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Reynolds V, Demarco J, Steinberg K. Better Breathing, Tougher Speaking? A Scoping Review of the Effects of Inhaled Corticosteroids on the Voice Quality of Asthmatic Children. J Voice 2024:S0892-1997(24)00003-1. [PMID: 38331703 DOI: 10.1016/j.jvoice.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/10/2024]
Abstract
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.
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Affiliation(s)
| | - Jenalee Demarco
- Lewis University, Romeoville, Illinois; Advanced Therapy and Wellness Clinic, Crest Hill, Illinois
| | - Katie Steinberg
- Lewis University, Romeoville, Illinois; Downers Grove Grade School District 58, Downers Grove, Illinois
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2
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Tanner K, Robison HJ, Stevens ME, Merrill RM, Dromey C, Barkmeier-Kraemer J, Ben Christensen M. Corticosteroid-LABA inhalers increase phonation threshold pressure (PTP) and flow (PTF) in rabbits. Laryngoscope 2023; 133:2680-2686. [PMID: 36757019 PMCID: PMC10409873 DOI: 10.1002/lary.30585] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 01/09/2023] [Accepted: 01/11/2023] [Indexed: 02/10/2023]
Abstract
OBJECTIVES This study examined the effects of a combination corticosteroid plus long-acting beta2 -adrenergic agonist inhaler (IC) on rabbit phonation. METHODS White New Zealand male rabbits were assigned randomly to experimental and control groups (n = 11 per group). The experimental group received twice-daily doses of Advair HFA™ (fluticasone propionate 45 mcg and salmeterol 21 mcg) via a veterinary facemask with 1-way valve and spacer; the control group received aerosolized saline. After 8 weeks, animals were euthanized, larynges excised, frozen, and subsequently thawed and mounted on a standard bench apparatus. Phonation was elicited during 15 successive trials, and phonation threshold pressure (PTP; cmH2 O) and flow (PTF; L/min) were quantified. RESULTS Repeated measures analysis of variance indicated significant differences between the experimental and control groups (p < 0.05). Mean PTP and PTF values were higher (worse) for rabbits that received Advair HFA™. CONCLUSION Following 8-week exposure to ICs, rabbit larynges required greater air pressure and flow to initiate phonation. Because even modest phonation onset differences can have a meaningful clinical impact on voice function, these findings suggest that LABA ICs may put patients at risk for voice disorders. Furthermore, these voice disorders may occur within a relatively short timeframe. The results from this study have important clinical implications for voice care in those who use ICs. LEVEL OF EVIDENCE NA Laryngoscope, 133:2680-2686, 2023.
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Affiliation(s)
- Kristine Tanner
- Department of Communication Disorders, Brigham Young University
- Department of Surgery, Otolaryngology—Head & Neck Surgery, The University of Utah
| | | | - Maya Elena Stevens
- Department of Communication Sciences & Disorders, The University of Utah
| | | | | | - Julie Barkmeier-Kraemer
- Department of Surgery, Otolaryngology—Head & Neck Surgery, The University of Utah
- Department of Communication Sciences & Disorders, The University of Utah
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Gaylord JN, Schaaf S, Frederick E. Exercise-Induced Dyspnea in Collegiate Athletes: Are We Missing the Diagnosis? J Voice 2023; 37:722-728. [PMID: 34162495 DOI: 10.1016/j.jvoice.2021.05.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/11/2021] [Accepted: 05/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Exercise-induced dyspnea (EID) can disrupt an athlete's participation and performance in their given sport. Differential diagnosis of EID is often completed using subjective report and may be inaccurate, therefore increasing the frustration and stress of the athlete. This nonexperimental research study was used to determine prevalence of EID and related respiratory symptoms in athletes at a small, Division I university. METHODS An anonymous survey was provided to athletes at Murray State University as they registered for participation in sports for the 2020-2021 school year. Data from this survey was analyzed as to reported physician-given diagnosis of a respiratory disorder as well as reported symptoms of EID. RESULTS Results showed that athletes with a physician-given diagnosis often did not report symptoms or responses to medications that support that diagnosis. Additionally, athletes frequently reported symptoms of EID without a formal diagnosis of a respiratory disorder. CONCLUSIONS These findings provide preliminary insight and pilot data that may be used to understand the prevalence of EID in collegiate athletes and the need for improved methods of diagnosis for etiologies of EID.
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Affiliation(s)
- J Nikki Gaylord
- Murray State University, Center for Communication Disorders, Murray, KY.
| | - Stephanie Schaaf
- Murray State University, Center for Communication Disorders, Murray, KY
| | - Eric Frederick
- Murray State University, Athletics Department, Murray, KY
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4
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Pfaff KE, Damrose EJ. Pill Ingestion and Caustic Laryngeal Injury. J Voice 2023; 37:260-262. [PMID: 33468367 DOI: 10.1016/j.jvoice.2020.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/27/2020] [Accepted: 11/27/2020] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To highlight an unusual mechanism of laryngeal injury. METHODS Case report and literature review. RESULTS A 66-year-old male ingested an over-the-counter preparation of bile acids as a dietary supplement. The capsule lodged in the patient's pharynx, and he sustained a caustic injury to the supraglottic and glottic larynx. His injury was managed conservatively, and his symptoms gradually resolved over a period of 8 weeks. A follow-up laryngoscopy at 8 weeks and 6 months showed no signs of injury. A barium swallow at 8 weeks was normal at that time and videostroboscopy results normalized with resolution of the injury as well. CONCLUSIONS Caustic injury to the upper aerodigestive tract from pill ingestion is uncommon, and laryngeal injury even less so. Urgent evaluation should be undertaken, and appropriate therapies instituted promptly. Laryngeal injury can respond to conservative therapy, but there is a lack of clinical information to evaluate optimum treatment of this unusual injury.
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Affiliation(s)
- Kayla E Pfaff
- Division of Laryngology, Department of Otolaryngology/Head & Neck Surgery, Stanford University Medical center, Stanford, California.
| | - Edward J Damrose
- Division of Laryngology, Department of Otolaryngology/Head & Neck Surgery, Stanford University Medical center, Stanford, California
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Kántor P, Staníková L, Švejdová A, Zeleník K, Komínek P. Narrative Review of Classification Systems Describing Laryngeal Vascularity Using Advanced Endoscopic Imaging. J Clin Med 2022; 12:jcm12010010. [PMID: 36614807 PMCID: PMC9821525 DOI: 10.3390/jcm12010010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/24/2022] Open
Abstract
Endoscopic methods are critical in the early diagnosis of mucosal lesions of the head and neck. In recent years, new examination methods and classification systems have been developed and introduced into clinical practice. All of these new techniques target the notion of optical biopsy, which tries to assess the nature of the lesion before histology examination. Many methods suffer from interpretation issues due to subjective interpretation of the findings. Therefore, multiple classification systems have been developed to assist the proper interpretation of mucosal findings and reduce the error rate. They provide various perspectives on the assessment and interpretation of mucosa changes. This article provides a comprehensive and critical view of the available classification systems as well as their advantages and disadvantages.
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Affiliation(s)
- Peter Kántor
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Craniofacial Surgery, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
- Correspondence: ; Tel.: +420-722-437-109
| | - Lucia Staníková
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Craniofacial Surgery, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Anna Švejdová
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Hradec Králove, Faculty of Medicine in Hradec Králove, Charles University, 500 03 Hradec Králové, Czech Republic
| | - Karol Zeleník
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Craniofacial Surgery, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
| | - Pavel Komínek
- Department of Otorhinolaryngology and Head and Neck Surgery, University Hospital Ostrava, 708 52 Ostrava, Czech Republic
- Department of Craniofacial Surgery, Faculty of Medicine, University of Ostrava, 701 03 Ostrava, Czech Republic
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Lechien JR. Do Otolaryngologists Over- or Underestimate Laryngopharyngeal Reflux Symptoms and Findings in Clinical Practice? A Comparison Study between the True Prevalence and the Otolaryngologist-Estimated Prevalence of Symptoms and Findings. J Clin Med 2022; 11:5192. [PMID: 36079120 PMCID: PMC9457400 DOI: 10.3390/jcm11175192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/20/2022] [Accepted: 08/30/2022] [Indexed: 11/25/2022] Open
Abstract
Purpose: To investigate the prevalence of symptoms and signs of laryngopharyngeal reflux (LPR) and to compare them with the otolaryngologist-estimated prevalence of the most common LPR-related symptoms and signs. Methods: The prevalence of LPR symptoms and signs was determined through the clinical data of 403 patients with a positive LPR diagnosis on hypopharyngeal−esophageal multichannel intraluminal impedance pH monitoring. The otolaryngologist-estimated prevalence was assessed through an international survey investigating the thoughts of 824 otolaryngologists toward LPR symptom and sign prevalence. The determination of potential over- or underestimation of LPR symptoms and findings was investigated through a data comparison between the ‘true’ prevalence and the ‘estimated prevalence’ of symptoms and findings by otolaryngologists. Results: The prevalence of breathing difficulties, coated tongue, and ventricular band inflammation was adequately evaluated by otolaryngologists. The prevalence of hoarseness, throat pain, odynophagia, dysphagia, throat clearing, globus sensation, excess throat mucus, tongue burning, heartburn, regurgitations, halitosis, cough after eating or lying down, and troublesome cough was overestimated by otolaryngologists (p < 0.01), while the prevalence of chest pain was underestimated as an LPR symptom. Most laryngeal signs, e.g., arytenoid/laryngeal erythema, inter-arytenoid granulation, posterior commissure hypertrophy, retrocricoid edema/erythema, and endolaryngeal sticky mucus, were overestimated (p < 0.01). The occurrence of anterior pillar erythema and tongue tonsil hypertrophy was underestimated by participants. Conclusion: Most laryngopharyngeal reflux symptoms and laryngeal signs were overestimated by otolaryngologists, while some non-laryngeal findings were underestimated. Future studies are needed to better understand the reasons for this phenomenon and to improve the awareness of otolaryngologists toward the most and least prevalent reflux symptoms and signs.
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Affiliation(s)
- Jerome R. Lechien
- Polyclinic of Poitiers, Elsan Hospital, 86000 Poitiers, France;
- Department of Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), B7000 Mons, Belgium
- Department of Otolaryngology-Head and Neck Surgery, EpiCURA Hospital, B7000 Baudour, Belgium
- Department of Otolaryngology-Head and Neck Surgery, EpiCURA Hospital, Rue L. Cathy, University of Mons, B7000 Mons, Belgium
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Krishnan NV, Pujary K, Bhandarkar AM, Devadas U, Magazine R. Videostroboscopy and Voice Profile in Long-Term Combination Inhaler Users With Obstructive Lower Airway Disease. Otolaryngol Head Neck Surg 2021; 166:927-932. [PMID: 34311589 DOI: 10.1177/01945998211031449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Neethu V Krishnan
- Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Kailesh Pujary
- Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Ajay M Bhandarkar
- Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Usha Devadas
- Manipal College of Health Professions, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Rahul Magazine
- Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Mesolella M, Maione N, Salerno G, Motta G. Laryngeal Candidiasis Mimicking Supraglottic Carcinoma by Prolonged Inhaled Steroid Therapy: A Case Report and Review of the Literature. EAR, NOSE & THROAT JOURNAL 2020; 100:761S-765S. [PMID: 32107940 DOI: 10.1177/0145561320907166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Candidiasis is a rare entity reported as an isolated and primary laryngeal disease. In this condition, inhaled steroids were the single most common predisposing factor. Also mycotic infections of larynx are frequently seen in patients with immune insufficiency, although they have also been reported in individual with normal immune status. We report a case of isolated laryngeal Candidiasis in an immunocompetent individual, with an unusual presentation with exophytic lesion, edema, ulceration, white plaque, and pseudomembranous formation mimicking supraglottic carcinoma, to highlight the clinical of this condition and provide a review of the literature.
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Affiliation(s)
- Massimo Mesolella
- Dipartimento di Neuroscienze e Scienze Riproduttive ed Odontostomatologiche, 9307Università Federico II, Napoli, Italy
| | - Nunzia Maione
- Dipartimento di Neuroscienze e Scienze Riproduttive ed Odontostomatologiche, 9307Università Federico II, Napoli, Italy
| | - Grazia Salerno
- Dipartimento di Neuroscienze e Scienze Riproduttive ed Odontostomatologiche, 9307Università Federico II, Napoli, Italy
| | - Gaetano Motta
- Dipartimento di Chirurgia Generale e Specialistica, Università "Luigi Vanvitelli" di Napoli, Napoli, Italy
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9
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Vance D, Alnouri G, Valentino W, Eichorn D, Acharya P, Sataloff RT. Effects of Particle Size of Inhaled Corticosteroid on the Voice. J Voice 2020; 35:455-457. [PMID: 31902681 DOI: 10.1016/j.jvoice.2019.11.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Revised: 11/15/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The purpose of this study was to determine if inhaled corticosteroid (ICS) particle size influences the development of laryngitis including candida laryngitis, dysphonia, or vocalis muscle atrophy in asthmatic patients. STUDY DESIGN Retrospective analysis. METHODS Medical records of patients from a quaternary care laryngology practice who have asthma were reviewed retrospectively. Subjects were divided into two groups determined by the particle size of their ICS, small or standard. Each patient only used one type of inhaler. All subjects had been seen in the office for dysphonia evaluation. Statistical analysis was performed on the collected data using χ2 analysis with Yate's Correction for categorical data and a student t-test for means. A P value of less than 0.05 was considered significant. RESULTS There was a significant difference in vocal fold atrophy rate between groups. CONCLUSION Routine use of standard particle size ICS is associated with more atrophy than small size ICS.
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Affiliation(s)
- Dylan Vance
- Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Ghiath Alnouri
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | | | - Daniel Eichorn
- Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Pankti Acharya
- Rowan University School of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Robert T Sataloff
- Department of Otolaryngology, Head and Neck Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania.
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10
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Abstract
Medications can have innumerable direct and indirect effects on laryngeal hydration, vocal fold mucosal integrity, laryngeal muscle function, and laryngeal sensation. Effects, therefore, can be subtle and slowly progressive over time. This article delineates the general classes of medications that are known to cause alterations of vocal function, highlights medical history symptoms that may help raise suspicion for medication-related vocal changes, and presents recommendations for approaches to treatment of these issues.
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Affiliation(s)
- Jonathan M Bock
- Division of Laryngology and Professional Voice, Department of Otolaryngology and Communication Sciences, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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11
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Spantideas N, Bougea A, Drosou E, Assimakopoulos D. The Role of Allergy in Phonation. J Voice 2018; 33:811.e19-811.e27. [PMID: 30145066 DOI: 10.1016/j.jvoice.2018.02.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 02/21/2018] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
| | | | - Eirini Drosou
- Athens Speech Language and Swallowing Institute, Athens, Greece
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12
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Tay TR, Hew M. Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation. Allergy 2018; 73:1369-1382. [PMID: 29178130 DOI: 10.1111/all.13370] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 01/07/2023]
Abstract
The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.
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Affiliation(s)
- T. R. Tay
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- Department of Respiratory and Critical Care Medicine; Changi General Hospital; Singapore
| | - M. Hew
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- School of Public Health & Preventive Medicine; Monash University; Melbourne Vic. Australia
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Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis C(CW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg 2018; 158:S1-S42. [DOI: 10.1177/0194599817751030] [Citation(s) in RCA: 146] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
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
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Libby J. Smith
- University of Pittsburgh Medical, Pittsburgh, Pennsylvania, USA
| | - Marshall Smith
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | | | - Peak Woo
- Icahn School of Medicine at Mt Sinai, New York, New York, USA
| | - Lorraine C. Nnacheta
- Department of Research and Quality, American Academy of Otolaryngology—Head and Neck Surgery Foundation, Alexandria, Virginia, USA
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14
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Salturk Z, Kumral TL, Sunnetçi G, Atar Y, Çakır Ç, Yıldırım G, Berkiten G, Uyar Y. Histopathological Analysis of the Effects of Corticosteroids on Vocal Cords: Experimental Study. Indian J Otolaryngol Head Neck Surg 2018; 70:111-114. [PMID: 29456953 PMCID: PMC5807272 DOI: 10.1007/s12070-015-0820-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 01/02/2015] [Indexed: 11/30/2022] Open
Abstract
Local treatment with corticosteroids results in side effects involving the upper respiratory tract including candidiasis, sore throat, and dysphonia. Although these effects are well known, they have not been evaluated using a histopathological approach. This study investigated the histopathological aspects of steroid-induced dysphonia. A total of 16 female Wistar albino rats were divided into two groups. The eight rats in the experimental group were given an inhaled dose of mometasone furoate daily for 4 weeks. The control group was kept at room temperature for 4 weeks. The vocal cords were evaluated histopathologically using hematoxylin and eosin staining. Both groups had typical epithelial lining and basal membranes. Inflammation differed between the two groups (P = 0.024). There were no differences in squamous metaplasia and hyperplasia (P = 0.302 and 0.302, respectively). This study revealed that inhaled corticosteroids inhibit mucosal immunity, and may result in reversible mucosal changes.
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Affiliation(s)
- Ziya Salturk
- Okmeydanı Training and Research Hospital ENT Clinic, Darulaceze cad., Şişli, Istanbul, Turkey
| | - Tolgar Lütfi Kumral
- Okmeydanı Training and Research Hospital ENT Clinic, Darulaceze cad., Şişli, Istanbul, Turkey
| | - Gürcan Sunnetçi
- Okmeydanı Training and Research Hospital ENT Clinic, Darulaceze cad., Şişli, Istanbul, Turkey
| | - Yavuz Atar
- Okmeydanı Training and Research Hospital ENT Clinic, Darulaceze cad., Şişli, Istanbul, Turkey
| | - Çağlar Çakır
- Okmeydanı Training and Research Hospital Pathology Clinic, Istanbul, Turkey
| | - Güven Yıldırım
- Okmeydanı Training and Research Hospital ENT Clinic, Darulaceze cad., Şişli, Istanbul, Turkey
| | - Güler Berkiten
- Okmeydanı Training and Research Hospital ENT Clinic, Darulaceze cad., Şişli, Istanbul, Turkey
| | - Yavuz Uyar
- Okmeydanı Training and Research Hospital ENT Clinic, Darulaceze cad., Şişli, Istanbul, Turkey
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15
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Hamdan AL, Ziade G, Kasti M, Akl L, Bawab I, Kanj N. Phonatory Symptoms and Acoustic Findings in Patients with Asthma: A Cross-Sectional Controlled Study. Indian J Otolaryngol Head Neck Surg 2016; 69:42-46. [PMID: 28239577 DOI: 10.1007/s12070-016-1035-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 12/05/2016] [Indexed: 11/25/2022] Open
Abstract
To investigate the prevalence of phonatory symptoms, perceptual, acoustic and aerodynamic findings in patients with asthma compared to a control group. This study is a cross-sectional study. A total of 50 subjects, 31 asthmatic and 19 control subjects matched according to age and gender were enrolled in this study. All subjects were asked about the presence or absence of dysphonia, vocal fatigue, phonatory effort, cough, dyspnea, and respiratory failure. Perceptual evaluation, acoustic analysis and aerodynamic measurements were also performed. Patient's self assessment using the Voice Handicap Index 10 was reported. The mean age of patients was 43.5 years with a female to male ratio of 2:1. There was a statistically significant difference in the prevalence of dysphonia between the two groups (32.3 vs. 5.3%, p value 0.025) with a non-significant higher prevalence of vocal fatigue and phonatory effort. The overall grade of dysphonia was significantly higher in asthmatics compared to controls (p value 0.002). Patients with asthma had also significantly higher degree of asthenia and straining (p value of 0.04 and 0.008, respectively) with borderline significant difference with respect to roughness. There was no significant difference in the means of any of the acoustic parameters between patients and controls except for Shimmer, which was higher in the asthmatic group (p value of 0.037). There was also no significant difference in the Maximum phonation time between the two groups. Dysphonia is significantly more prevalent in patients with asthma compared to controls.
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Affiliation(s)
- Abdul Latif Hamdan
- Department of Otolaryngology, Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Georges Ziade
- Department of Otolaryngology, Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maher Kasti
- Department of Otolaryngology, Head and Neck Surgery, Rafic Hariri University Hospital, Beirut, Lebanon
| | - Leslie Akl
- Department of Otolaryngology, Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ibrahim Bawab
- Department of Otolaryngology, Head and Neck Surgery, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nadim Kanj
- Department of Internal Medicine, American University of Beirut, P.O. Box: 11-0236, Beirut, Lebanon
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16
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Abstract
Superficial fungal infection of the mucous membranes (thrush) isolated to the larynx is neither widely reported nor well recognized clinically. Therefore, it is often associated with ineffective treatment and delay in diagnosis, and sometimes associated with unneeded surgical intervention. Eight cases of thrush isolated to the larynx, with no oral or oropharyngeal manifestations, are presented. Four of these were isolated to the vocal folds alone. All patients were adults, and 4 were smokers. Hoarseness was always present. Pain was present inconsistently, and there was no dysphagia or odynophagia, in contrast to other forms of upper aerodigestive tract candidiasis. On average, diagnosis was not made until 6 months after the onset of symptoms. Possible causative factors included use of systemic steroids (3 cases), broad-spectrum antibiotics (1 case), or inhaled steroids (5 cases); diabetes (2 cases); and neutropenia (1 case). In 3 cases, all with thrush isolated to the vocal folds, inhaled steroids were the only causative factor identifiable — a feature reported only twice previously. Three patients underwent surgical procedures that might have been avoided had an accurate diagnosis been made. All patients responded readily to oral fluconazole and removal of predisposing factors where possible. The signs, symptoms, predisposing factors, and treatment are compared to those of 14 cases reported in the literature over 35 years.
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Affiliation(s)
- Lucian Sulica
- Department of Otolaryngology, Beth Israel Medical Center, New York, New York 10003, USA
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17
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Abstract
PURPOSE OF REVIEW This article discusses the relationship between inhaled corticosteroids and dysphonia, with discussion of the therapeutic use of inhaled steroids in laryngeal disease and a review of negative laryngeal effects of this class of medication in patients with reactive airway disease. RECENT FINDINGS Although prescribed for their anti-inflammatory effects (predominantly for pulmonary disease and less often for laryngeal conditions), corticosteroid inhalers can cause laryngeal inflammation. This may relate to chemical irritation from the inhaler itself as well as fungal inflammation related to opportunistic candidiasis that may accompany inhaler use. Patients who suffer from dysphonia because of inhaler use may improve if switched to another inhaler. Studies suggest that ciclesonide metered-dose inhaler may have less oropharyngeal deposition and therefore be associated with reduced oropharyngeal candidiasis and dysphonia compared with other inhaled corticosteroids. SUMMARY Corticosteroid inhalers are a common cause of dysphonia and their use should be investigated in any patient with laryngeal complaints.
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18
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Voice changes in patients with chronic obstructive pulmonary disease. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2014. [DOI: 10.1016/j.ejcdt.2014.03.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Sahrawat R, Robb MP, Kirk R, Beckert L. Effects of inhaled corticosteroids on voice production in healthy adults. LOGOP PHONIATR VOCO 2013; 39:108-16. [PMID: 23570418 DOI: 10.3109/14015439.2013.777110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The isolated effects of inhaled corticosteroids (ICS) on voice production were examined in 30 healthy adults with no known pre-existing airway disease. All participants followed a daily ICS treatment regime of 500 μg in the morning and evening over a 6-day period. Sustained vowels and connected speech samples were audio recorded before, during, and after the ICS regime. Each participant's audio recorded samples were acoustically analysed. Results revealed that ICS has a short-term detrimental effect on various acoustic properties of voice. These effects were more evident in connected speech compared to isolated vowel productions. All acoustic parameters returned to normalcy after discontinuing the ICS. The study provides insight as to the influence of ICS on healthy voice production.
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Affiliation(s)
- Ramesh Sahrawat
- University of Canterbury, Health Sciences Centre , Private Bag 4800, Christchurch, 8140 New Zealand
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20
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de Souza AMV, de Campos Duprat A, Costa RC, de Oliveira Pimenta J, de Sá Andrade FF, da Silva FF. Use of inhaled versus oral steroids for acute dysphonia. Braz J Otorhinolaryngol 2013; 79:196-202. [PMID: 23670326 PMCID: PMC9443858 DOI: 10.5935/1808-8694.20130035] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 11/29/2012] [Indexed: 11/30/2022] Open
Abstract
Acute dysphonia is a frequent condition in clinical practice. Its treatment, especially in adults, is not well established in the literature. Steroids are the most recommended drug treatment. However, the existing studies are not enough to establish superiority among the different steroids and the best route of administration. Objective This prospective clinical study aimed at comparing the effect of inhaling steroids as a dry powder with the effect of oral steroids to treat acute dysphonia. Method We assessed 32 adult patients, broken down into two groups of 16 patients in each one of the treatments, before and seven days after the use of the medication. The patients were submitted to videolaryngoscopy and perceptive and acoustic voice assessment. Result Oral and inhalation treatment significantly reduced hyperemia and edema, and improved the muco-ondulatory movement; nonetheless, edema reduction was statistically more significant (p = 0.012) in the patients treated with the inhalation form of the drug. However, comparing the values of the auditory perceptive analysis and the acoustic measures after treatment between the groups was not statistically significant. Conclusion There was a significant improvement in the acute laryngitis concerning the assessments carried out in all the patients assessed, concerning the two treatments. The inhalation steroid treatment was significantly more effective in reducing the edema.
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Affiliation(s)
- Andréa Moreira Veiga de Souza
- MD MSc - Otorhinolaryngologist - Espaço da voz - MG - Brazil
- Send correspondence to: André de Campos Duprat. Av. 9 de Julho, nº 5519, cj 71. Jardim Europa. São Paulo - SP. Brazil. CEP: 01407-200. Fax: (11) 3168-6644
| | - André de Campos Duprat
- MD PhD - Otorhinolaryngologist. Professor at the Medical School of the Santa Casa - São Paulo
| | - Rejane Cardoso Costa
- MD Otorhinolaryngologist - Insttuto de Otorrinolaringologia de Minas Gerais - Brazil
| | - Janaína de Oliveira Pimenta
- MSc - Speech and Hearing Therapist - Espaço da voz - MG - Brazil. Irmandade da Santa Casa de Misericórdia de São Paulo
| | | | - Fernanda Ferreira da Silva
- MSc - Speech and Hearing Therapist - Espaço da voz - MG - Brazil. Irmandade da Santa Casa de Misericórdia de São Paulo
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21
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Galván CA, Guarderas JC. Practical considerations for dysphonia caused by inhaled corticosteroids. Mayo Clin Proc 2012; 87:901-4. [PMID: 22958993 PMCID: PMC3496982 DOI: 10.1016/j.mayocp.2012.06.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 06/14/2012] [Accepted: 06/15/2012] [Indexed: 10/27/2022]
Abstract
Inhaled corticosteroid (ICS) therapy has become standard in the treatment of asthma. A common local adverse effect of ICS therapy is dysphonia, which has been reported to affect 5% to 58% of patients. Although causes of dysphonia associated with ICS therapy have been underinvestigated, it may result from deposition of an active ICS in the oropharynx during administration, which then causes myopathy or a mucosal effect in the laryngopharynx. Use of ICS should be considered during any evaluation of dysphonia. We recommend using the lowest effective dosage of ICS, administering medication with a spacer, gargling, rinsing the mouth and washing the face after inhalation, and washing the spacer. If dysphonia develops despite these interventions, ICS use should be suspended until symptoms resolve, provided that asthma control is not compromised.
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Affiliation(s)
- César A Galván
- Clinical Immunology and Allergic Diseases Division, Hospital Nacional Guillermo Almenara Irigoyen, Lima, Perú.
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22
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Forrest LA, Husein T, Husein O. Paradoxical vocal cord motion: classification and treatment. Laryngoscope 2012; 122:844-53. [PMID: 22434681 DOI: 10.1002/lary.23176] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Paradoxical vocal cord motion (PVCM), or vocal cord dysfunction, is a descriptive term for inappropriate adduction of the vocal folds during respiration. The laryngeal mistiming leads to breathing difficulty and is often misdiagnosed as refractory asthma. The etiology of PVCM has been unclear but has long been hypothesized to be psychological. The present thesis is a prospective study of 170 patients older than 18 years being evaluated for PVCM, with 117 of the 170 (68.8%) identified as having PVCM by video laryngoscopy. Laryngeal edema (P = .021) and reflux (P = .026) were increased in patients with PVCM. A flat inspiratory arm of the flow volume loop during spirometry testing was a predictor of PVCM (P = .034). A subgroup of 47 newly diagnosed patients with PVCM underwent psychological analysis. The psychological profiles were elucidated using the Minnesota Multiphasic Personality Inventory and the Life Experiences Survey to evaluate stress. Compared to established normative data, PVCM demonstrated a conversion disorder pattern (P < .01) but not an anxiety disorder or a correlation with stress. A subgroup, 11 of the 47 (23.4%), had normal psychological outcomes, and two of the 47 (4.3%) were identified as malingering. Previous studies have suggested that PVCM is strictly a psychological disorder. It is proposed that PVCM is a descriptive term that is multifactorial and the etiology should direct treatment. A classification scheme divides PVCM into primary, or psychological, and secondary. The secondary form consists of medical disorders divided into irritable larynx syndrome and neurologic disorders.
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Affiliation(s)
- L Arick Forrest
- Department of Otolaryngology, Ohio State University College of Medicine, Columbus, Ohio 43212, USA.
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23
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Turley R, Cohen SM, Becker A, Ebert CS. Role of rhinitis in laryngitis: another dimension of the unified airway. Ann Otol Rhinol Laryngol 2011; 120:505-10. [PMID: 21922973 DOI: 10.1177/000348941112000803] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES We evaluated the prevalence of dysphonia and secondary laryngeal symptoms among patients with allergic rhinitis (AR), nonallergic rhinitis (NAR), and no rhinitis symptoms (controls). METHODS Patients with rhinitis symptoms with positive and negative allergy tests were recruited from allergy clinics, and patients without rhinitis symptoms were recruited from an orthopedic clinic. All groups completed the Voice-Related Quality of Life survey (VRQOL),the mini-Rhinoconjunctivitis Quality of Life Questionnaire (mini-RQLQ), and the Reflux Symptom Index (RSI). RESULTS Completing the study were 134 patients with AR, 54 patients with NAR, and 62 controls. Both AR and NAR patients had an increased prevalence of dysphonia compared to controls (32.8% and 26.9% versus 8.1%, respectively; p = 0.001). When we controlled for confounding variables such as asthma, inhaled steroid use, and gastroesophageal reflux, patients with either AR or NAR had higher odds of dysphonia (odds ratio, 4.22; 95% confidence interval, 1.03 to 17.32). Patients with worse mini-RQLQ scores had lower VRQOL scores and higher RSI scores (Spearman correlation of -0.47 and p < 0.001 and Spearman correlation of 0.6 and p <0.001, respectively). CONCLUSIONS Patients with rhinitis (AR or NAR) had a higher prevalence of dysphonia than did controls. Patients with worse rhinitis symptoms had worse voice-related quality of life and more severe chronic laryngeal symptoms.
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Affiliation(s)
- Richard Turley
- Division of Otolaryngology-Head and Neck Surgery, Duke University Medical Center, Durham, NC 27710, USA
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24
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Ovchinikova L, Smith L, Bosnic-Anticevich S. Inhaler technique maintenance: gaining an understanding from the patient's perspective. J Asthma 2011; 48:616-24. [PMID: 21623690 DOI: 10.3109/02770903.2011.580032] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The aim of this study was to determine the patient-, education-, and device-related factors that predict inhaler technique maintenance. METHODS Thirty-one community pharmacists were trained to deliver inhaler technique education to people with asthma. Pharmacists evaluated (based on published checklists), and where appropriate, delivered inhaler technique education to patients (participants) in the community pharmacy at baseline (Visit 1) and 1 month later (Visit 2). Data were collected on participant demographics, asthma history, current asthma control, history of inhaler technique education, and a range of psychosocial aspects of disease management (including adherence to medication, motivation for correct technique, beliefs regarding the importance of maintaining correct technique, and necessity and concern beliefs regarding preventer therapy). Stepwise backward logistic regression was used to identify the predictors of inhaler technique maintenance at 1 month. RESULTS In total 145 and 127 participants completed Visits 1 and 2, respectively. At baseline, 17% of patients (n = 24) demonstrated correct technique (score 11/11) which increased to 100% (n = 139) after remedial education by pharmacists. At follow-up, 61% (n = 77) of patients demonstrated correct technique. The predictors of inhaler technique maintenance based on the logistic regression model (X(2) (3, N = 125) = 16.22, p = .001) were use of a dry powder inhaler over a pressurized metered-dose inhaler (OR 2.6), having better asthma control at baseline (OR 2.3), and being more motivated to practice correct inhaler technique (OR 1.2). CONCLUSION Contrary to what is typically recommended in previous research, correct inhaler technique maintenance may involve more than repetition of instructions. This study found that past technique education factors had no bearing on technique maintenance, whereas patient psychosocial factors (motivation) did.
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25
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Krausert CR, Olszewski AE, Taylor LN, McMurray JS, Dailey SH, Jiang JJ. Mucosal wave measurement and visualization techniques. J Voice 2010; 25:395-405. [PMID: 20471798 DOI: 10.1016/j.jvoice.2010.02.001] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2009] [Accepted: 02/04/2010] [Indexed: 10/19/2022]
Abstract
Organized vibration of the vocal folds is critical for high-quality voice production. When the vocal folds oscillate, the superficial tissue of the vocal fold is displaced in a wave-like fashion, creating the so-called "mucosal wave." Because the mucosal wave is dependent on vocal fold structure, physical alterations of that structure cause mucosal wave abnormalities. Visualization and quantification of mucosal wave properties have become useful parameters in diagnosing and managing vocal fold pathology. Mucosal wave measurement provides information about vocal fold characteristics that cannot be determined with other assessment techniques. Here, we discuss the benefits, disadvantages, and clinical applicability of the different mucosal wave measurement techniques, such as electroglottography, photoglottography, and ultrasound and visualization techniques that include videokymography, stroboscopy, and high-speed digital imaging. The various techniques and their specific uses are reviewed with the intention of helping researchers and clinicians choose a method for a given situation and understand its limitations and its potential applications. Recent applications of these techniques for quantitative assessment demonstrate that additional research must be conducted to realize the full potential of these tools. Evaluations of existing research and recommendations for future research are given to promote both the quantitative study of the mucosal wave through accurate and standardized measurement of mucosal wave parameters and the development of reliable methods with which physicians can diagnose vocal disorders.
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Affiliation(s)
- Christopher R Krausert
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wisconsin, USA
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26
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Erickson E, Sivasankar M. Evidence for adverse phonatory change following an inhaled combination treatment. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2010; 53:75-83. [PMID: 19696437 DOI: 10.1044/1092-4388(2009/09-0024)] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
PURPOSE Voice problems are reported as a frequent side effect of inhaled combination (IC) treatments. The purpose of this experimental study was to investigate whether IC treatments are detrimental to phonation. We hypothesized that IC treatment would significantly increase phonation threshold pressure (PTP) and perceived phonatory effort (PPE), whereas sham treatment would not. METHOD Fourteen healthy adults participated in a repeated-measures design in which they received IC and sham treatments in counterbalanced order. PTP and PPE were measured prior to treatments, immediately following treatments, and at 1 and 2 hr following treatments. RESULTS IC treatment increased PTP, but sham treatment did not. The increase in PTP was maintained for a 2 hr period following administration. PPE ratings were not significantly correlated with PTP. CONCLUSIONS IC treatments can have acute, adverse effects on phonation. Detrimental phonatory effects were elicited in participants with no self-reported voice problems. IC treatments are being increasingly prescribed across the lifespan. The current data increase our understanding of the nature of phonatory deterioration associated with IC treatment and lay the groundwork for increased research effort to develop IC treatments that effectively control respiratory disease while minimizing an adverse effect on phonation.
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27
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A short-term investigation of dysphonia in asthmatic patients using inhaled budesonide. J Voice 2010; 25:88-93. [PMID: 20080023 DOI: 10.1016/j.jvoice.2009.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2009] [Accepted: 07/08/2009] [Indexed: 11/23/2022]
Abstract
BACKGROUND Dysphonia is one of the most common side effects of patients who use corticosteroid inhalers. The aim of this study was to investigate, prospectively, the occurrence of dysphonia in patients who used corticosteroid inhalers. METHODS Outpatients aged 18 years or older initially treated with inhaled corticosteroids were recruited. All patients were prescribed budesonide/formoterol. Questionnaires, perceptual studies, and acoustic analysis were performed five times during the study: at study entry and after 1, 4, 8, and 12 weeks. Videostroboscopy was performed at study entry and at 12 weeks. The data collected were analyzed by repeated-measures analysis of variance tests and Wilcoxon's signed rank test (P<0.01). RESULTS Sixty-two patients were enrolled and 29 patients (M:F=19:10) completed the study. Seven patients reported that they had problems with their voice; however, there were no statistically significant changes in the perceptual studies or the acoustic analysis. The videostroboscopy showed that "injection" and "increase of mucus" significantly increased by week 12. Vocal fold bowing was not noted in any of the patients. CONCLUSIONS The results of this study showed no significant voice changes in patients using corticosteroid inhalers over a period of 3 months. However, minor mucosal changes were found on videostroboscopy.
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28
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Ozbilen Acar G, Uzun Adatepe N, Kaytaz A, Edizer DT, Gemicioglu B, Yagiz C, Dirican A. Evaluation of laryngeal findings in users of inhaled steroids. Eur Arch Otorhinolaryngol 2009; 267:917-23. [PMID: 19908054 DOI: 10.1007/s00405-009-1141-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2009] [Accepted: 10/19/2009] [Indexed: 11/25/2022]
Abstract
The objective of the prospective study is to examine the laryngeal changes by laryngeal videostroboscopy and electromyography (EMG) regarding new-onset dysphonia in asthmatic patients taking inhaled corticosteroids (ICS). Laryngeal changes and electrophysiological status of the laryngeal muscles were evaluated by these methods in 12 patients both at the time of presentation of dysphonia and after cessation of therapy. Laryngeal changes of our patients were mucosal edema, erythema, thickening, adduction deficit, nodule and irregularity in videostroboscopy. Significant correlations were found between laryngeal pathology and dosage and duration of ICS therapy. We detected myopathy by EMG in most of the patients. Also, EMG revealed that cricothyroid muscle was much more affected than thyroarytenoid muscle. In conclusion, we consider that steroid myopathy or mucosal inflammatory theory alone is not sufficient to explain the etiopathogenesis of dysphonia in asthmatic patients taking ICS. The laryngeal mucosal changes were detected by laryngeal videostroboscopic examination in some asthmatic patients, with dysphonia using ICS, and/or laryngeal myopathy was found by laryngeal EMG in some of them in this study. Thus, various factors may have role simultaneously in the occurrence of dysphonia.
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Affiliation(s)
- Gul Ozbilen Acar
- Department of Otorhinolaryngology, Istanbul Goztepe Training and Research Hospital, Ata (3/4) Daire:249 Kat:20 Sedef Cad. 38. Ada, Atasehir/Kadikoy, Istanbul, Turkey.
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29
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Schwartz SR, Cohen SM, Dailey SH, Rosenfeld RM, Deutsch ES, Gillespie MB, Granieri E, Hapner ER, Kimball CE, Krouse HJ, McMurray JS, Medina S, O'Brien K, Ouellette DR, Messinger-Rapport BJ, Stachler RJ, Strode S, Thompson DM, Stemple JC, Willging JP, Cowley T, McCoy S, Bernad PG, Patel MM. Clinical Practice Guideline: Hoarseness (Dysphonia). Otolaryngol Head Neck Surg 2009; 141:S1-S31. [DOI: 10.1016/j.otohns.2009.06.744] [Citation(s) in RCA: 203] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Accepted: 06/26/2009] [Indexed: 12/27/2022]
Abstract
Objective: This guideline provides evidence-based recommendations on managing hoarseness (dysphonia), defined as a disorder characterized by altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life (QOL). Hoarseness affects nearly one-third of the population at some point in their lives. This guideline applies to all age groups evaluated in a setting where hoarseness would be identified or managed. It is intended for all clinicians who are likely to diagnose and manage patients with hoarseness. Purpose: The primary purpose of this guideline is to improve diagnostic accuracy for hoarseness (dysphonia), reduce inappropriate antibiotic use, reduce inappropriate steroid use, reduce inappropriate use of anti-reflux medications, reduce inappropriate use of radiographic imaging, and promote appropriate use of laryngoscopy, voice therapy, and surgery. In creating this guideline the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of neurology, speech-language pathology, professional voice teaching, family medicine, pulmonology, geriatric medicine, nursing, internal medicine, otolaryngology–head and neck surgery, pediatrics, and consumers. Results The panel made strong recommendations that 1) the clinician should not routinely prescribe antibiotics to treat hoarseness and 2) the clinician should advocate voice therapy for patients diagnosed with hoarseness that reduces voice-related QOL. The panel made recommendations that 1) the clinician should diagnose hoarseness (dysphonia) in a patient with altered voice quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related QOL; 2) the clinician should assess the patient with hoarseness by history and/or physical examination for factors that modify management, such as one or more of the following: recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve, recent endotracheal intubation, radiation treatment to the neck, a history of tobacco abuse, and occupation as a singer or vocal performer; 3) the clinician should visualize the patient's larynx, or refer the patient to a clinician who can visualize the larynx, when hoarseness fails to resolve by a maximum of three months after onset, or irrespective of duration if a serious underlying cause is suspected; 4) the clinician should not obtain computed tomography or magnetic resonance imaging of the patient with a primary complaint of hoarseness prior to visualizing the larynx; 5) the clinician should not prescribe anti-reflux medications for patients with hoarseness without signs or symptoms of gastroesophageal reflux disease; 6) the clinician should not routinely prescribe oral corticosteroids to treat hoarseness; 7) the clinician should visualize the larynx before prescribing voice therapy and document/communicate the results to the speech-language pathologist; and 8) the clinician should prescribe, or refer the patient to a clinician who can prescribe, botulinum toxin injections for the treatment of hoarseness caused by adductor spasmodic dysphonia. The panel offered as options that 1) the clinician may perform laryngoscopy at any time in a patient with hoarseness, or may refer the patient to a clinician who can visualize the larynx; 2) the clinician may prescribe anti-reflux medication for patients with hoarseness and signs of chronic laryngitis; and 3) the clinician may educate/counsel patients with hoarseness about control/preventive measures. Disclaimer: This clinical practice guideline is not intended as a sole source of guidance in managing hoarseness (dysphonia). 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 may not provide the only appropriate approach to diagnosing and managing this problem.
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Sivasankar M, Blazer-Yost B. Effects of long-acting beta adrenergic agonists on vocal fold ion transport. Laryngoscope 2009; 119:602-7. [DOI: 10.1002/lary.20091] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Menstrual Cycle Influences on Voice and Speech in Adolescent Females. J Voice 2009; 23:109-13. [DOI: 10.1016/j.jvoice.2007.03.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2006] [Accepted: 03/01/2007] [Indexed: 11/23/2022]
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Bhalla RK, Watson G, Taylor W, Jones AS, Roland NJ. Prospective, randomized cross-over trial to assess the ability of a dry-powder inhaler to reverse the local side effects of pressurized metered-dose inhalers. J Asthma 2008; 45:814-9. [PMID: 18972301 DOI: 10.1080/02770900802311485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To determine whether a corticosteroid dry-powder inhaler could reverse the pharyngeal and laryngeal side effects produced by a corticosteroid pressurised metered-dose inhaler. DESIGN Prospective, randomized, controlled, cross-over, evaluator-blinded study. SETTING University Hospital Aintree, Liverpool, United Kingdom. PATIENTS Thirty-seven adults recruited over a 12-month period from Ear, Nose and Throat clinics at our University hospital. Patients were randomized into three groups using a computer-generated random number list and sealed opaque envelopes. MAIN OUTCOME MEASURES Scores were achieved on respiratory symptom and vocal performance questionnaires. Acoustic analysis was performed followed by a standardized biopsy of the posterior pharyngeal wall. Histological markers of inflammation were correlated with pharyngitis. The data were tested for normality using the Kalmogorov-Smirnov test. The Kruskal-Wallis analysis of variance was used to investigate differences between medians and ranges. The data were further investigated for correlations using the Spearman test. Discriminant analysis was used to examine the effect of the three groups on each variable. RESULTS Discomfort scores (median and range) were significantly lower after dry-powder inhaler use than with either a spacer or water gargle (p < 0.01). These worsened after restoring pressurized metered-dose inhaler therapy. The reduction in pharyngitis in each of the three groups was not significant. Vocal performance scores improved with dry-powder inhaler use. Jitter, shimmer, and closed-phase quotient scores improved with dry-powder inhaler use (p < 0.01). Shimmer scores deteriorated once the pressurized metered-dose inhaler was restored (p < 0.01). There was no significant difference between the groups in most observed parameters of inflammation (p > 0.01). CONCLUSION A dry-powder inhaler may alleviate the local side effects produced by a pressurized metered-dose inhaler. Laryngeal dysfunction appears to be particularly responsive to the absence of propellant. More observational and randomized controlled trials are necessary to examine existing inhalers and specifically, how and why they cause local side effects.
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Affiliation(s)
- R K Bhalla
- Department of Otolaryngology, Head & Neck Surgery, University Hospital Aintree, Liverpool, UK.
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Bhalla RK, Watson G, Taylor W, Jones AS, Roland NJ. Acoustic analysis in asthmatics and the influence of inhaled corticosteroid therapy. J Voice 2008; 23:505-11. [PMID: 18346871 DOI: 10.1016/j.jvoice.2007.11.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2007] [Accepted: 11/01/2007] [Indexed: 10/22/2022]
Abstract
The impact of sustained inhaled corticosteroid (ICS) therapy on the larynx and pharynx was assessed using a prospective, cross-sectional, and investigator-blinded study conducted at the University Hospital Aintree, Liverpool, UK. Forty-six adults recruited from two local general practices and from general ENT clinics at our University hospital were investigated for the study. Patients were allocated to three groups according to ICS use. Laryngeal effects were measured by correlating the results of a vocal performance questionnaire, a respiratory symptom questionnaire, and measurements obtained by computerized speech analysis. Sustained vowels and connected speech were analyzed in normal and asthmatic subjects. Acoustic analysis was correlated with cellular markers of inflammation after biopsy. Regular ICS users had significantly more pharyngeal inflammation and throat discomfort (P<0.0001). Vocal performance was also worse in this group (P<0.0001). They were more likely to have hoarseness, weakness of voice, aphonia, sore throat, throat irritation, and cough (P<0.0001). All these variables were directly related to one another (P<0.0001). Multiple linear regression analysis showed that jitter was a good objective measure of hoarseness (P<0.05). Regular ICS users were significantly more likely to have abnormal jitter, shimmer, and closed-phase quotient scores (P<0.0001). There was no difference between the groups in the observed parameters of inflammation (P>0.01). A higher pharyngitis score did not correlate with any of the histological markers of inflammation (P>0.01). Local side effects are more common in asthmatics that use ICS regularly. Measures of laryngeal function are significantly worse in regular ICS users. However, histological markers and oropharyngeal redness are not reliable measures of inflammation.
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Affiliation(s)
- R K Bhalla
- Department of Otolaryngology, University Hospital Aintree, Liverpool, United Kingdom.
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Laforest L, Van Ganse E, Devouassoux G, Osman LM, Bauguil G, Chamba G. Patient-reported adverse events under asthma therapy: a community pharmacy-based survey. Clin Pharmacol Ther 2007; 82:167-72. [PMID: 17495876 DOI: 10.1038/sj.clpt.6100224] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The characteristics of patients who report adverse events (AEs) attributed to asthma therapy have been little investigated. Asthma patients aged 18-50 years were surveyed in pharmacies. Patients completed a questionnaire linked to computerized records of dispensed medications. Patients reported all AEs that they attributed to asthma therapy. The correlates of reporting 2+ AEs were identified. Almost 59% of the 1,351 patients (mean age: 37, 56% females) attributed AEs to asthma therapy, and 35% at least two. Most common AEs included tiredness (21.8%) and palpitations (21.1%). Poor asthma control and perception of asthma as a handicap were the major correlates of reporting 2+ AEs (odds ratio (OR)=2.5, 95% confidence interval (CI)=[1.7-3.7] and OR=1.9, 95% CI=[1.4-2.5]). Other significant correlates included age >30 years, female gender, and receiving psychotropic therapy. Inadequate control may partly account for AEs attributed by patients to asthma therapy. Improving patients' education may help to improve acceptability of asthma therapy.
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Branski RC, Verdolini K, Sandulache V, Rosen CA, Hebda PA. Vocal Fold Wound Healing: A Review for Clinicians. J Voice 2006; 20:432-42. [PMID: 16324825 DOI: 10.1016/j.jvoice.2005.08.005] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2005] [Accepted: 08/10/2005] [Indexed: 11/30/2022]
Abstract
SUMMARY The basic science of wound healing is largely omitted from the curriculum of many voice clinicians. This fact is relatively disheartening as most therapeutic manipulation in the realm of laryngology and voice disorders deals with injured tissue. Therefore, the selection of therapeutic tasks for persons with vocal injury should ideally be informed by basic science in wound healing. Recently, several investigators have initiated lines of research to determine the course of vocal fold wound healing and the potential role of therapeutic agents, including behavioral agents. The current review seeks to provide a foundation of basic wound healing science and present the most current data regarding the wound healing process in the vocal folds.
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Affiliation(s)
- Ryan C Branski
- Department of Head and Neck Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
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Dogan M, Eryuksel E, Kocak I, Celikel T, Sehitoglu MA. Subjective and objective evaluation of voice quality in patients with asthma. J Voice 2006; 21:224-30. [PMID: 16504474 DOI: 10.1016/j.jvoice.2005.11.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2005] [Accepted: 11/11/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVES To evaluate the voice quality in patients with mild-to-moderate asthma by subjective and objective methods. STUDY DESIGN Comparative, controlled, cross-sectional study. METHODS Patients with mild-to-moderate asthma (n=40) and age- and sex-matched healthy controls (n=40) were included. Acoustic analyses were performed by the Multi-Dimensional Voice Program (MDVP; Kay Elemetrics Corporation, Lincoln Park, NJ) and the movements of the vocal cords were examined by videolaryngostroboscopy (VLS). In addition, the duration of illness, maximum phonation time, "s/z" values, and vital capacity were evaluated. Voice Handicap Index (VHI) and GRB scales were used for subjective evaluations. RESULTS Maximum phonation time values were significantly shorter both in male and female asthma patients compared with controls (P<0.0001). Also, average shimmer values in MDVP were higher for both sexes in the patient group compared with controls (P=0.002 and P=0.04, respectively). There was a significant difference between female patients and sex-matched controls with regard to mean noise-to-harmonic ratio values (P=0.006). Female patients with asthma had higher average jitter values compared with sex-matched controls (P<0.0001). A significant difference was noted between asthma and control groups with regard to GRB scale (P<0.0001, P<0.001, and P<0.0001, respectively). The VHI score was above the normal limit in 16 (40%), and VLS findings were abnormal in 39 (97.5%) asthmatics. CONCLUSION In asthmatic patients, maximum phonation time, frequency, and amplitude perturbation parameters were impaired, but the vital capacity and the duration of illness did not correlate with these findings.
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Affiliation(s)
- Muzeyyen Dogan
- Marmara University School of Medicine, Department of Otorhinolaryngology Head and Neck Surgery, Istanbul, Turkey.
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Abstract
PURPOSE OF REVIEW In this article, we illustrate the evolution of studies that contribute to a better understanding of vocal care for professional voice users and singers in particular. RECENT FINDINGS Research on vocal hygiene is specific, focusing on concrete solutions. It has commonly been believed that hydration and vocal rest are beneficial; recent research proves this supposition. An exhaustive medical diagnosis and careful therapy is stressed to detect and treat any micro-organic lesions caused by reflux, infection, allergy and environmental circumstances, which can harm a singer's voice. The use of medication is reviewed and side effects are evaluated. SUMMARY Vocal coaches, speech therapists and otolaryngologists need to focus more specifically on the management of vocal care. Accurate medical diagnosis and specific guidelines for singers must be provided as higher voice demands imply more profound and structured voice care. In the past, vocal hygiene had a negative connotation; a more positive and supporting approach to voice care, with more attention to the singer, is recommended.
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