Independent exercise for glottal incompetence to improve vocal problems and prevent aspiration pneumonia in the elderly: a randomized controlled trial

Identifying Non-Traditional Approaches to Swallowing Rehabilitation: A Scoping Review

In recent years, dysphagia care has shifted toward a more patient-centered approach. This means that dysphagia clinicians are considering more factors in the treatment process including the goals of care, quality of life, and cultural values. The purpose of this scoping review was to examine relevant research and identify dysphagia interventions outside of those traditionally used by dysphagia clinicians that may improve swallowing function. A review of relevant studies was conducted using search terms related to swallowing and treatment. The search yielded 8439 unique studies. Of the 283 articles that underwent a full-text review, 37 articles were included in the final review. These articles highlighted three potential areas of non-traditional dysphagia intervention that may serve to provide holistic care, while also aiming to improve swallowing mechanisms: acupuncture and Eastern medicine interventions, vocal exercises, and physical function exercises. The results suggest that dysphagia clinicians should work collaboratively with other allied health professionals and consider non-traditional approaches to dysphagia care. Through the identification of potentially effective but non-traditional or non-Eurocentric interventions for dysphagia care, clinicians may promote a culturally relevant, patient-centered approach, in turn increasing patient acceptance of treatment plans and compliance. Future research should explore the efficacy and feasibility of these interventions in dysphagia rehabilitation, as well as their effectiveness compared to more traditional approaches.

Exploring the relationship between plasma substance P and glottal incompetence in the elderly

We speculated that increased blood-plasma levels of Substance P may serve as an indicator of glottal incompetence, which is usually indicated by reduced maximum phonation time. We performed an initial study to test the plausibility of this hypothesis. Patients with dysphonia caused by glottal incompetence were asked to perform vocal exercises for six months to reduce glottal incompetence and we compared the plasma concentration of Substance P before and after the vocal exercise to detect correlation between maximum phonation time and plasma concentration of Substance P. Based on the results, we further hypothesized that patients exhibiting dysphonia with maximum phonation time less than 14 s, in particular less than 10 sec, caused by glottal incompetence may have increased plasma concentration of Substance P with the results of elevated thresholds of cough reflex associated with subclinical aspiration in airways. Further study is needed on patients with decreased Substance P levels, with low scores on Activities of Daily Living and who are hospitalized with aspiration pneumonia.

A Systematic Review of Speech-Language Pathology Interventions for Presbyphonia Using the Rehabilitation Treatment Specification System

BACKGROUND

The prevalence of voice disorders for people aged >65 years is four times higher than for the population at large. The most common cause of dysphonia in this group is presbyphonia, the preferred first-line treatment for which is voice therapy with a speech-language pathologist. This systematic review seeks to identify how voice therapy affects multidimensional voice outcomes in people with presbyphonia.

METHODS

A systematic search of CINAHL, Embase, Emcare, MEDLINE, and Google Scholar was conducted in March 2023. Comparative and noncomparative studies of voice therapy in participants aged >50 years with presbyphonia were considered for inclusion. No limitations were placed on date or language of publication. Study quality and risk of bias were assessed with the Cochrane Risk of Bias 2 tool and the Methodological Index for Non-Randomized Studies. Subgroup analysis was used to compare studies based on participant sex, intervention duration, study design, and intervention content. Interventions were specified using the Rehabilitation Treatment Specification System (RTSS) employing a consensus methodology among reviewers. The results were synthesized utilizing meta-analysis when outcomes were adequately specified and narrative analysis when they were not.

RESULTS

Twenty-three studies were included with 1050 subjects (mean age: 72.5 ± 8.6 years; 51% female). The most reported intervention was vocal function exercises. Per the RTSS, 14 interventions employed a predominantly Organ Functions approach, and the 14 remaining interventions employed a Skills & Habits approach. Meta-analysis confirmed posttherapy improvement in patient-related outcome measures of 0.93 standard mean difference (P < 0.00001, 95% confidence interval [CI]: 0.70-1.17); studies with predominantly males and with longer treatment periods were associated with larger improvements, while randomized controlled trials reported more modest improvements. Meta-analysis also identified a mean posttherapy increase in maximum phonation time (MPT) of 5.37 seconds (P < 0.00001, 95% CI: 3.52-7.22). Treatments with an Organ Functions focus resulted in greater gains in MPT than those with a Skills & Habits focus (7.52 seconds versus 2.90 seconds). Finally, meta-analysis identified reductions in acoustic perturbation measures (jitter: 0.62%, P < 0.001, 95% CI: 0.26%-0.97%; shimmer 1.05%, P < 0.00001, 95% CI: 0.67%-1.44%). Narrative synthesis further identified improvement in auditory-perceptual voice quality in all active treatment groups as well as improved glottal function in most studies that reported this.

CONCLUSIONS

Despite the uncertainty around internal validity introduced by the inclusion of a wide range of study designs, there is convincing evidence that voice therapy for presbyphonia results in significant improvement in patient-reported, aerodynamic, acoustic, and expert-rated voice outcomes. Treatments with an Organ Functions focus may better address the underlying physiological deficits of presbyphonia, although future comparative studies with multidimensional voice assessment are warranted.

Treatments for Age-related Vocal Atrophy: A Systematic Review

OBJECTIVE

Age-related vocal atrophy (ARVA) can dramatically affect voice, communication, and quality of life. The objectives of this systematic review were to (1) determine whether treatments for ARVA were superior to controls (2) compare the relative efficacy of procedural and behavioral treatments (3) review the various types of outcome measures, and (4) evaluate the quality of studies.

REVIEW METHODS

The literature was searched using strategies designed by a medical librarian (2/18/21, updated 3/9/22). Studies investigating treatments for bilateral vocal atrophy were included. Studies involving unilateral atrophy, presbyphonia (without endoscopic findings), or an absent comparator group were excluded. The Preferred Reporting Items for Systematic Reviews and Meta-analyses checklist was used to guide this study.

RESULTS

After applying the inclusion/exclusion criteria, 8 articles remained, including 4 randomized trials and 4 cohort studies, and a narrative synthesis was performed. Surgical and behavioral treatments for ARVA appeared to be superior to control groups, based on specific outcome measures. However, the superiority of these treatments over controls was not uniformly observed across multiple outcome measures. When comparing different treatments, superiority could not be established based on the quality and completeness of the studies included in the systematic review. Outcome measures also varied between individual studies. Finally, the risk of bias was analyzed and scored. Consistent point deductions among reviewed studies were noted.

CONCLUSIONS

When comparing treatments for ARVA. Surgery and voice therapy were both superior to control groups based on specific outcome measures from different domains. Superiority of one treatment could not be established.

LEVEL OF EVIDENCE

N/A Laryngoscope, 133:2846-2855, 2023.

Maximum phonation time: an independent predictor of late-onset pneumonia after esophageal cancer surgery

Dysphagia after esophagectomy is a major risk factor for aspiration pneumonia, thus preoperative assessment of swallowing function is important. The maximum phonation time (MPT) is a simple indicator of phonatory function and also correlates with muscle strength associated with swallowing. This study aimed to determine whether preoperative MPT can predict postoperative aspiration pneumonia. The study included 409 consecutive patients who underwent esophagectomy for esophageal cancer between 2017 and 2021. Pneumonia detected by routine computed tomography on postoperative days 5-6 was defined as early-onset pneumonia, and pneumonia that developed later (most often aspiration pneumonia) was defined as late-onset pneumonia. The correlation between late-onset pneumonia and preoperative MPT was investigated. Patients were classified into short MPT (<15 seconds for males and <10 seconds for females, n = 156) and normal MPT groups (≥15 seconds for males and ≥10 seconds for females, n = 253). The short MPT group was significantly older, had a lower serum albumin level and vital capacity, and had a significantly higher incidence of late-onset pneumonia (18.6 vs. 6.7%, P < 0.001). Multivariate analysis showed that short MPT was an independent risk factor for late-onset pneumonia (odds ratio: 2.26, P = 0.026). The incidence of late-onset pneumonia was significantly higher in the short MPT group (15.6 vs. 4.7%, P = 0.004), even after propensity score matching adjusted for clinical characteristics. MPT is a useful predictor for late-onset pneumonia after esophagectomy.

Unilateral Vocal Fold Paralysis and Voice Therapy: Predictors of Long-Term Quality of Life

To date, little is known about the long-term predictors of quality of life (QoL) in unilateral vocal fold paralysis (UVFP). The main objective of this study was to evaluate the predictors of long-term QoL in UVFP patients submitted to voice therapy (VT) exclusively. Data from patients diagnosed with UVFP who followed a VT program between 2013 and 2019 were reviewed. Video laryngoscopy (VL) records were obtained at the beginning and at the end of VT. To assess QoL, Voice Handicap Index 30 (VHI-30) score was assessed in three temporal frames: before voice therapy (pre-VT), at the last VT session (post-VT), and in the present (cur-VHI). A longitudinal analysis was performed regarding the evolution of QoL and the factors influencing QoL through time were analyzed. Seventy-eight percent of patients had iatrogenic UVFP. The mean time of follow-up after VT was 3.942 years (range 6 months-7 years). There was a significant improvement in QoL through all time points (F (2,88)=72.179, p<0.001), with VHI-30 decrease from the baseline pre-VT to post-VT(p<0.001) and from post-VT to cur-VT (p=0.0013). In the iatrogenic UVFP population, patients starting VT earlier showed better long-term QoL (p=0.023). UVFP patients with dysphagia at presentation showed significantly worse QoL in the late follow-up (p=0.016). Hence, iatrogenic UVFP patients beginning VT rapidly may show better QoL in the future. Also, our results suggest that dysphagia at UVFP onset may predict higher morbidity later in life.

Terapia de voz en el contexto de la pandemia covid-19; recomendaciones para la práctica clínica

INTRODUCTION

Since the beginning of the new pandemic, COVID-19 health services have had to face a new scenario. Voice therapy faces a double challenge, interventions using telepractice, and delivering rehabilitation services to a growing population of patients at risk of functional impairment related to the COVID-19 disease. Moreover, as COVID-19 is transmitted through droplets, it is critical to understand how to mitigate these risks during assessment and treatment.

OBJECTIVE

To promote safety, and effective clinical practice to voice assessment and rehabilitation in the pandemic COVID-19 context for speech-language pathologists.

METHODS

A group of 11 experts in voice and swallowing disorders from 5 different countries conducted a consensus recommendation following the American Academy of Otolaryngology-Head and Neck Surgery rules building a clinical guide for speech-language pathologists during this pandemic context.

RESULTS

The clinical guide provides 79 recommendations for clinicians in the management of voice disorders during the pandemic and includes advice from assessment, direct treatment, telepractice, and teamwork. The consensus was reached 95% for all topics.

CONCLUSION

This guideline should be taken only as recommendations; each clinician must attempt to mitigate the risk of infection and achieve the best therapeutic results taking into account the patient's particular reality.

Terapia Vocal No Contexto Da Pandemia Do Covid-19; Orientações Para A Prática Clínica

INTRODUCTION

Since the beginning of the new pandemic, Corona Virus Disease 2019 (COVID-19) health services have had to face a new scenario. Voice therapy faces a double challenge, interventions using telepractice, and delivering rehabilitation services to a growing population of patients at risk of functional impairment related to the COVID-19 disease. Moreover, as COVID-19 is transmitted through droplets, it is critical to understand how to mitigate these risks during assessment and treatment.

OBJECTIVE

To promote safety, and effective clinical practice to voice assessment and rehabilitation in the pandemic COVID-19 context for speech-language pathologists.

METHODS

A group of 11 experts in voice and swallowing disorders from five different countries conducted a consensus recommendation following the American Academy of Otolaryngology-Head and Neck Surgery rules building a clinical guide for speech-language pathologists during this pandemic context.

RESULT

The clinical guide provides 79 recommendations for clinicians in the management of voice disorders during the pandemic and includes advice from assessment, direct treatment, telepractice, and teamwork. The consensus was reached 95% for all topics.

CONCLUSION

This guideline should be taken only as recommendation; each clinician must attempt to mitigate the risk of infection and achieve the best therapeutic results taking into account the patient's particular reality.

Voice Therapy in the Context of the COVID-19 Pandemic: Guidelines for Clinical Practice

INTRODUCTION

Since the beginning of the new pandemic, COVID-19 health services have had to face a new scenario. Voice therapy faces a double challenge, interventions using telepractice, and delivering rehabilitation services to a growing population of patients at risk of functional impairment related to the COVID-19 disease. Moreover, as COVID-19 is transmitted through droplets, it is critical to understand how to mitigate these risks during assessment and treatment.

OBJECTIVE

To promote safety, and effective clinical practice to voice assessment and rehabilitation in the pandemic COVID-19 context for speech-language pathologists.

METHODS

A group of 11 experts in voice and swallowing disorders from five different countries conducted a consensus recommendation following the American Academy of Otolaryngology-Head and Neck Surgery rules building a clinical guide for speech-language pathologists during this pandemic context.

RESULTS

The clinical guide provides 65 recommendations for clinicians in the management of voice disorders during the pandemic and includes advice from assessment, direct treatment, telepractice, and teamwork. The consensus was reached 95% for all topics.

CONCLUSION

This guideline should be taken only as recommendation; each clinician must attempt to mitigate the risk of infection and achieve the best therapeutic results taking into account the patient's particular reality.

Exercise versus no exercise for the occurrence, severity, and duration of acute respiratory infections

BACKGROUND

Acute respiratory infections (ARIs) last for less than 30 days and are the most common acute diseases affecting people. Exercise has been shown to improve health generally, but it is uncertain whether exercise may be effective in reducing the occurrence, severity, and duration of ARIs. This is an update of our review published in 2015.

OBJECTIVES

To evaluate the effectiveness of exercise for altering the occurrence, severity, or duration of acute respiratory infections.

SEARCH METHODS

We searched CENTRAL (2020, Issue 2), MEDLINE (1948 to March week 1, 2020), Embase (1974 to 05 March 2020), CINAHL (1981 to 05 March 2020), LILACS (1982 to 05 March 2020), SPORTDiscus (1985 to 05 March 2020), PEDro (searched 05 March 2020), OTseeker (searched 05 March 2020), and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov (searched 05 March 2020).

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs (method of allocation that is not truly random, e.g. based on date of birth, medical record number) of exercise for ARIs in the general population.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data from the included trials using a standard form. One review author entered data, which a second review author checked. We contacted trial authors to request missing data. There were sufficient differences in the populations trialed and in the nature of the interventions to use the random-effects model (which makes fewer assumptions than the fixed-effect model) in the analysis.

MAIN RESULTS

We included three new trials for this update (473 participants) for a total of 14 trials involving 1377 adults, published between 1990 and 2018. Nine trials were conducted in the USA, and one each in Brazil, Canada, Portugal, Spain, and Turkey. Sample sizes ranged from 16 to 419 participants, aged from 18 to 85 years. The proportion of female participants ranged from 52% to 100%. Follow-up duration ranged from 1 to 36 weeks (median = 12 weeks). Moderate-intensity aerobic exercise (walking, bicycling, treadmill, or a combination) was evaluated in 11 trials, and was most commonly prescribed at least three times a week for 30 to 45 minutes. There was no difference between exercise and no exercise in the number of ARI episodes per person per year (risk ratio (RR) 1.00, 95% confidence interval (CI) 0.77 to 1.30; 4 trials; 514 participants; low-certainty evidence); proportion of participants who experienced at least one ARI over the study period (RR 0.88, 95% CI 0.72 to 1.08; 5 trials; 520 participants; low-certainty evidence); and the number of symptom days per episode of illness (mean difference (MD) -0.44 day, 95% CI -2.33 to 1.46; 6 trials; 557 participants; low-certainty evidence). Exercise reduced the severity of ARI symptoms measured on the Wisconsin Upper Respiratory Symptom Survey (WURSS-24) (MD -103.57, 95% CI -198.28 to -8.87; 2 trials; 373 participants; moderate-certainty evidence) and the number of symptom days during follow-up period (MD -2.24 days, 95% CI -3.50 to -0.98; 4 trials; 483 participants; low-certainty evidence). Excercise did not have a significant effect on laboratory parameters (blood lymphocytes, salivary secretory immunoglobulin, and neutrophils), quality of life outcomes, cost-effectiveness, and exercise-related injuries. There was no difference in participant dropout between the intervention and control groups. Overall, the certainty of the evidence was low, downgraded mainly due to limitations in study design and implementation, imprecision, and inconsistency. Seven trials were funded by public agencies; five trials did not report funding; and two trials were funded by private companies.

AUTHORS' CONCLUSIONS

Exercise did not reduce the number of ARI episodes, proportion of participants experiencing at least one ARI during the study, or the number of symptom days per episode of illness. However, exercise reduced the severity of ARI symptoms (two studies) and the number of symptom days during the study follow-up period (four studies). Small study size, risk of bias, and heterogeneity in the populations studied contributed to the uncertainty of the findings. Larger trials that are designed to avoid risk of bias associated with participant selection, blinding of outcomes assessors, and with adequate reporting of all outcomes proposed for measurement in trials, would help to provide more robust evidence.

Dose in Exercise-Based Dysphagia Therapies: A Scoping Review

BACKGROUND

Optimal exercise doses for exercise-based approaches to dysphagia treatment are unclear. To address this gap in knowledge, we performed a scoping review to provide a record of doses reported in the literature. A larger goal of this work was to promote detailed consideration of dosing parameters in dysphagia exercise treatments in intervention planning and outcome reporting.

METHODS

We searched PubMed, Scopus[Embase], CINAHL, and Cochrane databases from inception to July 2019, with search terms relating to dysphagia and exercises to treat swallowing impairments. Of the eligible 1906 peer-reviewed articles, 72 met inclusionary criteria by reporting, at minimum, both the frequency and duration of their exercise-based treatments.

RESULTS

Study interventions included tongue exercise (n = 16), Shaker/head lift (n = 13), respiratory muscle strength training (n = 6), combination exercise programs (n = 20), mandibular movement exercises (n = 7), lip muscle training (n = 5), and other programs that did not fit into the categories described above (n = 5). Frequency recommendations varied greatly by exercise type. Duration recommendations ranged from 4 weeks to 1 year. In articles reporting repetitions (n = 66), the range was 1 to 120 reps/day. In articles reporting intensity (n = 59), descriptions included values for force, movement duration, or descriptive verbal cues, such as "as hard as possible." Outcome measures were highly varied across and within specific exercise types.

CONCLUSIONS

We recommend inclusion of at least the frequency, duration, repetition, and intensity components of exercise dose to improve reproducibility, interpretation, and comparison across studies. Further research is required to determine optimal dose ranges for the wide variety of exercise-based dysphagia interventions.

Effect of Unilateral Cordotomy on Perception of Dysphagia

Objectives:

CO2 laser medial transverse cordotomy is a permanent static procedure performed to achieve adequate functional airway in cases of posterior glottic stenosis and bilateral vocal fold paralysis. Although it is the preferred method to manage long-term bilateral vocal fold immobility, it is widely believed that cordotomy has the potential to cause aspiration. The minimal existing data on the effect surgical enlargement of the glottic airway on swallowing function is heterogeneous. Through investigation of dysphagia after cordotomy, we hope to better understand the influence of glottic function and its role in dysphagia. The Eating Assessment Tool (EAT-10), is a validated dysphagia symptom-specific outcome measure. We hypothesized that EAT-10 scores would not change after CO2 laser cordotomy despite causing glottic insufficiency.

Methods:

Retrospective review was performed on sequential patients having undergone unilateral CO2 laser cordotomy with complete pre- and postoperative EAT-10 questionnaire data available for evaluation.

Results:

Fifteen patients were available for analysis; 10 patients underwent primary unilateral medial transverse cordotomy, 5 patients underwent revision cordotomy, and 20 unique procedures were included in the dataset. The median EAT-10 score during the visit prior to surgery was 3.5, whereas the post-surgery median score was 2. Furthermore, the median difference of 0 was statistically non-significant ( P = .91).

Conclusion:

CO2 laser cordotomy does not contribute to patient-reported dysphagia despite creating glottic incompetence. This suggests vocal fold apposition may play a less significant role in normal swallowing function than widely believed.

Detectable voice change with the edrophonium test in laryngeal myasthenia gravis

A case of laryngeal myasthenia gravis in a 65-year-old woman presenting with hoarseness as the sole symptom is reported. Voice spectrography was performed before and after injection of intravenous edrophonium. There was a marked improvement in the patient's voice after the administration of edrophonium, which was confirmed by the changes seen on the sound spectrogram. This was the only objective indication of a diagnosis of myasthenia gravis. No thymoma was seen on chest X-ray and the patient was negative for anti-acetylcholine receptor antibodies. Treatment for laryngeal myasthenia gravis was initiated and the patient's vocal problems resolved. This case emphasizes the need to consider systemic diseases in the differential diagnosis of hoarseness and demonstrates the need for careful follow-up in such patients.