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Granell M, Martín A, Oishi N, Gimeno Coret M, Zapater E. Anesthetic Technique and Functional Outcomes in Modified Montgomery Thyroplasty. J Pers Med 2023; 13:jpm13020194. [PMID: 36836427 PMCID: PMC9962128 DOI: 10.3390/jpm13020194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 01/08/2023] [Accepted: 01/19/2023] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Montgomery thyroplasty type I is a surgical technique indicated in vocal cord paralysis which consists of the paralyzed cord medialization, improving the voice quality. The objective of the study is to describe in detail the anesthetic method to obtain optimal post-medialization voice results. METHODOLOGY Retrospective case series study including patients who underwent medialization thyroplasty using the modified Montgomery technique at the General University Hospital of Valencia between 2011 and 2021. The anesthetic technique consisted of general anesthesia with neuromuscular relaxation and a laryngeal mask. Pre- and post-surgical vocal functional data of maximum phonation times (MPT), G score, and Voice Handicap Index-30 (VHI-30) were evaluated. RESULTS All the patients presented an improvement in voice results, increasing MPT after surgery and a decrease in VHI-30 and G score postoperatively, with statistically significant differences between the pre- and post-surgical results (p-value < 0.05). There were no complications related to anesthesia or surgery. CONCLUSIONS The use of general anesthesia with muscle relaxation in modified Montgomery thyroplasty may be a good option to consider. The use of a laryngeal mask for ventilation combined with a fiberoptic check allows direct visualization of the vocal cords intraoperatively, providing good functional voice results.
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Affiliation(s)
- Manuel Granell
- Department of Anesthesia, Critical Care and Pain Medicine, Valencia University General Hospital, 46014 Valencia, Spain
- Faculty of Medicine, University of València, 46010 Valencia, Spain
| | - Ana Martín
- Department of Anesthesia, Critical Care and Pain Medicine, Valencia University General Hospital, 46014 Valencia, Spain
| | - Natsuki Oishi
- ENT Department, Valencia University General Hospital, 46014 Valencia, Spain
- Correspondence: ; Tel.: +34-690164321
| | - Mar Gimeno Coret
- Faculty of Medicine, University of València, 46010 Valencia, Spain
| | - Enrique Zapater
- Faculty of Medicine, University of València, 46010 Valencia, Spain
- ENT Department, Valencia University General Hospital, 46014 Valencia, Spain
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Abi Lutfallah A, Jabbour K, Gergess A, Hayeck G, Matar N, Madi-Jebara S. [Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report]. Rev Bras Anestesiol 2020; 70:556-560. [PMID: 33012560 DOI: 10.1016/j.bjan.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Accepted: 07/11/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. CASE REPORT A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia. An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. CONCLUSION The use of regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.
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Affiliation(s)
- Antoine Abi Lutfallah
- Saint Joseph University, School of Medicine, Hôtel-Dieu de France Hospital, Department of Anesthesia. Critical Care and Pain Management, Beirut, Líbano.
| | - Khalil Jabbour
- Saint Joseph University, School of Medicine, Hôtel-Dieu de France Hospital, Department of Anesthesia. Critical Care and Pain Management, Beirut, Líbano
| | - Afrida Gergess
- Saint Joseph University, School of Medicine, Hôtel-Dieu de France Hospital, Department of Anesthesia. Critical Care and Pain Management, Beirut, Líbano
| | - Gemma Hayeck
- Saint Joseph University, School of Medicine, Hôtel-Dieu de France Hospital, Department of Anesthesia. Critical Care and Pain Management, Beirut, Líbano
| | - Nayla Matar
- Saint Joseph University, School of Medicine, Hôtel-Dieu de France Hospital, Department of Otolaryngology Head and Neck Surgery, Beirut, Líbano
| | - Samia Madi-Jebara
- Saint Joseph University, School of Medicine, Hôtel-Dieu de France Hospital, Department of Anesthesia. Critical Care and Pain Management, Beirut, Líbano
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Abi Lutfallah A, Jabbour K, Gergess A, Hayeck G, Matar N, Madi-Jebara S. Cervical plexus block as an alternative anesthetic approach for type I thyroplasty: a case report. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33012560 PMCID: PMC9373069 DOI: 10.1016/j.bjane.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background The role of type I thyroplasty (TIP) is well established as the treatment for glottal insufficiency due to vocal fold paralysis, but the ideal anesthetic management for this procedure is still largely debated. We present the case of a novel anesthetic approach for TIP using combined intermediate and superficial Cervical Plexus Block (CPB) and intermittent mild sedation analgesia. Case report A 51-year-old presenting with left vocal fold paralysis and obstructive sleep apnea was scheduled for TIP. An ultrasound-guided intermediate CPB was performed using the posterior approach, and 15 mL of ropivacaine 0.5% were injected in the posterior cervical space between the sternocleidomastoid muscle and the prevertebral fascia. Then, for the superficial CPB, a total of 10 mL 0.5% ropivacaine was injected subcutaneously, adjacently to the posterior border of the sternocleidomastoid muscle, without penetrating the investing fascia An intermittent sedation analgesia with a target-controlled infusion of remifentanyl (target 0.5 ng.mL-1) was used to facilitate prosthesis insertion and the fiberoptic laryngoscopy. This technique offered a safe anesthetic airway and good operating conditions for the surgeon, as well as feasible voice monitoring and optimal patient comfort. Conclusion The use of a regional technique is a promising method for the anesthetic management in TIP, especially in patients with compromised airway.
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Handlogten KS, Ekbom DC, Hamre MC, Weingarten TN, Schroeder DR, Seelhammer TG. Anesthetic management for medialization laryngoplasty using concurrent infusions of dexmedetomidine, remifentanil, and propofol versus controls. Am J Otolaryngol 2019; 40:147-151. [PMID: 30658839 DOI: 10.1016/j.amjoto.2019.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/07/2019] [Accepted: 01/10/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Medialization laryngoplasty (ML) ± arytenoid adduction (AA) surgery poses a unique anesthetic challenge that requires periods of deep sedation and patient cooperation with phonation to assess voice function. The purpose of this study was to assess if the protocolized administration of dexmedetomidine, remifentanil, and propofol (DRP) is associated with reduced procedural duration and administration of other sedating medications. MATERIALS AND METHODS This was a retrospective 2:1 case matched study design; matched on age, sex, body mass index, AA, and surgical revision status. Data was obtained from the electronic medical record of a tertiary referral center. Cases underwent ML ± AA using DRP. Control subjects underwent surgery ML ± AA without DRP. RESULTS 58 DRP cases (43.1% AA) were matched with 116 control patients (44.8% AA). DRP was associated with decreases in fentanyl dose (50 [25, 100] vs. 100 [50, 150] mcg; p < 0.01), incidence and dose of midazolam (4 [6.9%] vs. 70 [60.3%]; p < 0.01; 1 [1, 1] vs. 2 [2, 2]; p < 0.02), operative duration (131 ± 33 vs. 160 ± 50 min; p < 0.01), and anesthetic duration (182 ± 35 vs. 219 ± 60.3 min; p < 0.01). When adjusted for timeline, it was observed that case duration was declining prior to DRP introduction; this trend persisted after DRP introduction. Hypopnea was more common with DRP (14 [24.1%] vs. 7 [6.0%]; p < 0.01). CONCLUSIONS DRP was associated with a substantial decrease in opioid and benzodiazepine administration. A reduction in procedural duration over time was also observed.
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Hamre MC, Ekbom DC, Handlogten KS, Weingarten TN, Seelhammer TG. Anesthetic Management for Medialization Laryngoplasty Performed Under Concurrent Dexmedetomidine, Remifentanil, and Propofol Infusions. J Voice 2018; 34:134-139. [PMID: 30482475 DOI: 10.1016/j.jvoice.2018.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 08/30/2018] [Accepted: 09/05/2018] [Indexed: 12/25/2022]
Abstract
INTRODUCTION Type I thyroplasty, or medialization larygoplasty (ML), is a procedure which improves the voice by medializing a vocal fold with a permanent implant. Anesthetic management of these cases is challenging because patients can require periods of deep sedation followed by fully awake moments for phonation to assess the implant size. We present our experience of ML with or without arytenoid adduction (AA) using a multimodal anesthetic regimen consisting of concurrent infusions of dexmedetomidine, remifentanil, and propofol. METHODS This is a retrospective case series of patients anesthetized using this protocol from June 1, 2015 through June 30, 2017. RESULTS Seventy-five consecutive ML with or without AA patients anesthetized with dexmedetomidine and remifentanil infusions were identified, of which 74 (98.7%) also received concurrent propofol infusions. Mean duration of sedation was 190.9 ± 36.9 minutes and surgery was 139 ± 35.3 minutes. Transient hypopnea treated with supplemental oxygen complicated 18 (24%) cases and bradycardia requiring pharmacologic treatment complicated 3 (4%) cases. There were no other adverse anesthetic complications. One patient required surgical re-exploration due to postsurgical bleeding after the initial hospital discharge. CONCLUSION In this cohort, a combination of remifentanil, dexmedetomidine and propofol infusions was well tolerated without serious adverse perioperative events.
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Affiliation(s)
- Megan C Hamre
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, MN, USA.
| | - Dale C Ekbom
- Mayo Clinic Department of Otolaryngology, Rochester, MN, USA
| | - Kathryn S Handlogten
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, MN, USA
| | - Toby N Weingarten
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, MN, USA
| | - Troy G Seelhammer
- Mayo Clinic Department of Anesthesiology and Perioperative Medicine, Rochester, MN, USA
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Walton C, Carding P, Conway E, Flanagan K, Blackshaw H. Voice Outcome Measures for Adult Patients With Unilateral Vocal Fold Paralysis: A Systematic Review. Laryngoscope 2018; 129:187-197. [DOI: 10.1002/lary.27434] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 06/14/2018] [Accepted: 06/18/2018] [Indexed: 11/08/2022]
Affiliation(s)
- Chloe Walton
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University (ACU); Brisbane Australia
| | - Paul Carding
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University (ACU); Brisbane Australia
| | - Erin Conway
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University (ACU); Brisbane Australia
| | - Kieran Flanagan
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University (ACU); Brisbane Australia
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Saadeh CK, Rosero EB, Joshi GP, Ozayar E, Mau T. Reducing sedation time for thyroplasty with arytenoid adduction with sequential anesthetic technique. Laryngoscope 2017; 127:2813-2817. [DOI: 10.1002/lary.26743] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 05/22/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Charles K. Saadeh
- Clinical Center for Voice Care, Department of Otolaryngology-Head and Neck Surgery
| | - Eric B. Rosero
- Department of Anesthesiology and Pain Management; University of Texas Southwestern Medical Center; Dallas Texas U.S.A
| | - Girish P. Joshi
- Department of Anesthesiology and Pain Management; University of Texas Southwestern Medical Center; Dallas Texas U.S.A
| | - Esra Ozayar
- Department of Anesthesiology and Pain Management; University of Texas Southwestern Medical Center; Dallas Texas U.S.A
| | - Ted Mau
- Clinical Center for Voice Care, Department of Otolaryngology-Head and Neck Surgery
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Fukuhara T, Morisaki T, Kataoka H, Miyake N, Taira K, Koyama S, Fujiwara K, Kitano H, Takeuchi H. Modifications to the Fenestration Approach for Arytenoid Adduction Under Local Anesthesia. J Voice 2016; 31:490-494. [PMID: 27916331 DOI: 10.1016/j.jvoice.2016.10.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 10/21/2016] [Accepted: 10/26/2016] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We modified the fenestration approach for arytenoid adduction to make it easier to perform the surgery. The aim of this study was to evaluate the usefulness of our modifications, which included (1) use of an Alexis wound retractor (Applied Medical) to secure the surgical field through a small incision, and (2) use of a 12-mm, 1/2 R, insert-molded taper needle with 3-0 nylon suture to prevent damage to the arytenoid cartilage. STUDY DESIGN This is a retrospective non-randomized observational cross-sectional study. METHODS We compared the operative time and skin incision length between the conventional fenestration approach and our modified procedure, and verified the improvement of patients' voice by our procedure. RESULTS Seven patients underwent the conventional fenestration approach for arytenoid adduction with type I thyroplasty, whereas nine patients underwent our modified fenestration approach for arytenoid adduction with type I thyroplasty. The skin incision length with our modifications (median, 3.0 cm; interquartile range [IQR], 3.0-4.0) was significantly shorter than with the conventional procedure (median, 5.0 cm; IQR, 4.3-5.8) (P = 0.001). The operative time with our modifications (median, 95 minutes; IQR, 90-100) was significantly shorter than without our modifications (median, 115; IQR, 100-130) (P = 0.035). All patients who underwent our modified fenestration approach for arytenoid adduction had maximum phonation time greater than 11 seconds after surgery. CONCLUSIONS Our two distinctive modifications reduced the operative time and skin incision length for the fenestration approach, which improved the procedure by making it less invasive.
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Affiliation(s)
- Takahiro Fukuhara
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Yonago, Japan.
| | - Tsuyoshi Morisaki
- Center for Head and Neck Surgery, Kusatsu General Hospital, Kusatsu, Japan
| | - Hideyuki Kataoka
- Division of Medical Education, Department of Social Medicine, Tottori University Faculty of Medicine, Yonago, Japan
| | - Naritomo Miyake
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| | - Kenkichiro Taira
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| | - Satoshi Koyama
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| | - Kazunori Fujiwara
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| | - Hiroya Kitano
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Yonago, Japan
| | - Hiromi Takeuchi
- Department of Otolaryngology-Head and Neck Surgery, Tottori University Faculty of Medicine, Yonago, Japan
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Rosero EB, Ozayar E, Mau T, Joshi GP. A sequential anesthesia technique for surgical repair of unilateral vocal fold paralysis. J Anesth 2016; 30:1078-1081. [PMID: 27522215 DOI: 10.1007/s00540-016-2231-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 08/02/2016] [Indexed: 11/30/2022]
Abstract
Thyroplasty with arytenoid adduction, a combined procedure for treatment of unilateral vocal fold paralysis, is typically performed under local anesthesia with sedation to allow for intraoperative voice assessment. However, the need for patient immobility and suppression of laryngeal responses to surgical manipulation can make sedation-analgesia challenging. We describe our first 26 consecutive cases undergoing thyroplasty and arytenoid adduction with a standardized technique consisting of a combination of general anesthesia with tracheal intubation followed by sedation-analgesia. Most patients (69 %) were women, with age of 53 ± 15 years (mean ± SD). Neck surgery was the cause of vocal fold paralysis in 50 % of patients. Initially, general anesthesia was maintained with desflurane and remifentanil with dexmedetomidine added just before tracheal extubation. During the sedation-analgesia phase, patients received infusions of remifentanil and dexmedetomidine. Duration of general anesthesia and sedation-analgesia phases was 162 ± 68.2 and 79 ± 18.3 min, respectively. Mean (SD) wake-up time was 8.0 ± 4.0 min after desflurane discontinuation. Extubation occurred without coughing, bucking, or agitation in 96 % of patients. All the patients were able to phonate appropriately and remained comfortable after emergence. This technique allowed improved surgical conditions with reduced patient discomfort and may be advantageous for other laryngeal and neck surgeries in which intraoperative patient feedback is required.
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Affiliation(s)
- Eric B Rosero
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Esra Ozayar
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Ted Mau
- Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Konomi U, Watanabe Y, Komazawa D. Sex Differences in Pitch Range and Speech Fundamental Frequency After Arytenoid Adduction and Thyroplasty. J Voice 2016; 30:362-70. [DOI: 10.1016/j.jvoice.2015.03.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 03/18/2015] [Indexed: 10/23/2022]
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Mayerhoff RM, Kuo C, Meyer T. A Novel Approach to the Challenging Injection Laryngoplasty. Ann Otol Rhinol Laryngol 2015; 125:415-20. [DOI: 10.1177/0003489415618677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Injection laryngoplasty (IL) is typically performed either awake or under general anesthesia with paralysis. There is a subgroup of patients, however, for whom neither of these is a good option. For such patients, we report a hybrid technique that allows for a percutaneous injection without paralysis but with sedation to increase patient tolerance. Supraglottic airway laryngotracheal intervention (SALTI) brings the benefits of injection laryngoplasty to a group of patients previously underserved. Methods: Injection laryngoplasty cases using SALTI technique from July 1, 2013, to October 21, 2014, were reviewed. Data were collected regarding the indication, success of injection, comorbidities, and outcomes. Results: Seventeen subjects were reviewed. All were successfully injected without complications. Follow-up data were available for 15 subjects. The majority of patients experienced improved symptoms of dysphonia and/or dysphagia after the procedure. Discussion and Conclusions: This study demonstrates the feasibility of the SALTI technique for IL. The technique may also be useful for other procedures. Advantages include maintenance of spontaneous ventilation without paralysis, no neck extension, improved patient tolerance, and accommodation of difficult anatomy. Disadvantages are increased time and cost related to the operating room and the need for an assistant. Overall, SALTI permits IL in previously ineligible patients.
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Affiliation(s)
- Ross M. Mayerhoff
- Wayne State University, University Health Center, Detroit, Michigan, USA
| | - Connie Kuo
- University of Washington, Seattle, Washington, USA
| | - Tanya Meyer
- University of Washington, Seattle, Washington, USA
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Correlation of VHI-10 to Voice Laboratory Measurements Across Five Common Voice Disorders. J Voice 2014; 28:440-8. [DOI: 10.1016/j.jvoice.2013.10.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 10/30/2013] [Indexed: 11/24/2022]
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