OF REVIEW

Meta-analysis.

SEARCH STRATEGY

We searched in MEDLINE (PubMed, 1950 to 2019), Embase (1974 to 2019) and Science Citation Index (1994 to 2019) using five key terms. The inclusion criteria were reports of randomised controlled/clinical trials (RCTs) published in English or German which evaluated the effectiveness of a specific voice therapy treatment using VHI-30 as an outcome measure in adult participants with non-organic or organic voice disorders. Studies were excluded if participants had been diagnosed with neurological motor speech disorders or who were vocally healthy. Furthermore, no medical, pharmacological or instrumental (eg voice amplification) treatments were considered.

EVALUATION METHOD

The primary outcome variable was VHI-30 with a score from 0 to 120. The pre-post treatment change in VHI-30 scores was an average score of 13 points related to various VHI-30 test-retest results.

RESULTS

We retrieved 464 publications (ie with duplicates) and included 13 RCTs, which evaluated nine interventions, in the final analysis. The most effective intervention with a significant and clinically relevant effect was Stretch-and-Flow Phonation (SFP) (mean pre-post difference -28.37, 95% confidence interval [CI], -43.05 to-13.68). Resonant Voice (RV), the Comprehensive Voice Rehabilitation Program (CVRP) and Vocal Function Exercises (VFE) also demonstrated significant improvements.

CONCLUSIONS

Of the nine voice interventions identified with the present NMA, SFP, RVT, CVRP, and VFE effectively improved VHI-30 scores from pre- to post-treatment. SFP proved to be the most significant and clinically relevant treatment. Further contributions of high-quality intervention studies are needed to support evidence-based practice in vocology.

Predictors of Voice Therapy Initiation: A Cross-Sectional Cohort Study

OBJECTIVES/HYPOTHESIS

To determine predictors of voice therapy initiation.

STUDY DESIGN

Cross-sectional cohort study.

METHODS

All patients were evaluated in an interdisciplinary model at the University of Wisconsin Voice and Swallow Clinics between June 2016 and October 2017. Patients were eligible if they were diagnosed with a voice disorder and recommended for voice therapy as the only treatment. The dependent variable was attendance in at least once voice therapy session. Independent variables included therapeutic alliance, measured using the Session Rating Scale, and patient- and disease-related factors. These factors included gender, age, distance to the clinic, education level, household composition, occupational voice demand, Voice Handicap Index score, auditory-perceptual dysphonia severity (Grade, Roughness, Breathiness, Asthenia, Strain), and medical voice diagnosis.

RESULTS

Ninety-five patients were enrolled in the study. Voice therapy initiation rate was 70%. Having fewer school-aged children (5-18 years) in the household was significantly different between the group that initiated voice therapy and the group that did not (P = 0.048). There was no difference between groups for all other factors.

CONCLUSIONS

This investigation suggests that household composition, specifically having fewer school-aged children in the household, may predict initiation of voice therapy. This study confirms in a prospective fashion the absence of relationship between voice therapy initiation and most patient- and disease-related factors. Therapeutic alliance should be further investigated for its ability to predict voice therapy initiation using a measure that is validated for the population of patients with dysphonia.

Efficacy of speech language therapy intervention in unilateral vocal fold paralysis - a systematic review and a meta-analysis of visual-perceptual outcome measures

OBJECTIVE

Unilateral vocal folds paralysis is a disorder that affects a patient's quality-of-life by disturbing their phonation, breathing, and swallowing activities. This systematic review aimed to estimate the efficacy of voice treatment on the vocal fold motility in adult patients with unilateral vocal folds paralysis.

METHODS

PubMed, CINAHL, CENTRAL, and Web of Science were searched for retrospective and prospective cohort, case-control, and cross-sectional with comparative studies with adults that were published between 1 January 2008 to 31 December 2018. After applying the inclusion and exclusion criteria a total of 10 studies containing morpho-functional evaluation results were included in the analysis. Pooled data analysis of the motility of the vocal folds before and after voice therapy allowed inferring about the efficacy of voice therapy intervention in patients with unilateral vocal folds paralysis. A random-effect model was used to estimate the effect size. Publication bias was considered.

RESULTS

The pooled data analysis of the visual-perceptual measures revealed that vocal fold motility improved in 72% (95% CI: 64.0-80.0) of all patients after the therapeutic interventions. The inconsistency index (I² = 18.35%) of the studies included in this meta-analysis revealed an extremely low heterogeneity. Funnel plot and Cochran's Q test showed no publication bias. The systematic review was limited to only English language articles.

CONCLUSION

This meta-analysis supports the evidence that voice therapy intervention can have a positive effect on the vocal fold motility, that is, they can improve the glottal gap closure, irrespective of the exercises and techniques used.

Impact of patient-related factors on successful autologous fat injection laryngoplasty in thyroid surgical treated related unilateral vocal fold paralysis- observational study

The aim of this study was to compare major voice indicators in different sub-categories, the outcome of lipoinjection for patients might be refined and some voice prognostic factors could be more particularized in specific sub-groups. This is an observational study, and sub-grouped UVFP patients into 3 categories: male vs female, BMI ≥ 24 vs BMI < 24, Age ≥ 60 vs Age < 60 for more detailed exploring whether sub-categories affected voice diagnostic and prognostic parameters. Patients' voice data is recorded before and after the autologous fat injection laryngoplasty by a multidimensional voice program. Overall, 73 patients' voice performance were improved 12 months later by vocal fold lipoinjection. In the comparison of the male with female revealed female obtained better Jita than male by surgery (Female: 174.50 ± 100.58 Hz; Male: 294.82 ± 253.65 Hz; P < .05). BMI ≥ 24 vs BMI < 24 showed no statistical difference. Patients aged under 60 demonstrated better Highest F0, lowest F0, NHR and ShdB than elder ones 12 months after receiving vocal fold lipoinjection. Thus, Noise-to-harmonics ratio (NHR), voice turbulence index (VTI), and ShdB (Absolute shimmer, dB) may be the major post-operative evaluating markers of patients' age under 60. Voice parameters showed no significant correlation with BMI. Female patients performed lower Jita (Absolute jitter, μsec) than male patients 1 year after receiving treatment. The experimental results in this study showed UVFP patients' gender and age may stand as significant categories on analyzing clinical voice prognostic indicators, ShdB and Jita of autologous injection laryngoplasty.

Efficacy of trans-nasal fiberendoscopic injection laryngoplasty with centrifuged autologous fat in the treatment of glottic insufficiency due to unilateral vocal fold paralysis

SUMMARY

The objective of this work is to evaluate the safety, feasibility and efficacy of trans-nasal fiberendoscopic injection laryngoplasty (IL) with centrifuged autologous fat, performed under local anaesthesia, in the treatment of glottic insufficiency due to unilateral vocal fold paralysis (UVFP). It is a within-subject study with follow-up 1 week after phonosurgery and after 6 months. A total of 22 patients with chronic dysphonia caused by glottic insufficiency due to UVFP were enrolled. Each patient underwent trans-nasal IL with centrifuged autologous fat through flexible operative endoscope under local anaesthesia and was evaluated before and twice (1 week and 6 months) after phonosurgery, using a multidimensional set of investigations. The assessment protocol included videolaryngostroboscopy, perceptual evaluation of dysphonia, maximum phonation time and patient's self-assessment on voice-related quality of life (QOL) with the Voice Handicap Index-10 and the comparative self-assessment on vocal fatigue and voice quality pre-post treatment. Trans-nasal IL with centrifuged autologous fat was performed in all 22 patients and there were no complications in any case. Significant improvements in videolaryngostroboscopic findings, perceptual evaluation of dysphonia, maximum phonation time and QoL self-assessment were reported after 1 week and were maintained at 6 months. In one patient, the result after 6 months was not satisfactory and this patient then underwent a medialization laryngoplasty (thyroplasty type I) with satisfactory long-term results. In conclusion, trans-nasal fiberendoscopic IL with centrifuged autologous fat seems to be a safe, feasible and efficacious phonosurgical procedure for treatment of glottic insufficiency due to unilateral vocal fold paralysis.

Predicting the Outcome of Unilateral Vocal Fold Paralysis: A Multivariate Discriminating Model Including Grade of Dysphonia, Jitter, Shimmer, and Voice Handicap Index-10

OBJECTIVES

The aim of this study was to investigate if any clinical and phoniatric characteristics or quality-of-life measures could predict the outcome of unilateral vocal fold paralysis (UVFP) initially managed with speech therapy.

METHODS

Forty-six patients with UVFP were evaluated using laryngostroboscopy, the GIRBAS (grade, instability, roughness, breathiness, asthenia, and strain) scale, acoustic analysis, and the Voice Handicap Index-10 (VHI-10) questionnaire. Treatment was speech therapy according to a 3-phase protocol. The main outcome measure was incomplete vocal fold mobility 12 months after symptom onset. Univariate and multivariate modeling ( k-nearest neighbors model) were applied.

RESULTS

Fifteen patients had incomplete motion recovery 12 months after the onset of UVFP. On univariate analysis, time to diagnosis (0.01), global grade of dysphonia (0.018), jitter (0.01), shimmer (0.012), and VHI-10 score (0.006) were associated with the outcome of vocal fold paralysis. Using a k-nearest neighbors multivariate discriminating model, the best discrimination of UVFP outcome was achieved with 4 parameters: global grade of dysphonia 2 or 3, jitter > 2.46%, shimmer > 6.97%, and VHI-10 score > 13. The model's misclassification rate for incomplete motion recovery was only 6%. The model showed sensitivity of 93% and specificity of 74%.

CONCLUSIONS

Delayed diagnosis and speech therapy was associated with negative outcomes. Higher grade of dysphonia, jitter, shimmer, and VHI-10 score on initial phoniatric assessment may help clinicians in predicting the outcomes of UVFP patients.

Perspectives on voice treatment for unilateral vocal fold paralysis

PURPOSE OF REVIEW

Unilateral vocal fold paralysis (UVFP) is a common cause of neurogenic dysphonia resulting in glottal insufficiency. To restore glottal sufficiency and reduce the presenting dysphonia, treatment involving either surgical intervention, voice therapy or a combination of the two is typically provided. Currently, there is no consensus for the most effective voice treatment for UVFP. This results in an inability to compare current studies, and a lack of treatment effectiveness for the management of UVFP. This study aims to review the most recent literature for the management of dysphonia due to UVFP to establish the current evidence base for voice treatment options.

RECENT FINDINGS

There was found to be a lack of consistency in the rationale, selection and timing of the surgical intervention and/or voice therapy being provided for patients with UVFP.

SUMMARY

Further consensus is required for the rationale and selection of voice treatment prescriptions for the management of UVFP in order to improve treatment effectiveness and voice outcomes in patients with UVFP.

Speech therapy after thyroidectomy

Common complaints of patients who have received thyroidectomy include dysphonia (voice dysfunction) and dysphagia (difficulty swallowing). One cause of these surgical outcomes is recurrent laryngeal nerve paralysis. Many studies have discussed the effectiveness of speech therapy (e.g., voice therapy and dysphagia therapy) for improving dysphonia and dysphagia, but not specifically in patients who have received thyroidectomy. Therefore, the aim of this paper was to discuss issues regarding speech therapy such as voice therapy and dysphagia for patients after thyroidectomy. Another aim was to review the literature on speech therapy for patients with recurrent laryngeal nerve paralysis after thyroidectomy. Databases used for the literature review in this study included, PubMed, MEDLINE, Academic Search Primer, ERIC, CINAHL Plus, and EBSCO. The articles retrieved by database searches were classified and screened for relevance by using EndNote. Of the 936 articles retrieved, 18 discussed "voice assessment and thyroidectomy", 3 discussed "voice therapy and thyroidectomy", and 11 discussed "surgical interventions for voice restoration after thyroidectomy". Only 3 studies discussed topics related to "swallowing function assessment/treatment and thyroidectomy". Although many studies have investigated voice changes and assessment methods in thyroidectomy patients, few recent studies have investigated speech therapy after thyroidectomy. Additionally, some studies have addressed dysphagia after thyroidectomy, but few have discussed assessment and treatment of dysphagia after thyroidectomy.