Multi-institutional Study of Voice Disorders and Voice Therapy Referral: Report from the CHEER Network

The Impact of Referral Source on Voice Therapy

INTRODUCTION

Adherence to voice therapy is essential in achieving successful voice outcomes. Previous studies within the field of voice therapy have suggested that shorter wait times and utilization of an interprofessional practice (IPP) model of care have a positive effect on voice therapy completion rates. While the implementation of IPP has gained popularity, especially at academic voice centers, the majority of speech-language pathologists (SLP) practice in a traditional (T) setting where they are unaffiliated with the referring otolaryngologist.

PURPOSE

This study aims to further examine how SLP practice models (interprofessional vs traditional) affect voice therapy initiation and completion rates. The secondary aim is to determine if voice therapy attendance rates have changed since the authors' initial investigations over 10 years ago.

METHODS

A retrospective chart review of 452 patients was conducted. Data was collected on patient demographics (sex, age), diagnosis, severity of dysphonia (CAPE-V), quality of life impact (V-RQOL raw score), practice setting (IPP vs T), date of referral, date of voice therapy initial evaluation, number of therapy sessions completed, and attendance to therapy sessions defined as completion or dropout.

RESULTS/CONCLUSIONS

Initiation of voice therapy treatment was the point in the referral process that was most impacted by practice model. Over half (53%) of referrals to voice therapy in a traditional practice model did not lead to initiation of treatment, while only 23% of the referrals taking place in an IPP model failed to initiate (P < 0.001). This study also demonstrated an improving, but continued rate of noninitiation and dropout from voice therapy when compared to data that was collected 10 years prior.

Perceived Control, Voice Handicap, and Barriers to Voice Therapy

OBJECTIVE

To characterize the associations of perceived control with voice outcomes and self-reported likelihood of attending voice therapy using a national practice-based research network.

STUDY DESIGN

Cross-sectional study of prospectively enrolled adult patients seen for dysphonia.

SETTING

Creating Healthcare Excellence through Education and Research (CHEER) network of community and academic practice sites.

SUBJECTS AND METHODS

Data collected included patient-reported demographics, outcome measures of voice (Voice Handicap Index-10), perceived control (present control subscale of voice-specific Perceived Control over Stressful Events Scale), personality (Ten Item Personality Inventory), likelihood of attending voice therapy if recommended, and barriers to attending voice therapy.

RESULTS

Patients (N = 247) were enrolled over 12 months from 10 sites, of whom 170 received a recommendation for voice therapy. The majority (85%) of this group planned to attend voice therapy. Voice-specific perceived control and VHI-10 were inversely related (r = -0.31, P < 0.001), even when controlling for personality. No study variables were associated with self-reported likelihood of attending voice therapy, but perceived control was the most consistent correlate of specific barriers to attending voice therapy (eg, "hard to translate into everyday use") and was inversely related to these barriers.

CONCLUSIONS

Patients scoring higher on a voice-specific measure of perceived control reported less voice handicap, independent of personality, and higher perceived control was associated with having fewer concerns about voice therapy goals and process. Perceived control is a potential target for intervention in patients with voice disorders.

First-line treatment of exudative vocal fold-lesions by in-office local corticosteroid injection: A literature review

OBJECTIVES

There are emerging reports of the effectiveness of in-office awake vocal-fold corticosteroid injection in the treatment of exudative vocal-fold lesions. The aim of this study was to review this therapy and specify indications, practical modalities and outcomes.

STUDY DESIGN

Systematic review of the literature without meta-analysis.

METHODS

A systematic review by PubMed search for the period January 2000 to December 2018 was carried out.

RESULTS

Nine articles were included, for a total of 502 lesions: nodules (46.4%), polyps (31.7%), and Reinke's edema (21.9%). Submucosal injection of low-dose triamcinolone acetonide (0.1 to 0.3mL) was transoral, transcutaneous or transnasal via flexible endoscope with operating channel. Lesion volume was significantly reduced in more than 90% of cases, with significant vocal improvement in all studies. Relapse rates ranged between 4% and 31%, with time to relapse of 1 to 40 months.

CONCLUSIONS

First-line treatment of exudative glottic lesions by submucosal corticosteroid injection provides at least transient significant reduction in lesion volume and vocal improvement. It is consensually reserved to moderate-sized mainly exudative lesions without fibrosis. In-office injection provides an immediate therapeutic response in case of vocal impairment, enabling surgery under general anesthesia to be postponed.

Epidemiological Patterns and Treatment Outcomes in a Private Practice Community Voice Clinic

OBJECTIVES

Voice therapy is administered by speech-language pathologists in multiple practice settings, including private practice community voice clinics. However, the evidence for diagnosis patterns and voice treatment outcomes in community voice clinics is very limited. The purpose of this study was to extend knowledge from a previous investigation by assessing the epidemiological patterns of patient referrals to a private practice community voice clinic across a 4-year period (50 months) and to measure the effectiveness of treatment outcomes for patients who were followed up with voice therapy in the same setting.

STUDY DESIGN

Retrospective case series.

METHODS

Consecutive patient records from November 2014 through January 2019 were reviewed. Patients were grouped into seven categories of distinctive diagnoses. Descriptive data for each group were extracted to determine epidemiological patterns of disorder diagnosis, voice handicap, voice quality severity, age, and gender. For patients who completed at least three treatment sessions, pre- and posttreatment measurements of two assessments, the Voice Handicap Index (VHI) and the Acoustic Voice Quality Index (AVQI), were extracted and compared using a multivariate analysis of variance.

RESULTS

Records from 454 consecutive patient referrals over a 50-month time period were reviewed. The most frequent diagnoses were multifactorial etiologies or those with only a few cases, categorized collectively as an "other" diagnosis category. Diagnoses of nonspecific dysphonia and mid-membranous lesions were also common. Consensus Auditory Perceptual Evaluation of Voice-scale scores were not different among disorders; however, group differences were found for VHI and AVQI. Treatment data were available for 292 patients, with 47 of those patients completing at least three treatment sessions and with data for pre- and posttreatment VHI and AVQI. A mixed multivariate analysis of variance showed a significant effect of treatment (Wilks' Lambda = 0.42, F[2] = 27.58, P < 0.001, ƞ_p² = 0.58), where both AVQI and VHI improved significantly across the pre- to posttreatment measurements.

CONCLUSIONS

Patient characteristics and diagnosis patterns across a 50-month period were similar when compared to a previous study that investigated epidemiological patterns in this clinic across 28 months. Voice therapy administered in this community voice clinic to patients with varied diagnoses was found to be effective based on changes in VHI and AVQI measurements.

Dysphonia, Perceived Control, and Psychosocial Distress: A Qualitative Study

OBJECTIVES

The purpose of this qualitative study was to examine relationships between psychological factors, particularly perceived control, and voice symptoms in adults seeking treatment for a voice problem.

METHODS

Semistructured interviews of adult patients with a clinical diagnosis of muscle tension dysphonia were conducted and transcribed. Follow-up interviews were conducted as needed for further information or clarification. A multidisciplinary team analyzed interview content using inductive techniques. Common themes and subthemes were identified. A conceptual model was developed describing the association between voice symptoms, psychological factors, precipitants of ongoing voice symptoms, and perceived control.

RESULTS

Thematic saturation was reached after 23 interviews. No participants reported a direct psychological cause for their voice problem, although half described significant life events preceding voice problem onset (eg, miscarriage and other health events, interpersonal conflicts, and family members' illnesses, injuries, and deaths). Participants described psychological influences on voice symptoms that led to rapid exacerbation of their voice symptoms. Participants described the helpfulness of speech therapy and sometimes also challenges of applying techniques in daily life. They also discussed personal coping strategies that included behavioral (eg, avoiding triggers and seeking social support) and psychological (eg, mind-body awareness and emotion regulation) components. Voice-related perceived control was associated with adaptive emotional and behavioral responses, which appeared to facilitate symptom improvement.

CONCLUSIONS

In this qualitative pilot study, participant narratives suggested that psychological factors and emotions influence voice symptoms, facilitating development of a preliminary conceptual model of how adaptive and maladaptive responses develop and how they influence vocal function.

Does the accuracy of case history affect interpretation of videolaryngostroboscopic exams?

OBJECTIVE

To determine the effect of initial diagnostic hypotheses on clinicians' 1) detection and perceived severity of abnormalities, and 2) clinical impressions and treatment recommendations for individuals with and without voice disorders following interpretation of videolaryngostroboscopy (VLS).

METHODS

Thirty-two experienced speech-language pathologists and otolaryngologists specializing in voice disorders read case histories prior to interpreting exams. Case histories suggested specific accurate or inaccurate laryngeal diagnoses, or a control scenario that suggested a normal larynx. The effects of the accuracy of case histories on perceived severity of associated visual-perceptual parameters, clinical impressions, and treatment recommendations were examined.

RESULTS

Significant increases in perceived severity of posterior laryngeal appearance (P < 0.05) and mucosal wave (P < 0.02) were observed when these abnormalities were suggested by case histories. Overall agreement with clinical impressions improved from 49% to 72% when the case history was consistent with the examination. Case histories (accurate and inaccurate) indicating voice symptoms predicted recommendations for treatment above and beyond that of VLS presentation alone, P < 0.001.

CONCLUSION

Case histories suggesting specific abnormalities significantly affected severity ratings for two of three associated visual-perceptual parameters selected as primary outcome measures. Accurate case histories suggesting specific abnormalities increased the probability of detection and perceived severity. Inaccurate case histories led to false-positive findings and failures to detect abnormalities or to interpret them as less severe. Case histories affected visual-perceptual judgments and contributed to decisions about clinical impressions and treatment.

LEVEL OF EVIDENCE

2b Laryngoscope, 130:718-725, 2020.

Factors Affecting Initiation of Voice Therapy for Paradoxical Vocal Fold Motion Disorder

OBJECTIVE

To investigate patient-level predictors of initiation of voice therapy for paradoxical vocal fold motion disorder (PVFM).

STUDY DESIGN

Prospective outcomes database study.

METHODS

Patients consented to the University of Wisconsin Voice and Swallow Clinics Outcomes Database between March 2010 and November 2016 who were diagnosed with PVFM and recommended for voice therapy were eligible. Patients who attended at least one voice therapy session were considered to have initiated therapy. Analyzed variables included age, gender, distance to the clinic, insurance status, socioeconomic factors, comorbidity score, spirometry results, presence of asthma and/or dysphonia diagnoses, length of evaluation and evaluation model, and patient scores on the Voice Handicap Index and Generalized Anxiety Disorder 7-item scale.

RESULTS

One-hundred seventy-eight patients met inclusion criteria. Of these, 118 initiated voice therapy as recommended (66.29%). The majority of patients were female (n = 127; 71.35%). Age was the only factor significantly associated with therapy initiation in both univariate (P = 0.0359) and multivariable (P = 0.0295) analyses, with patients aged 30-39 least likely to attend compared with other age groups. Multivariable analysis also showed that patients evaluated by a speech-language pathologist alone were an estimated three times as likely to initiate therapy compared to patients evaluated by speech-language pathologist and otolaryngologist (ENT) together (P = 0.0407). Other variables were not statistically significant for prediction of therapy initiation.

CONCLUSIONS

This study suggests that age group and evaluation model are associated with initiation of voice therapy for PVFM. Further study is needed to investigate social-cognitive and quality-of-life factors in predicting therapy initiation.

Treatment Receipt and Outcomes of Self-Reported Voice Problems in the US Population Aged ≥65 Years

Objectives

(1) Characterize the US population aged ≥65 years with self-reported voice problems, (2) describe voice treatment characteristics in this group, and (3) identify factors associated with self-reported voice improvement.

Study Design

Retrospective cohort study.

Setting

Population-based cross-sectional US national survey sample.

Subjects and Methods

We identified a cohort of adults aged ≥65 years from the 2012 National Health Interview Survey, a population-based US national survey. Descriptive and multivariable regression analyses were performed.

Results

The prevalence of self-reported voice problems in this cohort was 10%. Of those, 44% reported voice problems for >1 month. The strongest predictor of reporting voice improvement was receipt of voice treatment (odds ratio, 3.50; 95% confidence interval, 1.36-9.00), after adjusting for sex, age, race, education, and health status. Eleven percent reported voice treatment, which included 20% of those with moderate or worse voice problem severity. Female sex and worse health status were associated with reporting voice treatment. Among those with voice treatment, 38% reported “better,” 33% “same,” and 29% “worse” voice symptoms over the past year, compared to 17%, 67%, and 16%, respectively, among those without treatment. Health status influenced likelihood of reporting voice improvement but not universally.

Conclusions

We observed a significant self-reported burden of voice problems in the US population aged ≥65 years. Most are untreated and thus not well represented in the current literature. Vocal improvement was strongly associated with treatment. Further investigation is needed to clarify patient and treatment characteristics most associated with vocal improvement.

High-Performance Agent-Based Modeling Applied to Vocal Fold Inflammation and Repair

Fast and accurate computational biology models offer the prospect of accelerating the development of personalized medicine. A tool capable of estimating treatment success can help prevent unnecessary and costly treatments and potential harmful side effects. A novel high-performance Agent-Based Model (ABM) was adopted to simulate and visualize multi-scale complex biological processes arising in vocal fold inflammation and repair. The computational scheme was designed to organize the 3D ABM sub-tasks to fully utilize the resources available on current heterogeneous platforms consisting of multi-core CPUs and many-core GPUs. Subtasks are further parallelized and convolution-based diffusion is used to enhance the performance of the ABM simulation. The scheme was implemented using a client-server protocol allowing the results of each iteration to be analyzed and visualized on the server (i.e., in-situ) while the simulation is running on the same server. The resulting simulation and visualization software enables users to interact with and steer the course of the simulation in real-time as needed. This high-resolution 3D ABM framework was used for a case study of surgical vocal fold injury and repair. The new framework is capable of completing the simulation, visualization and remote result delivery in under 7 s per iteration, where each iteration of the simulation represents 30 min in the real world. The case study model was simulated at the physiological scale of a human vocal fold. This simulation tracks 17 million biological cells as well as a total of 1.7 billion signaling chemical and structural protein data points. The visualization component processes and renders all simulated biological cells and 154 million signaling chemical data points. The proposed high-performance 3D ABM was verified through comparisons with empirical vocal fold data. Representative trends of biomarker predictions in surgically injured vocal folds were observed.

Clinical Practice Guideline: Hoarseness (Dysphonia) (Update)

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

Characteristics of a Treatment-seeking Population in a Private Practice Community Voice Clinic: An Epidemiologic Study

OBJECTIVE

The purpose of this study was to evaluate epidemiologic characteristics of a treatment-seeking population referred to a private practice community voice clinic.

STUDY DESIGN

This is a retrospective cohort study.

METHODS

Patient files representing evaluation referrals over a 28-month period were reviewed. Variables tabulated from records included disorder diagnosis, age, gender, perceptual voice quality ratings, and self-perceived voice handicap at initial evaluation. Descriptive statistics were used to evaluate the diagnosis category and demographic patterns. Parametric statistics were applied to quantitative clinical measurements to test the effect of voice disorder category on perceptual voice quality ratings and self-perceived voice handicap.

RESULTS

A total of 216 consecutive patient files were reviewed. Collectively, the most common disorder diagnosis was "other," consisting of a varied cluster of etiologies, including reflux laryngitis, chronic cough, bilateral paralysis or paresis, leukoplakia, and polypoid degeneration. The most common diagnosis in women was midmembranous lesions, and that in men was the "other" category followed by atrophy and bowing associated with presbylaryngis. The greatest severity and handicap measures were found in patients with unilateral paralysis.

CONCLUSIONS

Collectively, the demographic patterns reported in this study align with those from specialty voice clinics housed in academic medical centers and community voice clinics led by laryngologists and general otolaryngologists. Translating these findings to professional practice, the data support the notion that speech-language pathologists specializing as voice therapists who seek to establish private practice clinics should possess competencies in the knowledge and skills required to serve treatment-seeking populations with a wide variety of voice impairments.

Long-term esophageal motility changes after thyroidectomy: associations with aerodigestive disorders

BACKGROUND

Patients undergoing thyroidectomy often complain aerodigestive disorders. In a previous study we showed the associations between voice impairment and proximal acid reflux, swallowing impairment and Upper Esophageal Sphyncter (UES) incoordination and the decrease in UES pressure in thirty-six patients observed before and soon afterwards uncomplicated thyroidectomy. This study investigated the state of post-thyroidectomy esophageal motility changes and its associations with these disorders after 18-24 months.

PATIENTS AND METHODS

The thirty-six patients prospectively recruited according to selection criteria (thyroid volume ≤60 ml, benign disease, age 18-65 years, previous neck surgery, thyroiditis, pre- or postoperative vocal cord palsy) underwent voice (VIS) and swallowing (SIS) impairment scores, esophageal manometry and pH monitoring once again.

RESULTS

After 18-24 months, both VIS and SIS recovered (respectively: p=0,022; p=0,0001); UES pressure increased (p=0,0001) nearing the preoperative values. The persistence of swallowing complaints were associated with the persistence of esophageal incoordination (p=0,03); the association between voice impairment and proximal acid reflux was confirmed (p<0,001).

CONCLUSIONS

Our study confirms that aerodigestive disorders after uncomplicated thyroidectomy, largely transient, are strictly connected with upper esophageal motility changes. In this viewpoint, the innervation of upper aerodigestive anatomical structures (larynx, pharynx, upper esophagus) and its variations should be focused.

In Situ Visualization for 3D Agent-Based Vocal Fold Inflammation and Repair Simulation

A fast and insightful visualization is essential in modeling biological system behaviors and understanding underlying inter-cellular mechanisms. High fidelity models produce billions of data points per time step, making in situ visualization techniques extremely desirable as they mitigate I/O bottlenecks and provide computational steering capability. In this work, we present a novel high-performance scheme to couple in situ visualization with the simulation of the vocal fold inflammation and repair using little to no extra cost in execution time or computing resources. The visualization component is first optimized with an adaptive sampling scheme to accelerate the rendering process while maintaining the precision of the displayed visual results. Our software employs VirtualGL to perform visualization in situ. The scheme overlaps visualization and simulation, resulting in the optimal utilization of computing resources. This results in an in situ system biology simulation suite capable of remote simulation of 17 million biological cells and 1.2 billion chemical data points, remote visualization of the results, and delivery of visualized frames with aggregated statistics to remote clients in real-time.

CHEER National Study of Chronic Rhinosinusitis Practice Patterns: Disease Comorbidities and Factors Associated with Surgery

Objectives (1) Describe national patterns of chronic rhinosinusitis (CRS) care across academic and community practices. (2) Determine the prevalence of comorbid disorders in CRS patients, including nasal polyposis, allergic rhinitis, asthma, and cystic fibrosis. (3) Identify demographic, clinical, and practice type factors associated with endoscopic sinus surgery (ESS). Study Design Multisite cross-sectional study. Setting Otolaryngology's national research network CHEER (Creating Healthcare Excellence through Education and Research). Subjects and Methods A total of 17,828 adult patients with CRS were identified, of which 10,434 were seen at community practices (59%, n = 8 sites) and 7394 at academic practices (41%, n = 10 sites). Multivariate logistic regression was used to evaluate the association between demographic, practice type, and clinical factors and the odds of a patient undergoing ESS. Results The average age was 50.4 years; 59.5% of patients were female; and 88.3% were Caucasian. The prevalence of comorbid diseases was as follows: allergic rhinitis (35.1%), nasal polyposis (13.3%), asthma (4.4%), and cystic fibrosis (0.2%). In addition, 24.8% of patients at academic centers underwent ESS, as compared with 12.3% at community sites. In multivariate analyses, nasal polyposis (odds ratio [OR], 4.28), cystic fibrosis (OR, 2.42), and academic site type (OR, 1.86) were associated with ESS ( P < .001), while adjusting for other factors. Conclusions We describe practice patterns of CRS care, as well as demographic and clinical factors associated with ESS. This is the first study of practice patterns in CRS utilizing the CHEER network and may be used to guide future research.

Factors Influencing Likelihood of Voice Therapy Attendance

Objective To identify factors associated with the likelihood of attending voice therapy among patients referred for it in the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure. Study Design Prospectively enrolled cross-sectional study. Setting CHEER network of community and academic sites. Methods Data were collected on patient-reported demographics, voice-related diagnoses, voice-related handicap (Voice Handicap Index-10), likelihood of attending voice therapy (VT), and opinions on factors influencing likelihood of attending VT. The relationships between patient characteristics/opinions and likelihood of attending VT were investigated. Results A total of 170 patients with various voice-related diagnoses reported receiving a recommendation for VT. Of those, 85% indicated that they were likely to attend it, regardless of voice-related handicap severity. The most common factors influencing likelihood of VT attendance were insurance/copay, relief that it was not cancer, and travel. Those who were not likely to attend VT identified, as important factors, unclear potential improvement, not understanding the purpose of therapy, and concern that it would be too hard. In multivariate analysis, factors associated with greater likelihood of attending VT included shorter travel distance, age (40-59 years), and being seen in an academic practice. Conclusions Most patients reported plans to attend VT as recommended. Patients who intended to attend VT reported different considerations in their decision making from those who did not plan to attend. These findings may inform patient counseling and efforts to increase access to voice care.