Challenges and opportunities in the management of the aging voice

Laryngologists' Reported Decision-Making in Presbyphonia Treatment

OBJECTIVE

Decision-making regarding behavioral versus procedural intervention in the treatment of presbyphonia has not been well defined. The study objective was to survey laryngologists' reported practice patterns and decision-making in presbyphonia.

METHODS

All laryngology faculty in U.S. academic medical centers with residency programs were recruited to complete an anonymous 29-item survey regarding decision-making in presbyphonia treatment. The survey included 5 sections: demographics, first-line treatment distribution, factors that drive decision-making toward procedural intervention, treatment progression if first-line treatment is insufficient, durable treatment.

RESULTS

Of 153 laryngologists surveyed, 89 responded (58%). Voice therapy (VT) was the most often reported first-line treatment, with 57% of respondents indicating the majority of their patients receive VT initially. Most respondents (83%) indicated they occasionally use procedural intervention as first-line treatment. Factors driving first-line procedural intervention were severe glottal insufficiency (87%), high occupational/social voice demands (76%), voice not stimulable for change (73%), difficulty attending VT (70%), severe dysphonia (65%), and dysphagia (61%). The majority of respondents indicated the following do not affect their decision to pursue procedural intervention: patient age (88%); medical comorbidities (63%); patient's desire for a "quick fix" (55%); patient-reported outcome measures (51%). Most respondents (81%) use trial injection augmentation before durable treatment. Of durable treatments, bilateral thyroplasty was preferred (71%), followed by CaHA (15%) and lipoinjection (11%).

CONCLUSIONS

This study is the first to our knowledge to examine factors that influence decision-making in presbyphonia treatment. While VT remains the most frequent first-line treatment, study results better inform decision-making regarding first-line procedural intervention.

Preliminary assessment of portable sleep monitoring for diagnosis of obstructive sleep apnea in children

OBJECTIVE

By observing the differences in sleep parameters between portable sleep monitoring (PM) and polysomnography (PSG) in children, we aimed to investigate the diagnostic value and feasibility of PM in children with suspected obstructive sleep apnea (OSA).

STUDY DESIGN

This prospective study enrolled consecutive children (aged 3-14 years) with suspected OSA in Shenzhen Children's Hospital. They had PSG and PM in the sleep laboratory. Clinical parameters of the two sleep monitoring methods were compared.

RESULTS

A total of 58 children participated. They were classified into two groups according to age: 28 children aged 3 to 5 years and 30 children aged 6 to 14 years. No significant differences were observed in apnea-hypopnea index (AHI), lowest oxygen saturation (LSaO2), and mean oxygen saturation (MSaO2) between PM and PSG, but the sleep efficiency with PM was significantly higher (3-5 years age: 92.2 ± 11.3% vs 85.2 ± 14.3%, 6-14 years age: 93.2 ± 14.5% vs 84.8 ± 16.3%, both P < 0.05) than the sleep efficiency with PSG. Pearson correlation analysis indicated a strong correlation between AHI, LSaO2, MSaO2, and sleep efficiency measured by PSG and PM. Receiver operating characteristic curve (ROC) analysis showed that PM was a reliable diagnostic tool for OSA. PM has high sensitivity (3-5 years age: 95.8%, 6-14 years age: 96.3%) and low specificity (3-5 years age: 25.0%, 6-14 years age: 33.3%) for OSA in children. Thus, there is a low rate of missed diagnoses, but there is some inaccuracy in excluding children who do not have OSA.

CONCLUSION

The results showed that PM has a good correlation with the various parameters of PSG. PM may be a reliable tool for diagnosing moderate and severe OSA in children, especially those who cannot cooperate with PSG or who have limited access to PSG.

Voice and Communication in News Anchors: What is the Impact of the Passage of Time?

INTRODUCTION

News anchors, as high-performance voice professionals, may be subject to voice and communication changes throughout their careers.

OBJECTIVE

To compare the overall degree of vocal deviation, use of vocal and nonverbal resources, pleasantness and expressiveness of Brazilian journalists - news anchors - at 2 time points: at the beginning of their career and late in their career, when they are at an old age.

METHODS

A longitudinal observational study that analyzed voice samples collected indirectly from 20 professional male journalists at 2 time points with a minimum interval of 25 years: at the beginning of the career (T1) and at present (T2). The journalists were 60 years old or older, and the samples were narratives with similar communicative content. The overall degree of vocal deviation and use of vocal resources (presence/absence of vocal alteration, vocal attack, loudness, pitch, resonance, articulation of speech sounds, speech speed and breath-speech coordination) and nonverbal resources (emphasis, pauses, rhythm and loudness and pitch variations) were analyzed. Nine judges analyzed the expressiveness and pleasantness of the participants' voices.

THE RESULTS

The mean age of the participants was 38.6 years at T1 and 73.7 years at T2. Differences observed between T1 and T2 included greater overall degree of deviation at T2; greater presence of vocal alterations; and worsening of vocal attack, loudness, pitch, articulation and breath-speech coordination. A directly proportional correlation between pleasantness and expressiveness and an inversely proportional correlation between pleasantness and expressiveness and the overall degree of vocal deviation were observed.

CONCLUSION

Worsening of some vocal aspects was observed; however, the participants' nonverbal characteristics, pleasantness and expressiveness were unchanged throughout their careers.

Do You Like Your Voice? A Population-Based Survey of Voice Satisfaction and Voice Enhancement

OBJECTIVES

Voice enhancement for patients without obvious vocal pathology or loss of function is rarely discussed clinically or in academic research. Our objectives were to: (1) determine voice satisfaction on a population level, and (2) assess willingness to consider interventions to change one's voice.

METHODS

A standardized questionnaire was created to assess current and past voice disorders. Questions assessed demographics, health status, prevalence of voice disorders, and questions regarding satisfaction with voice. Iterative survey testing and piloting were performed. A cohort with age, gender, and geographic distribution of the general adult population was then queried in an online survey. Qualitative analysis and both descriptive and multivariate statistics were performed.

RESULTS

A total of 1522 respondents were included, with an age, gender, and regional distribution reflective of the US population. A minority (38.8%) of respondents reported that they did not like the sound of their own voice in normal conversation; when asked about listening to a recording of their own voice, a majority (57.5%) reported dissatisfaction with voice. Discontent with one's voice was associated with being middle age (p = 0.005), female gender (p < 0.0001), and white race (p < 0.0001). Approximately 50.6% of respondents without a history of dysphonia would consider interventions to change their voice. Of those who indicated they may elect to change their voice, qualities regarding clarity and pitch were paramount.

CONCLUSION

Dissatisfaction with one's speaking voice is common. A considerable percentage of the general population without a voice disorder would consider interventions to change their voice.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3455-3461, 2023.

Predicting Airflow from Measures Sensitive to Mid-cord Glottal Gap During the COVID-19 Pandemic

OBJECTIVES

To determine if trans-laryngeal airflow, important in assessing vocal function in paresis/paralysis and presbylarynges patients with mid-cord glottal gaps, could be predicted by other measures sensitive to mid-cord glottal gap size but with smaller risks of spreading COVID-19, and if any patient factors need consideration.

METHODS

Four populations were: unilateral vocal fold paresis/paralysis (UVFP, 148), aging and UVFP (UVFP plus aging, 22), bilateral vocal fold paresis/paralysis without airway obstruction (BVFP, 49), and presbylarynges (66). Five measures were selected from the initial clinic visit: mean airflow from repeated /pi/ syllables, longer of 2 /s/ and 2 /z/ productions, higher of 2 cepstral peak prominence smoothed for vowel /a/ (CPPSa), and Glottal Function Index (GFI). S/Z ratios were computed. Stepwise regression models used 3 measures and 5 patient factors (age, sex, etiology, diagnosis, and potentially impaired power source for voicing) to predict airflow.

RESULTS

Log-transformations were required to normalize distributions of airflow and S/Z ratio. The final model revealed age, sex, impaired power source, log-transformed S/Z ratio, and GFI predicted log-transformed airflow (R2 = .275, F[5,278] = 21.1; P < .001).

CONCLUSIONS

The amount of variance explained by the model was not high, suggesting adding other predictive variables to the model might increase the variance explained.

Voice analysis results in individuals with Alzheimer's disease: How do age and cognitive status affect voice parameters?

BACKGROUND

Reports of acoustic changes in the voice in individuals with Alzheimer's disease (AD) and the relationship of acoustic changes with age and cognitive status are still limited.

OBJECTIVE

This study aims to determine the changes in voice analysis results in AD, as well as the effects of age and cognitive status on voice parameters.

METHODS

The study included 47 (AD: 30; healthy: 17) women with a mean age of 76.13 years. The acoustic voice parameters mean fundamental frequency (F0), relative average perturbation (RAP), jitter percent (Jitt), shimmer percent (Shim), and noise-to-harmonic ratio were detected. The mini-mental state examination (MMSE) was utilized.

RESULTS

F0, Shim, Jitt, and RAP values were found to be statistically significantly higher in individuals with AD compared to healthy individuals. There was a significant negative correlation between MMSE and F0, Jitt, RAP and Shim, and the MMSE score had a significant negative effect on F0, Jitt, and RAP (p < .05).

CONCLUSION

Cognitive status was discovered to significantly impact the voice, with fundamental frequency and frequency and amplitude perturbations increasing as cognitive level decreases. In order to contribute to the therapy process for voice disorders, cognitive functions can be focused on in addition to voice therapy.

Effect of Aging on Vocal Outcomes After Laryngeal Reinnervation Combined With Arytenoid Adduction

OBJECTIVE

To evaluate the impact of aging on vocal function following laryngeal reinnervation combined with arytenoid adduction (AA) in the treatment of paralytic dysphonia.

METHODS

Sixty-eight patients with unilateral vocal fold paralysis who underwent refined nerve-muscle pedicle flap (NMP) implantation and AA were classified into four groups according to age: under 50 years (-50), in their 50s, 60s, and 70 years and older (70+). These groups consisted of 15, 14, 22, and 17 patients, respectively. Their vocal function was followed periodically for 24 months after surgery.

RESULTS

Vocal function in all groups showed significant improvement after surgery. Significant improvements in vocal function were observed during a 24-month follow-up period: maximum phonation time in the -50 and 50 seconds groups; pitch range and voice handicap index-10 in the -50, 50s, and 60s groups; "Grade" in the -50, 50s, and 70+ groups; and "Breathiness" and voice-related quality of life in all groups. There were no significant differences in vocal function among the four groups, except for pitch range, at the 24-month postoperative assessment.

CONCLUSIONS

Although the younger groups tended to exhibit better vocal function compared to the older groups 24 months postoperatively, the refined NMP+AA proved effective in the treatment of breathy dysphonia resulting from unilateral vocal fold paralysis, not only in the younger population but also in the older population.

A 4-Week Straw Phonation in Water Exercise Program for Aging-Related Vocal Fold Atrophy

PURPOSE

This study evaluated the efficacy of a 4-week straw phonation in water (SPW) exercise program on aging-related vocal fold atrophy (VFA), with a secondary objective to examine the immediate effects of SPW exercises.

METHOD

Thirty-eight older adults aged 60 years and above formally diagnosed with aging-related VFA were randomly assigned into an experimental group undergoing SPW exercises with an 8-cm depth of straw submersion into water for 4 weeks plus vocal hygiene practice (n = 20), and a control group with only vocal hygiene practice (n = 18). Outcome measures included laryngeal endoscopic measures of glottal gap, auditory-perceptual ratings of voice quality, acoustic measures, aerodynamic measures, and standardized self-assessment questionnaire scores. An additional round of acoustic and aerodynamic assessment following 20 min of SPW exercises was conducted to examine the immediate effects.

RESULTS

Significant improvements in normalized glottal gap area, perceptual rating of breathiness, smoothed cepstral peak prominence, harmonics-to-noise ratio (HNR), mean oral airflow, subglottal pressure and laryngeal airway resistance at comfortable loudness, Voice-related Quality of Life scores, and Chinese Vocal Fatigue Index Factor 3 scores were observed in the experimental group relative to the control group. There were also significant immediate effects for HNR, mean oral airflow, subglottal pressure, and laryngeal airway resistance.

CONCLUSIONS

These findings suggested significant immediate improvements in vocal function following SPW exercises, with additional significant improvements in vocal function as well as significant improvements in quality of life following the 4-week SPW exercise program. Further studies with more long-term follow-up are recommended to better understand the efficacy of SPW exercises with deep levels of straw submersion into water as an effective clinical option for the management of hypofunctional dysphonia associated with aging-related VFA.

Severe Pediatric Sleep Apnea: Drug-Induced Sleep Endoscopy Based Surgery

Although adenotonsillectomy is the recommended treatment of obstructive sleep apnea (OSA) in children, some patients with preoperative severe OSA (Apnea-hypopnea index/AHI > 10) remain symptomatic after surgery and may need further workup. This study aims to: (1) analyse preoperative factors and its relation with surgical failure/persistent OSA (AHI > 5 after adenotonsillectomy) in severe pediatric OSA; (2) determine the levels of airway collapse during DISE (drug induced sleep endoscopy) in cases of surgical failure; (3) evaluate the efficacy of targeted surgery based on DISE findings. This retrospective study was conducted between August and September 2020. Across 9 years (from 2011 to 2020), all children diagnosed with severe OSA in our Hospital underwent adenotonsillectomy and repeated type 1 polysomnography (PSG) 3 months after surgery. Cases of surgical failure underwent DISE for planning eventual directed surgery. Chi-square test was used to assess the relationship between persistent OSA and preoperative patients' characteristics. 80 cases of severe pediatric OSA were diagnosed (68.8% males; mean age: 4.3 years-standard deviation: 2.49; mean AHI: 16.3-standard deviation 7.14) in the aforementioned period. We found a significant association between surgical failure (11.3% of cases; mean AHI: 6.9-SD 0.91) and obesity (p = 0.002; confidence level of 95%). Neither preoperative AHI nor other PSG parameters were associated with surgical failure. In cases of surgical failure, epiglottis collapse was present in every DISEs and adenoid tissue was present in 66% of children. All cases of surgical failure had directed surgery and surgical cure (AHI ≤ 5) was obtained in 100% of cases. This study suggests that obesity is the strongest predictor of surgical failure in children with severe OSA who undergo adenotonsillectomy. Epiglottis collapse and presence of adenoid tissue are the most common findings in postoperative DISEs of children with persistent OSA after primary surgery. DISE based surgery seems a safe and effective tool to manage persistent OSA after adenotonsillectomy.

Presbylarynx: Is it Possible to Predict Glottal Gap by Cut-Off Points in Auto-Assessment Questionnaires?

PURPOSE

To determine cut-off points in auto-assessment questionnaires to predict the presence and extent of presbylarynx signs.

METHOD

This case control, prospective, observational, and cross-sectional study was carried out on consecutive subjects observed by Otorhinolaryngology, in a tertiary center, in 2020. Each subject underwent fiberoptic videolaryngoscopy with stroboscopy, and presbylarynx was considered when it was identified two or more of the following endoscopic findings: vocal fold bowing, prominence of vocal processes in abduction, and a spindle-shaped glottal gap. Each subject completed three questionnaires: the Voice Handicap Index (VHI), with 30 and 10 questions, and the "Screening for voice disorders in older adults questionnaire" (RAVI).

RESULTS

The studied population included 174 Caucasian subjects (60 males; 114 females), with a mean age of 73.99 years (standard deviation = 6.37; range 65-95 years). Presbylarynx was identified in 71 patients (41%). Among patients with presbylarynx, a glottal gap was identified in 22 patients (31%). The mean score of VHI-30 between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. The presence of glottal gap was associated to a higher mean score of VHI-30 (41.64 ± 11.87) (P < 0.001). The mean score of VHI-10 between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. Among patients with presbylarynx, the presence of glottal gap was associated to higher mean score of VHI-10 (14.04 ± 3.91) (P < 0.001). There was a strong positive correlation between VHI-30 and VHI-10 (rs = 0.969; P < 0.001). The mean score of RAVI between "no presbylarynx" and "presbylarynx" groups was statistically different (P < 0.001), with a higher score for subjects with signs of presbylarynx. Among patients with presbylarynx, the presence of glottal gap was associated to a higher mean score of RAVI (11.68 ± 1.61) (P < 0.001). There was a strong positive correlation not only between RAVI and VHI-30 (rs = 0.922; P < 0.001), but also between RAVI and VHI-10 (rs = 0.906; P < 0.001). The optimal cut-off points to discriminate "no presbylarynx" from "presbylarynx", obtained by the Youden' index, were 3.5 for RAVI, 4.5 for VHI-30 and 1.5 for VHI-10. RAVI had the highest sensitivity and specificity. The optimal cut-off points to predict glottal gap, obtained by the Youden' index, were 9.5 for RAVI, 21 for VHI-30 and 7.5 for VHI-10.

CONCLUSION

The optimal cut-off points do discriminate "no presbylarynx" from "presbylarynx" were 3.5 for RAVI, 4.5 for VHI-30 and 1.5 for VHI-10. RAVI had the highest sensitivity and specificity, probably because it was designed specifically for vocal complaints of the elderly. Among patients with presbylarynx, cut-off points of 9.5 for RAVI, 21 for VHI-30 and 7.5 for VHI-10 were determined to predict patients with and without glottal gap. It was found a strong positive correlation between RAVI, VHI-30 and VHI-10. Thus, VHI-10 can be preferred to VHI-30 to assess voice impairment in clinical practice, because for elderly patients it is easier to answer. However, to predict endoscopic signs of presbylarynx, RAVI should be preferred.

A Comprehensive Analysis of Age and Gender Effects in European Portuguese Oral Vowels

The knowledge about the age effects in speech acoustics is still disperse and incomplete. This study extends the analyses of the effects of age and gender on acoustics of European Portuguese (EP) oral vowels, in order to complement initial studies with limited sets of acoustic parameters, and to further investigate unclear or inconsistent results. A database of EP vowels produced by a group of 113 adults, aged between 35 and 97, was used. Duration, fundamental frequency (f0), formant frequencies (F1 to F3), and a selection of vowel space metrics (F1 and F2 range ratios, vowel articulation index [VAI] and formant centralization ratio [FCR]) were analyzed. To avoid the arguable division into age groups, the analyses considered age as a continuous variable. The most relevant age-related results included: vowel duration increase in both genders; a general tendency to formant frequencies decrease for females; changes that were consistent with vowel centralization for males, confirmed by the vowel space acoustic indexes; and no evidence of F3 decrease with age, in both genders. This study has contributed to knowledge on aging speech, providing new information for an additional language. The results corroborated that acoustic characteristics of speech change with age and present different patterns between genders.

Voice biomarkers as indicators of cognitive changes in middle and later adulthood

Voice prosody measures have been linked with Alzheimer's disease (AD), but it is unclear whether they are associated with normal cognitive aging. We assessed relationships between voice measures and 10-year cognitive changes in the MIDUS national sample of middle-aged and older adults ages 42-92, with a mean age of 64.09 (standard deviation = 11.23) at the second wave. Seven cognitive tests were assessed in 2003-2004 (Wave 2) and 2013-2014 (Wave 3). Voice measures were collected at Wave 3 (N = 2585) from audio recordings of the cognitive interviews. Analyses controlled for age, education, depressive symptoms, and health. As predicted, higher jitter was associated with greater declines in episodic memory, verbal fluency, and attention switching. Lower pulse was related to greater decline in episodic memory, and fewer voice breaks were related to greater declines in episodic memory and verbal fluency, although the direction of these effects was contrary to hypotheses. Findings suggest that voice biomarkers may offer a promising approach for early detection of risk factors for cognitive impairment or AD.

Stem cell therapy for vocal fold regeneration after scarring: a review of experimental approaches

This review aims at becoming a guide which will help to plan the experimental design and to choose adequate methods to assess the outcomes when testing cell-based products in the treatment of the damaged vocal folds. The requirements to preclinical trials of cell-based products remain rather hazy and dictated by the country regulations. Most parameters like the way the cells are administered, selection of the cell source, selection of a carrier, and design of in vivo studies are decided upon by each research team and may differ essentially between studies. The review covers the methodological aspects of preclinical studies such as experimental models, characterization of cell products, assessment of the study outcome using molecular, morphological and immunohistochemical analyses, as well as measuring the tissue physical properties. The unified recommendations to perform preclinical trials could significantly facilitate the translation of cell-based products into the clinical practice.

Laryngoscopic Findings of Age-related Vocal Fold Atrophy are Reliable but not Specific

OBJECTIVES

We aimed to evaluate the reliability of laryngoscopic features of vocal fold atrophy as assessed by novice otolaryngology trainees and expert laryngologists.

DESIGN

Two expert fellowship-trained laryngologists and three non-expert otolaryngology resident trainees were recruited to view 50 anonymized laryngo-stroboscopic examinations of patients presenting with dysphonia and non-voice, laryngeal complaints. Reviewers were asked to stratify the patient's age, provide an opinion about the presence of age-related vocal fold atrophy, and specify which laryngoscopy features were present to make the diagnosis.

SETTING

Tertiary care laryngology practice.

PARTICIPANTS

Two fellowship-trained laryngologists and three trainee otolaryngologists.

MAIN OUTCOME MEASURES

Accuracy of age categorization was determined and Kappa analysis was performed to assess inter-rater agreement.

RESULTS

The mean age of patients was 54.9 years old with near equal male to female distribution. The overall accuracy of age category determination by raters was only 30.8%. Kappa analysis demonstrated fair agreement regarding the presence of vocal fold atrophy in non-expert reviewers, and moderate agreement amongst expert reviewers. Features of glottic gap, muscular atrophy of vocal folds, and prominent vocal processes were all identified with high agreement (>80.0%).

CONCLUSION

Our study illustrates that while raters can agree on the presence of age-related vocal fold atrophy, the findings may be non-specific and do not necessarily correlate with age.

Deep Learning Application for Vocal Fold Disease Prediction Through Voice Recognition: Preliminary Development Study

Background

Dysphonia influences the quality of life by interfering with communication. However, a laryngoscopic examination is expensive and not readily accessible in primary care units. Experienced laryngologists are required to achieve an accurate diagnosis.

Objective

This study sought to detect various vocal fold diseases through pathological voice recognition using artificial intelligence.

Methods

We collected 189 normal voice samples and 552 samples of individuals with voice disorders, including vocal atrophy (n=224), unilateral vocal paralysis (n=50), organic vocal fold lesions (n=248), and adductor spasmodic dysphonia (n=30). The 741 samples were divided into 2 sets: 593 samples as the training set and 148 samples as the testing set. A convolutional neural network approach was applied to train the model, and findings were compared with those of human specialists.

Results

The convolutional neural network model achieved a sensitivity of 0.66, a specificity of 0.91, and an overall accuracy of 66.9% for distinguishing normal voice, vocal atrophy, unilateral vocal paralysis, organic vocal fold lesions, and adductor spasmodic dysphonia. Compared with the accuracy of human specialists, the overall accuracy rates were 60.1% and 56.1% for the 2 laryngologists and 51.4% and 43.2% for the 2 general ear, nose, and throat doctors.

Conclusions

Voice alone could be used for common vocal fold disease recognition through a deep learning approach after training with our Mandarin pathological voice database. This approach involving artificial intelligence could be clinically useful for screening general vocal fold disease using the voice. The approach includes a quick survey and a general health examination. It can be applied during telemedicine in areas with primary care units lacking laryngoscopic abilities. It could support physicians when prescreening cases by allowing for invasive examinations to be performed only for cases involving problems with automatic recognition or listening and for professional analyses of other clinical examination results that reveal doubts about the presence of pathologies.

Evaluating Safety of Awake, Bilateral Injection Laryngoplasty for Bilateral Vocal Fold Atrophy

OBJECTIVE

Office-based injection laryngoplasty (IL) has emerged as a useful procedure for otolaryngologists to correct glottic insufficiency while avoiding the costs and risks of general anesthesia. This is the first study focused on addressing the safety of bilateral IL for bilateral vocal fold (VF) atrophy.

METHODS

Patient records were reviewed from Emory University Hospital Midtown during the period of 2005 to 2017. Patients who underwent awake, bilateral transthyrohyoid, transoral, transcricothyroid, or transthyroid cartilage IL for bilateral VF atrophy were analyzed. All procedures, including repeat injections, were bilateral. Complication rate was used to evaluate safety. Patients with vocal cord paralysis, paresis, scar, and sulcus were excluded from the study.

RESULTS

Total 174 procedures met inclusion criteria. There were four complications, yielding a complication rate of 2.3%. Complications included aborted cases for difficult anatomy or poor patient tolerance, injection material not resorbing, and a VF hematoma. No patients had any airway emergencies or required admission to the hospital or evaluation in the emergency room.

CONCLUSIONS

This study illustrates a low complication rate for awake, bilateral IL in treating bilateral VF atrophy. This supports other studies that promote the safety of this procedure in the awake setting. Complications were associated with patient tolerance, unique anatomy, and in one case, anticoagulant medication. The low complication rate supports the conclusion that bilateral medialization IL is safe to perform in the office-based, awake setting.

Effects of thyroplasty implant stiffness on glottal shape and voice acoustics

OBJECTIVES

Vocal fold (VF) stiffness and geometry are determinant variables in voice production. Type 1 medialization thyroplasty (MT), the primary surgical treatment for glottic insufficiency, changes both of these variables. Understanding the cause and effect relationship between these variables and acoustic output might improve voice outcomes after MT. In this study, the effects of thyroplasty implants with variable stiffness on glottal shape and acoustics were investigated.

METHODS

In an ex vivo human larynx phonation model, bilateral MT with implants of four stiffness levels (1386, 21.6, 9.3, and 5.5 kPa) were performed. Resulting acoustics and aerodynamics were measured across multiple airflow levels. A vertical partial hemilaryngectomy was performed and stereoscopic images of the VF medial surface taken to reconstruct its three-dimensional (3D) surface contour. The results were compared across implants.

RESULTS

The effects of implant stiffness on acoustics varied by airflow. Softer implants resulted in improved acoustics, as measured by cepstral peak prominence (CPP), at lower airflow levels compared to stiffer implants but this relationship reversed at high airflow levels. Stiffer implants generally required less airflow to generate a given subglottal pressure. Stiffer implants resulted in greater medialized surface area and maximal medialization, but all implants had similar effects on overall VF medial surface contour.

CONCLUSION

Softer implants result in less medialization but better acoustics at low airflow rates. Stiffer implants provide better acoustics and more stable pressure-flow relationships at higher airflow rates. This highlights a potential role for patient-specific customized thyroplasty implants of various stiffness levels.

LEVEL OF EVIDENCE

NA.

Vocal Fold Vibration in Older Adults With and Without Age-Related Dysphonia

PURPOSE

The purpose of this study was to identify the extent to which 7 measures of glottal area timing and regularity differ between older adults with and without age-related dysphonia (ARD).

METHOD

Laryngeal high-speed videoendoscopy was completed at 4,000 frames per second for 42 adults aged 70 years and older (ARD: 9 female, 5 male; control group: 15 female, 13 male). Relative glottal gap, open quotient, speed index, maximum area declination rate, harmonics-to-noise ratio, harmonic richness factor, and standard deviation of fundamental frequency were measured from a 0.5-s segment of the glottal area waveform. Eta squared (η2) was computed to estimate group effect.

RESULTS

Small effect sizes (η2 = .18-.35) were present for relative glottal gap, open quotient, maximum area declination rate, harmonic richness factor, and standard deviation of fundamental frequency. Speed index and glottal harmonics-to-noise ratio did not explain group membership (η2 = .001 and .05, respectively).

CONCLUSION

These findings provide evidence that vocal fold vibration in ARD is different than in normal aging, whereas the overlap in values for every measure is consistent with the concept that normal aging and ARD exist as a continuum of health and disease.

Effects of Aging on Vocal Fundamental Frequency and Vowel Formants in Men and Women

PURPOSE

This study reports data on vocal fundamental frequency (f_o) and the first four formant frequencies (F1, F2, F3, F4) for four vowels produced by speakers in three adult age cohorts, in a test of the null hypothesis that there are no age-related changes in these variables. Participants were 43 men and 53 women between the ages of 20 and 92 years.

RESULTS

The most consistent age-related effect was a decrease in f_o for women. Significant differences in F1, F2, and F3 were vowel-specific for both sexes. No significant differences were observed for the highest formant F4.

CONCLUSIONS

Women experience a significant decrease in f_o, which is likely related to menopause. Formant frequencies of the corner vowels change little across several decades of adult life, either because physiological aging has small effects on these variables or because individuals compensate for age-related changes in anatomy and physiology.

Medialization Laryngoplasty in the Elderly: Outcomes and Expectations

Objective

To describe the profile and outcomes of elderly patients undergoing medialization laryngoplasty for vocal cord paralysis.

Study Design

Case series with retrospective review.

Setting

Tertiary care hospital.

Subjects and Methods

Patients were included in the study if they were >65 years old at the time of medialization laryngoplasty between 2008 and 2015. Patient comorbidities, anticoagulation status, disease etiology, and physical examination findings were recorded with postoperative length of stay, complications, pre- and posttreatment voice outcomes with the Voice Handicap Index (at 6 weeks, 4 months, 8 months, and 1 year), and postprocedural interventions (revision injections, surgery, therapy).

Results

A total of 112 patients met the eligibility criteria. Iatrogenic injury to the recurrent laryngeal nerve (50%) was the most common etiology, followed by idiopathic (31%) causes. Sixty percent of patients were receiving long-term antiplatelet and/or anticoagulation therapy. All but 14 patients on aspirin therapy stopped their antiplatelet/anticoagulation therapy prior to surgery. Most patients were discharged on the day of surgery. Postprocedure Voice Handicap Index scores significantly improved ( P < .001) by 47%, 53%, 64%, and 57% at each of the 4 measured postprocedure dates, respectively. Two patients had major nonsurgical complications postoperatively requiring inpatient hospitalization. Chi-square analysis revealed no differences between intraoperative aspirin use, sex, or comorbidities and the incidence of complications ( P > .05).

Conclusion

The clinical profile and outcomes of our patients undergoing medialization laryngoplasty are comparable to those seen in younger cohorts. Medialization laryngoplasty is a safe and successful option for elderly patients with vocal cord paralysis and vocal handicap.

Reversing Age Related Changes of the Laryngeal Muscles by Chronic Electrostimulation of the Recurrent Laryngeal Nerve

Age related atrophy of the laryngeal muscles -mainly the thyroarytenoid muscle (TAM)- leads to a glottal gap and consequently to a hoarse and dysphonic voice that significantly affects quality of life. The aim of our study was to reverse this atrophy by inducing muscular hypertrophy by unilateral functional electrical stimulation (FES) of the recurrent laryngeal nerve (RLN) in a large animal model using aged sheep (n = 5). Suitable stimulation parameters were determined by fatiguing experiments of the thyroarytenoid muscle in an acute trial. For the chronic trial an electrode was placed around the right RLN and stimulation was delivered once daily for 29 days. We chose a very conservative stimulation pattern, total stimulation time was two minutes per day, or 0.14% of total time. Overall, the mean muscle fiber diameter of the stimulated right TAM was significantly larger than the non-stimulated left TAM (30μm±1.1μm vs. 28μm±1.1 μm, p<0.001). There was no significant shift in fiber type distribution as judged by immunohistochemistry. The changes of fiber diameter could not be observed in the posterior cricoarytenoid muscle (PCAM). FES is a possible new treatment option for reversing the effects of age related laryngeal muscle atrophy.

Efficacy of intensive phonatory-respiratory treatment (LSVT) for presbyphonia: two case reports

OBJECTIVES

Research evidence has shown that neither traditional voice therapy nor surgery was efficacious in managing age-related dysphonia, specifically for more severe cases with pronounced fold atrophy or larger glottal gaps. The purpose of this study was to examine the efficacy of intensive respiratory-phonatory treatment (Lee Silverman voice treatment [LSVT]) for glottal incompetence associated with presbyphonia.

STUDY DESIGN

Nonrandomized prospective study.

METHODS

Two subjects with age-related vocal fold bowing received 4 weeks of the LSVT. Strobolaryngoscopic examination, phonatory function measurement, acoustical analyses, and perceptual judgments of voice were obtained at baseline and 2 weeks posttreatment. Additional acoustic measures of phonatory function, including vocal intensity, maximum phonation time, and pitch range, were also obtained during 16 treatment sessions.

RESULTS

Both subjects exhibited significant improvements in glottal closure, phonatory function, acoustic features, and perceptual ratings of voice after treatment. Significant changes of phonatory function measures were noticed relatively early and remained steady throughout the course of treatment.

CONCLUSIONS

These findings provide solid evidence that speakers with age-related vocal fold bowing and dysphonia may improve glottal competence and related vocal function with neither laryngeal trauma nor maladaptive laryngeal hyperfunction after the LSVT.

Utility of the pediatric sleep questionnaire and pulse oximetry as screening tools in pediatric patients with suspected obstructive sleep apnea syndrome

Objective. To assess the screening tools in snoring patients. Material and Methods. A retrospective review of data was conducted from children between 2 and 15 years old who were referred on suspicion of obstructive sleep apnea-hypopnea (OSAH) between June 2008 and June 2011. We excluded patients with significant comorbidities. Pediatric Sleep Questionnaire (PSQ), physical exam (PE), and pulse-oximetry data were collected and correlated with the results of the nightly polygraph at home. Results. We selected 98 patients. The 22-item version of the PSQ had sensitivity of 96% and specificity of 36.8%. The overall value of the clinic predictor of OSAH (PSQ and PE together) exhibited an increased specificity 57.6% with 94.6% of sensitivity. The nocturnal home oximetry method used alone was very specific, 92.1%, but had a lower sensitivity, 77.1%. The set of clinical assessment tools used together with pulse-oximetry screening provided excellent specificity 98.1% and a positive predictive value 94.1% globally. The performance of this screening tool is related with the severity of OSAH and accuracy is better in moderate and severe cases. Conclusion. The combination of clinical assessment and pulse-oximetry screening can provide a sufficient diagnostic approach for pediatric patients with suspected OSAH at least in moderate and severe cases.