Voice Quality Following Unilateral Vocal Fold Paralysis: A Randomized Comparison of Therapeutic Modalities

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.

Effects of Medical Masks on Voice Quality in Patients With Voice Disorders

PURPOSE

The purpose of this study was to explore the effects of medical masks on the voice quality of patients with voice disorders.

METHOD

We included 106 patients diagnosed with voice disorders. Among them, 59 were diagnosed with vocal-fold benign lesions, 27 with insufficient glottis closure, and 20 with precancerous lesions/early-stage glottic carcinoma. Perceptual parameters (GRBAS [grade, roughness, breathiness, asthenia, strain] scale), acoustic parameters (f _o, sound pressure level [SPL], jitter, shimmer, noise-to-harmonic ratio [NHR], and cepstral peak prominence [CPP]), and maximum phonation time (MPT) without and with medical masks were analyzed. Changes in the GRBAS scale after wearing medical masks were also evaluated.

RESULTS

With medical mask wearing, the G, R, and B scales in the vocal-fold benign lesion and insufficient glottic closure groups decreased, with a statistical significance seen in the G and R scales of the vocal-fold benign lesion group (G 1.07 ± 0.59, 0.95 ± 0.68, p < .01; R 1.07 ± 0.59, 0.95 ± 0.68, p < .01). The B scale in the precancerous lesions/early-stage glottic carcinoma (95%) and vocal-fold benign lesion groups (83%) and R scale in the insufficient glottic closure group (77.8%) were stable with mask wearing. f _o and SPL in the vocal-fold benign lesion group and f _o and jitter in the insufficient glottic closure group increased significantly with medical masks. The NHR and CPP in each group changed little, and all the parameters in the precancerous lesions/early-stage glottic carcinoma group showed no significant change.

CONCLUSIONS

The effects of medical masks on the voice quality of patients with voice disorders were associated with the type of the disease, degree of hoarseness, and subjective scale influencing specific voice disorder. When wearing medical masks, the pitch and loudness of patients increased as compensation. Medical masks had the least impact on the precancerous lesions/early-stage glottic carcinoma group.

Effects of Laryngeal Vibratory Asymmetry and Neuromuscular Compensation on Voice Quality

INTRODUCTION

Vibratory asymmetry and neuromuscular compensation are often seen in laryngeal neuromuscular pathology. However, the ramifications of these findings on voice quality are unclear. This study investigated the effects of varying levels of vibratory asymmetry and neuromuscular compensation on cepstral peak prominence (CPP), an analog of voice quality.

STUDY DESIGN

In vivo canine phonation model.

METHODS

Varying degrees of vocal fold vibratory asymmetry were achieved by stimulating one recurrent laryngeal nerve (RLN) over 11 levels from threshold to maximal muscle activation. For each of these levels, phonation was induced at systematically varied combinations of neuromuscular compensation: three levels each of contralateral RLN stimulation (80%, 90%, and 100% of maximal), superior laryngeal nerve (SLN) activation (0%, 50%, and 100% of maximal), and airflow levels (500, 700, and 900 mL/s). Vocal fold symmetry was determined by assessing the opening phase of the vibratory cycle in high-speed video recordings. Voice quality was estimated acoustically by calculating CPP for each voice sample.

RESULTS

Eight hundred twenty-two phonatory conditions with varying degrees of vibratory asymmetry were evaluated. CPP was highest at vibratory symmetry. Increasing levels of asymmetry resulted in significant decreases in CPP. CPP increased significantly with increasing contralateral RLN activation. CPP was significantly higher at 50% SLN activation than 0% or 100% SLN activation.

CONCLUSION

Voice quality, as approximated by CPP, is best at vibratory symmetry and deteriorates with increasing degrees of asymmetry. Voice quality may be improved with neuromuscular compensation by increased adduction of the contralateral vocal fold or increased vocal fold tension at mid-levels of SLN activation.

LEVEL OF EVIDENCE

NA, Basic Science Laryngoscope, 132:130-134, 2022.

Injection laryngoplasty under ultrasonographic control

BACKGROUND

Cervical ultrasound allows real-time visualization of the laryngeal structures. We describe its application for injection laryngoplasty in the voice clinic.

METHODS

Hyaluronic acid infiltration of the vocal fold under ultrasonographic control.

CONCLUSIONS

With this technique, the position of the needle in the depth of the vocal fold and its spatial relations with nearby structures can be assessed. This allows for an accurate infiltration of the material in contrast to other techniques and avoids discomfort related to the gag reflex with nasofibrolaryngoscopy. No specific complications have been observed so far, however, this technique may be difficult in cases with calcified cartilages or uncooperative patients.

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.

Early Injection Laryngoplasty With a Long-Lasting Material in Patients With Potentially Recoverable Unilateral Vocal Fold Paralysis

Objectives.

Injection laryngoplasty (IL) is one of the major options for treatment of unilateral vocal fold paralysis (UVFP). Early IL in patients with abrupt-onset UVFP can reduce hoarseness and aspiration-related discomfort and complications. Temporary or short-lasting materials are recommended for the early IL since permanent or long-lasting materials may negatively affect the voice quality when vocal fold motion is spontaneously recovered.

Methods.

Patients who received IL with a long-lasting material (ArteSense) within 1 month following development of postoperative UVFP were enrolled for this study. They were categorized into a spontaneously recovered group (n=30) and unrecovered group (n=276) from UVFP. The subjective and objective voice parameters were collected before and 6 months after IL. Patients’ demographics and collected voice parameters were compared between the two groups.

Results.

Age and sex distributions were not different between the two groups. Aspiration symptom, maximum phonation time (MPT), jitter, shimmer, noise to harmonic ratio (NHR), overall grade (G) and breathiness (B) of GRBAS (grade of dysphonia, roughness, breathiness, asthenia, strain) scale score, and voice handicap index (VHI) were significantly improved after IL in both groups. The amounts of improvement in MPT, jitter, shimmer, NHR and VHI were significantly greater in the recovered group. There was no IL-related complication including granuloma formation, hypersensitivity to injection material, or worsening of hoarseness.

Conclusion.

Early IL with a long-lasting material can be safely performed to improve voice quality and to reduce aspiration episode for the patients with postoperative UVFP, regardless of recovery from the paralysis. The amounts of improvement in the subjective and objective voice parameters were significantly greater in patients who showed spontaneous recovery from UVFP when compared with those in patients who did not.