Evidence-Based Systematic Review: Effects of Speech-Language Pathology Treatment for Individuals With Paradoxical Vocal Fold Motion

PURPOSE

In this article, our goal was to determine the state of the evidence and the effect of speech-language pathology (SLP) treatment for individuals with paradoxical vocal fold motion (PVFM).

METHOD

The American Speech-Language-Hearing Association's National Center for Evidence-Based Practice in Communication Disorders searched 22 electronic databases using key words related to PVFM, speech or voice treatment, and behavioral intervention for articles published through July 2013. Identified articles were systematically evaluated to assess the quality of the evidence using a modification of the American Speech-Language-Hearing Association's critical appraisal scheme.

RESULTS

Sixty-five articles met the search criteria. Only 2 out of the 65 articles were judged to contain adequate evidence to evaluate the effect of SLP treatment for PVFM. All 65 articles exemplify the state of the evidence for SLP treatment for PVFM.

CONCLUSION

The state of the evidence for the use of SLP treatment is in its infancy, with a majority of articles in the exploratory stage of research. Consequently, few clinical implications can be drawn at this time. SLP treatment for PVFM is promising; however, there is clearly a pressing need for systematic experimental studies that involve a control group to further the evidence base.

A Wearable Skinlike Ultra-Sensitive Artificial Graphene Throat

Most mute people cannot speak due to their vocal cord lesion. Herein, to assist mute people to "speak", we proposed a wearable skinlike ultrasensitive artificial graphene throat (WAGT) that integrated both sound/motion detection and sound emission in single device. In this work, the growth and patterning of graphene can be realized at the same time, and a thin poly(vinyl alcohol) film with laser-scribed graphene was obtained by a water-assisted transferring process. In virtue of the skinlike and low-resistant substrate, the WAGT has a high detection sensitivity (relative resistance changes up to 150% at 133 Ω) and an excellent sound-emitting ability (up to 75 dB at 0.38 W power and 2 mm distance). On the basis of the excellent mechanical-electrical performance of graphene structure, the sound detecting and emitting mechanisms of WAGT are realized and discussed. For sound detection, both the motion of larynx and vibration of vocal cord contribute to throat movements. For sound emission, a thermal acoustic model for WAGT was established to reveal the principle of sound emitting. More importantly, a homemade circuit board was fabricated to build a dual-mode system, combining the detection and emitting systems. Meanwhile, different human motions, such as strong and small throat movements, were also detected and transformed into different sounds like "OK" and "NO". Therefore, the implementation of these sound/motion detection acoustic systems enable graphene to achieve device-level applications to system-level applications, and those graphene acoustic systems are wearable for its miniaturization and light weight.

The Olin EILOBI Breathing Techniques: Description and Initial Case Series of Novel Respiratory Retraining Strategies for Athletes with Exercise-Induced Laryngeal Obstruction

INTRODUCTION

Exercise-induced laryngeal obstruction (EILO), the condition previously known as paradoxical vocal fold motion and vocal cord dysfunction, is characterized by inappropriate glottic or supraglottic obstruction during high-intensity exercise, causing exertional dyspnea, frequently with stridor. EILO is definitively diagnosed through upper-airway visualization during a characteristic episode. Although respiratory retraining is a primary therapy for EILO, many patients report symptom persistence despite adequate performance of traditional techniques. This report describes three novel breathing techniques for EILO, the Olin EILOBI (EILO biphasic inspiratory) breathing techniques. We include a teaching process and case series with patient-reported assessments.

MATERIALS AND METHODS

Following descriptions of the techniques and teaching process, we present data from a questionnaire offered to all patients who learned at least one of the techniques between September 2015 and March 2017. Subjects evaluated (1) expectation setting, (2) teaching processes, (3) their ability to implement the techniques during high-intensity exercise, and (4) perceived clinical effectiveness.

RESULTS

Ninety-five percent of eligible patients participated, a primarily young, female, and Caucasian sample. Over 50% of subjects competed at the high school varsity level. Sixty-two percent of subjects perceived reasonable expectations, and 82% positively evaluated the teaching process. Seventy-nine percent were able to employ their technique in the high-intensity activity of choice, and 66% perceived clinical effectiveness with the techniques.

CONCLUSIONS

The Olin EILOBI breathing techniques are novel respiratory retraining techniques for use in high-intensity exercise. Case series subjects reported reasonable expectations, a helpful teaching process, the ability to use these techniques during high-intensity exercise, and perceived clinical effectiveness.

Paradoxic vocal fold movement disorder

Paradoxical Vocal Fold Movement Disorder (PVFMD) is a cause of dyspnea that can mimic or occur alongside asthma or other pulmonary disease. Treatment with Laryngeal Control Therapy is very effective once the entity is properly diagnosed and contributing comorbidities are managed appropriately. In understanding the etiology of PVFMD, focus has broadened beyond psychiatric factors alone to include the spectrum of laryngeal irritants (laryngopharyngeal reflux, allergic and sinus disease, sicca, and possibly obstructive sleep apnea). The following is a discussion of the history, terminology, epidemiology, diagnosis, comorbid conditions, and treatment of this entity.

Breathing exercises for dysfunctional breathing/hyperventilation syndrome in children

BACKGROUND

Dysfunctional breathing is described as chronic or recurrent changes in breathing pattern causing respiratory and non-respiratory symptoms. It is an umbrella term that encompasses hyperventilation syndrome and vocal cord dysfunction. Dysfunctional breathing affects 10% of the general population. Symptoms include dyspnoea, chest tightness, sighing and chest pain which arise secondary to alterations in respiratory pattern and rate. Little is known about dysfunctional breathing in children. Preliminary data suggest 5.3% or more of children with asthma have dysfunctional breathing and that, unlike in adults, it is associated with poorer asthma control. It is not known what proportion of the general paediatric population is affected. Breathing training is recommended as a first-line treatment for adults with dysfunctional breathing (with or without asthma) but no similar recommendations are available for the management of children. As such, breathing retraining is adapted from adult regimens based on the age and ability of the child.

OBJECTIVES

To determine whether breathing retraining in children with dysfunctional breathing has beneficial effects as measured by quality of life indices.To determine whether there are any adverse effects of breathing retraining in young people with dysfunctional breathing.

SEARCH METHODS

We identified trials for consideration using both electronic and manual search strategies. We searched CENTRAL, MEDLINE and EMBASE. We searched the National Research Register (NRR) Archive, Health Services Research Projects in Progress (HSRProj), Current Controlled Trials register (incorporating the metaRegister of Controlled Trials and the International Standard Randomised Controlled Trial Number (ISRCTN) to identify research in progress and unpublished research. The latest search was undertaken in October 2013.

SELECTION CRITERIA

We planned to include randomised, quasi-randomised or cluster-randomised controlled trials. We excluded observational studies, case studies and studies utilising a cross-over design. The cross-over design was considered inappropriate due to the purported long-lasting effects of breathing retraining. Children up to the age of 18 years with a clinical diagnosis of dysfunctional breathing were eligible for inclusion. We planned to include children with a primary diagnosis of asthma with the intention of undertaking a subgroup analysis. Children with symptoms secondary to cardiac or metabolic disease were excluded.We considered any type of breathing retraining exercise for inclusion in this review, such as breathing control, diaphragmatic breathing, yoga breathing, Buteyko breathing, biofeedback-guided breathing modification and yawn/sigh suppression. We considered programmes where exercises were either supervised (by parents or a health professional, or both) or unsupervised. We also considered relaxation techniques and acute episode management as long as it was clear that breathing exercises were a component of the intervention.Any intervention without breathing exercises or where breathing exercises were not key to the intervention were excluded.

DATA COLLECTION AND ANALYSIS

We planned that two authors (NJB and MJ) would extract data independently using a standardised form. Any discrepancies would be resolved by consensus. Where agreement could not be reached a third review author (MLE) would have considered the paper.

MAIN RESULTS

We identified 264 potential trials and reviews from the search. Following removal of duplicates, we screened 224 papers based on title and abstract. We retrieved six full-text papers and further evaluated them but they did not meet the inclusion criteria. There were, therefore, no studies suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

The results of this systematic review cannot inform clinical practice as no suitable trials were identified for inclusion. Therefore, it is currently unknown whether these interventions offer any added value in this patient group or whether specific types of breathing exercise demonstrate superiority over others. Given that breathing exercises are frequently used to treat dysfunctional breathing/hyperventilation syndrome, there is an urgent need for well-designed clinical trials in this area. Future trials should conform to the CONSORT statement for standards of reporting and use validated outcome measures. Trial reports should also ensure full disclosure of data for all important clinical outcomes.

Diagnostic and Therapeutic Outcomes Following Systematic Assessment of Patients with Concurrent Suspected Vocal Cord Dysfunction and Asthma

BACKGROUND

Vocal cord dysfunction (VCD) is present in 25% to 50% of patients with asthma. When both diagnoses are suspected, accurate diagnosis and targeted management represent a clinical challenge.

OBJECTIVE

To evaluate diagnostic and therapeutic outcomes following systematic assessment for patients with concurrent suspected VCD and asthma.

METHODS

Patients underwent systematic evaluation by clinical assessment and validated questionnaires, followed by multidisciplinary management. VCD was confirmed by visualization of paradoxical vocal fold motion at baseline or following provocation. Asthma was confirmed by demonstrating variable airflow obstruction. Asthma medications were deescalated in those with low clinical probability of asthma and no variable airflow obstruction. Response to 2 or more sessions of speech pathology was assessed by subjective report and standardized questionnaires.

RESULTS

Among 212 consecutive patients, 62 (29%) patients had both VCD and asthma, 54 (26%) had VCD alone, 51 (24%) had asthma alone, and 45 (21%) had neither. Clinician assessment and the Laryngeal Hypersensitivity Questionnaire both predicted laryngoscopy-confirmed VCD. Deescalation or discontinuation of asthma therapy was possible in 37 of 59 (63%) patients without variable airflow obstruction, and was most successful (odds ratio, 5.5) in the presence of laryngoscopy-confirmed VCD (25 of 31, or 81%) Patients with VCD responded subjectively to 2 or more sessions of speech pathology, but laryngeal questionnaire scores did not improve.

CONCLUSIONS

Expert clinician assessment and the Laryngeal Hypersensitivity Questionnaire predict the presence of laryngoscopy-confirmed VCD. Systematic assessment for both VCD and asthma facilitates deescalation or discontinuation of unnecessary asthma medications. Subjective symptom improvement following speech pathology was not paralleled by laryngeal questionnaire scores in this cohort.

Factors impacting therapy duration in children and adolescents with Paradoxical Vocal Fold Movement (PVFM)

PURPOSE

Paradoxical Vocal Fold Movement (PVFM) may cause airway restriction and resulting dyspnea in the pediatric population. Therapy with a speech-language pathologist (SLP) is the primary treatment for children and adolescents diagnosed with Paradoxical Vocal Fold Movement (PVFM). This study examined treatment duration and factors predicting number of therapy sessions required.

METHODS

Data were drawn from the University of Wisconsin-Madison Voice and Swallow Clinics Outcome Database. One hundred and twelve children and adolescents were included in this study. Participants were diagnosed with PVFM, followed for therapy with a SLP, and were subsequently discharged from therapy with successful outcomes. Extracted data included number of therapy sessions, PVFM symptoms, patient demographics, medical history, and comorbid diagnoses. Regression was used to determine factors predicting therapy duration.

RESULTS

Patients completed an average of 3.4 therapy sessions before discharge. Comorbid behavioral health diagnosis (β = 1.96, t = 3.83, p < .01) and a history of upper airway surgeries (β = 1.26, t = 2.615, p = .01) were significant predictors of the number of therapy sessions required before discharge; both factors significantly increased therapy duration. Age, symptom trigger-type, reflux symptoms, and dysphonia did not predict therapy duration. Overall, our regression model accounted for 42% of the variance in number of sessions required (r2 = 0.42).

CONCLUSIONS

On average, 3.4 sessions of therapy with an SLP resolved PVFM symptoms. Children with a behavioral health diagnosis required an average of 5.45 sessions and those with a history of upper airway surgery an average of 4.3 sessions. Future work should examine the relationship between behavioral health care and PVFM treatment, as well as how PVFM treatment efficiency can be maximized.

LEVEL OF EVIDENCE: 3

Inducible Laryngeal Obstruction Differential Diagnosis in Adolescents and Adults: A Tutorial

Inducible laryngeal obstruction (ILO), formerly referred to as paradoxical vocal fold motion and vocal cord dysfunction, is a complex disorder of the upper airway that requires skillful differential diagnosis. There are several medical conditions that may mimic ILO (or which ILO may mimic) that should be considered in the differential diagnosis before evidence-supported behavioral intervention is initiated to mitigate or eliminate this upper airway condition. A key in treatment planning is determination of an isolated presentation of ILO or ILO concurrent with other conditions that affect the upper airway. Accurate, timely differential diagnosis in the clinical assessment of this condition mitigates delay of targeted symptom relief and/or insufficient intervention. Accurate assessment and nuanced clinical counseling are necessary to untangle concurrent, competing conditions in a single patient. This tutorial describes the common and rare mimics that may be encountered by medical professionals who evaluate and treat ILO, with particular attention to the role of the speech-language pathologist. Speech-language pathologists receive referrals for ILO from several different medical specialists (allergy, pulmonology, and sports medicine), sometimes without a comprehensive team assessment. It is paramount that speech-language pathologists who assess and treat this disorder have a solid understanding of the conditions that may mimic ILO. Summary tables that delineate differential diagnosis considerations for airway noise, origin of noise, symptoms, triggers, role of the speech-language pathologist, and β-agonist response are included for clinician reference. A clinical checklist is also provided to aid clinicians in the critical assessment process.

Short-Term Intensive Therapy and Outcomes for Athletes With Paradoxical Vocal Fold Motion Disorder

Purpose The aim of the study was to develop a treatment for athletes with paradoxical vocal fold motion disorder (PVFMD) based on exercise physiology and learning theory principles and administer it over a preestablished time frame. Method A prospective, repeated-measures, within-subject group design was used. Eleven adolescent/teen athletes diagnosed with PVFMD via laryngoscopy received short-term intensive (STI) therapy. Eight of the athletes returned for extended follow-up. Changes in postexercise inspiratory ( R _i) and expiratory ( R _e) resistances and Modified Borg Dyspnea Scale (MBDS) ratings collected at baseline were compared immediately posttreatment and at extended follow-up. Dyspnea Index scores were collected at baseline and at extended follow-up. Two no-treatment control athletes with PVFMD participated in two exercise challenges-baseline and 6 weeks later. Results Immediately after STI therapy, athletes attained significant improvement in R _i, R _e, and MBDS ratings. These changes were maintained at extended follow-up as well as a significant change in Dyspnea Index scores. The 2 control athletes who were reassessed 6 weeks after baseline experienced negative changes in postexercise R _i and MBDS ratings. Conclusion STI therapy that incorporated individuality, specificity, and variable practice effectively changed outcome measures posttreatment with further improvement observed at extended follow-up. These results provide preliminary evidence for STI therapy for PVFMD.

Demographic Differences in Clinical Presentation of Pediatric Paradoxical Vocal Fold Motion (PVFM)

OBJECTIVES

Paradoxical vocal fold motion (PVFM) is involuntary closure of the vocal folds during inspiration, often presenting in children and young adults. Although common symptoms and triggers are known, differences in clinical presentation based on patient demographics are unknown. This study characterizes differences in clinical presentation of pediatric PVFM based on age, sex, and race/ethnicity.

METHODS

We reviewed electronic medical records of patients 0-21 years old with PVFM based on ICD codes from 2009 to 2019 within a tertiary academic health system. Demographics, symptoms, triggers, concurrent diagnoses, and laryngoscopy findings were abstracted. Odds ratios (ORs) and 95% confidence intervals (CI) were estimated using logistic regression.

RESULTS

Among 96 individuals the mean age was 10.6 years (standard deviation ±6.5) and 66 (69%) were female. In comparison to 13-21 year olds, those 0-2 years more often had PVFM observed on laryngoscopy (OR = 17.84, 95% CI: 3.14-101.51) and had less shortness of breath (OR = 0.01, 95% CI: 0.00-0.09). Those 3-12 years had more asthma (OR = 3.07, 95% CI: 1.07-8.81) and cough (OR = 6.12, 95% CI: 1.77-21.13). Both 0-2 (OR = 0.07, 95% CI: 0.02-0.24) and 3-12 year olds (OR = 0.13, 95% CI: 0.04-0.40) presented less with activity as a trigger. Racial/ethnic minorities were more likely to present with pharyngeal findings (eg mucosal inflammation, adenotonsillar hypertrophy) on laryngoscopy (OR = 4.58, 95% CI: 1.45-15.37) compared to non-Hispanic Whites. Differences in clinical presentation by sex were not observed.

CONCLUSION

We identified several differences in symptoms, triggers, and laryngoscopy findings in pediatric PVFM based on age and race/ethnicity. Associations between sex and clinical presentation were not observed.

Reduced Asthma Medication Use after Treatment of Pediatric Paradoxical Vocal Fold Motion Disorder

OBJECTIVES/HYPOTHESES

The primary objective of this study was to determine whether the diagnosis and treatment of pediatric Paradoxical Vocal Fold Motion Disorder (PVFMD) leads to decreased asthma medication use. Our secondary objective was to determine dyspnea outcomes following diagnosis and treatment for PVFMD.

STUDY DESIGN

Prospective observational study.

METHODS

Patients with newly diagnosed PVFMD between the ages of 11 and 17 were recruited at a single pediatric institution. A medication questionnaire and Dyspnea Index (DI) were completed at the initial visit, at the first return visit, and at greater than 6 months post-diagnosis and therapy. Laryngeal Control Therapy (LCT) consisted of teaching breathing techniques and identifying emotional, physical, and environmental contributing factors and strategies to reduce them.

RESULTS

Twenty-six patients were recruited to the study. There were 19/26 (73%) patients diagnosed with asthma prior to a diagnosis of PVFMD, and 26/26 (100%) patients were using an inhaler prior to the enrollment visit. Twenty-two (85%) patients completed follow-up questionnaires. Five patients participated in no therapy, seven patients in partial therapy, and 14 patients in full therapy. Significant reduction in asthma medication use was seen in the full therapy group (P < .05) and in those with exercise as their only trigger (P < .05). Furthermore, symptoms as scored by the DI decreased overall from 25.5 to 18.8 (P < .001).

CONCLUSIONS

Diagnosis and treatment of pediatric PVFMD leads to a decline in asthma medication use in those patients who participate in at least two LCT sessions and in those with exercise-induced PVFMD. LCT for pediatric PVFMD leads to a significant decrease in symptoms as measured by the DI.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1639-1646, 2021.

Paradoxical Vocal Cord Motion in Pediatric Patients

Paradoxical vocal cord motion (PVCM), also termed vocal cord dysfunction, is a poorly understood disorder of episodic dyspnea characterized by inappropriate vocal cord adduction during inspiration and potentially during expiration. It can coexist or be confused with asthma, so appropriate diagnosis is key to optimizing treatment success. Although many patients with PVCM may have underlying psychologic issues, there is emerging evidence to suggest that this entity is not psychogenic in every patient. Both laryngeal irritants and exercise have been identified as additional contributing factors in PVCM. Diagnosis of PVCM requires awake laryngoscopic confirmation. However, many patients do not exhibit signs of PVCM during this examination, despite provocation during testing. Therefore, clinical history remains key in determining which patients should proceed with behavioral therapy under the guidance of a speech pathologist. In addition, treatment may include limiting patient exposure to potential sources of laryngeal irritation. Refractory patients may benefit from psychologic assessment and treatment. [Pediatr Ann. 2016;45(5):e184-e188.].

The Effect of Exercise on Respiratory Resistance in Athletes With and Without Paradoxical Vocal Fold Motion Disorder

PURPOSE

An investigational, portable instrument was used to assess inspiratory (R(i)) and expiratory (R(e)) resistances during resting tidal breathing (RTB), postexercise breathing (PEB), and recovery breathing (RB) in athletes with and without paradoxical vocal fold motion disorder (PVFMD).

METHOD

Prospective, controlled, repeated measures within-subject and between-groups design. Twenty-four teenage female athletes, 12 with and 12 without PVFMD, breathed into the Airflow Perturbation Device for baseline measures of respiratory resistance and for two successive 1-min trials after treadmill running for up to 12 min. Exercise duration and dyspnea ratings were collected and compared across groups.

RESULTS

Athletes with PVFMD had lower than control R(i) and R(e) values during RTB that significantly increased at PEB and decreased during RB. Control athletes' R(e) decreased significantly from RTB to PEB but not from PEB to RB, whereas R(i) did not change from RTB to PEB but decreased from PEB to RB. Athletes without PVFMD ran longer, providing lower dyspnea ratings.

CONCLUSION

Immediately following exercise, athletes with PVFMD experienced increased respiratory resistance that affected their exercise performance. The difference in resting respiratory resistances between groups is intriguing and could point to anatomical differences or neural adaptation in teenagers with PVFMD. The Airflow Perturbation Device appears to be a clinically feasible tool that can provide insight into PVFMD and objective data for tracking treatment progress.

Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics

INTRODUCTION

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based.

AREAS COVERED

A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure.

EXPERT OPINION

Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.

A retrospective review of infant-inducible laryngeal obstruction a subtype of paradoxical vocal fold motion: Evaluation and management

INTRODUCTION

There is a paucity of literature on pre-adolescent paradoxical vocal fold motion (PVFM), PVFM is a sub-type of inducible laryngeal obstruction. Studies typically focus on older patients, however the discovery of this entity in pre-adolescent pediatric patients has led to more questions about how this entity manifests differently and is treated differently in younger populations. Initially considered psychosomatic and commonly mistaken for asthma, PVFM etiology is now thought to be associated underlying neurologic conditions and may have irritant triggers with proposed mechanisms related to laryngeal hypersensitivity. Treatment is multimodal. Diagnosis is with flexible laryngoscopy and clinical exam but other modalities like functional endoscopic evaluation of swallow may provide more information than flexible laryngoscopy alone.

METHODS

After obtaining IRB approval, a retrospective review of all charts of patients ages 0-18 months (pre-adolescent pediatric patients) who underwent flexible endoscopic evaluation of swallow and/or flexible laryngoscopy from 1/2013-8/2021 was performed. Twenty-four subjects diagnosed with PVFM were identified.

RESULTS

The most common presenting symptom was stridor or coughing with feeds. 63 % were male, mean age at time of diagnosis was 3.4 months, and mean follow-up length was 11.4 months. Comorbidities included reflux (45 %), pulmonary diagnoses (25 %) and neurologic diagnoses (54 %). 16/24 subjects had otolaryngology diagnoses (laryngomalacia, tracheomalacia, subglottic stenosis, or ankyloglossia). 12/24 subjects were treated with conservative management such as anti-reflux medications or precautions. 33 % of patients treated with conservative management had complete symptom resolution. PVFM patients with neurologic comorbidities were more likely to require alternative feeding access (p < 0.05). All 11 subjects who required surgical feeding access had neurologic diagnoses. 5/10 of patients with neonatal abstinence syndrome (NAS) required alternative feeding means, and 40 % tolerated oral feeds after medical management of NAS.

CONCLUSION

Our findings suggest PVFM is most commonly seen in pre-adolescent pediatric patients with medical comorbidities. Healthy pre-adolescent pediatric patients with PVFM frequently improved with conservative management. The differential diagnosis of the stridulous infant should include PVFM. It is imperative to consider nutritional access in PVFM patients with neurologic comorbidities.

A narrative review of basic and clinical studies for vocal fold regeneration therapies

OBJECTIVE

To review the various basic research and treatments available to regenerate the vocal folds and to discuss the direction for future treatments.

METHODS

A comprehensive review was performed in PubMed database and Google Scholar utilizing search terms including combinations and variations of the following concepts: vocal fold anatomy, vocal fold disorders, and regenerative therapies. No particular inclusion or exclusion criteria were set due to the nature of this narrative review article.

RESULTS/DISCUSSION

The regenerative treatments available for each vocal fold layer are the following: 1) epidermal growth factor and transforming growth factor-β1 for the epithelial layer, 2) autologous fibroblasts, autologous bone-marrow derived mesenchymal stem cells (MSCs), autologous adipose tissue-derived stromal vascular fraction (ADSVF), basic fibroblast growth factor (bFGF), collagen-hyaluronic acid nanofiber, pirfenidone, hepatocyte growth factor (HGF), pulsed dye laser (PDL), diode laser, and platelet-rich plasma (PRP) for the lamina propria, 3) bFGF and controlled-release bFGF with autologous fascia, HGF, c-Met agonistic antibody, and PRP for the muscular layer, 4) and bFGF and PRP-loaded nerve guidance conduit for the nerve. Treatments deemed clinically safe with sustained efficacy assessed up to 6 months are HGF and PDL, while bFGF, autologous fibroblasts, autologous bone marrow-derived MSCs, ADSVF, and PRP have been studied up to 12 months.

CONCLUSION

An ideal regenerative treatment is one that restores the injured or lost components of the vocal fold. The layered structure of the vocal fold allows for several mechanisms of action for these regenerative therapies. Further experimental and clinical studies are warranted, and these would dictate the impact of vocal fold regenerative therapies. Regenerative medicine may soon be at the forefront for treating vocal fold disorders. Clinicians should be open to advancements in treatment and consider the potential of novel therapies to treat specific pathologies.

[Paradoxical vocal fold motion, a real breathing problem : diagnosis and treatment]

The paradoxical vocal fold motion (PVFM) is a temporary total inability to breathe, which is important to rule out from other more or less important breathing difficulties encountered in asthma. Overtreatment for asthma instead of treatment for PVFM can lead to iatrogenic complications which can be averted by early and correct diagnosis. This article presents a list of symptoms and related disorders, enabling to more easily diagnose PVFM, as well as its specifics treatments and a « Block-unblock maneuver » not yet described in the literature, allowing the patient to respond to the crisis and to prevent future crises.

Gastroesophageal reflux disease, laryngopharyngeal reflux, and vocal cord dysfunction/inducible laryngeal obstruction-overlapping conditions that affect asthma

Asthma is a chronic lung condition that may be affected by numerous medical comorbidities. Such comorbidities can influence the presentation and even the severity of asthma. Alternatively, asthma may be misdiagnosed as a comorbidity when symptoms overlap. The 3 medical conditions that commonly affect asthma management are gastroesophageal reflux disease, laryngopharyngeal reflux, and vocal cord dysfunction/inducible laryngeal obstruction). These conditions can be difficult to distinguish from one another, as well as from asthma itself. In this review, the epidemiology, pathophysiology, symptomatology, and diagnostic considerations of each condition in both adult and pediatric populations are discussed. Treatment options, as well as how such options may influence asthma outcomes, are included. Finally, knowledge gaps in each area are highlighted, as a better understanding of the optimal diagnostic and therapeutic approaches will allow for improved individualized care of patients with asthma.

Vocal Cord Disorders

Vocal cord disorders present with a variety of symptoms including dysphonia, respiratory symptoms, and stridor. When evaluating symptoms, a complete history and through head, neck, and neurologic examinations are necessary. If dysphonia persists for greater than 4 w or there is associated smoking, then larngoscopy is necessary to evaluate the vocal folds. Empiric treatment of dysphonia is not recommended without direct visualization of the vocal folds. Most masses of the vocal folds are benign and resolve with voice hygiene and speech therapy. Surgery is reserved for persistent symptomatic nodules and cancerous lesions.

Vocal Cord Dysfunction: Rapid Evidence Review

Vocal cord dysfunction (i.e., vocal cords closing when they should be opening, particularly during inspiration) should be suspected in patients presenting with inspiratory stridor or wheezing; sudden, severe dyspnea (without hypoxia, tachypnea, or increased work of breathing); throat or chest tightness; and anxiety, particularly in females. Common triggers include exercise, asthma, gastroesophageal reflux disease, postnasal drip, upper or lower respiratory tract infection, and irritants. Nasolaryngoscopy and pulmonary function testing, with provocative exercise and methacholine, can help diagnose vocal cord dysfunction and are helpful to evaluate for other etiologies. Conditions that can trigger vocal cord dysfunction should be optimally treated, particularly asthma, gastroesophageal reflux disease, and postnasal drip, while avoiding potential irritants. Therapeutic breathing maneuvers and vocal cord relaxation techniques are first-line therapy for dyspnea that occurs with vocal cord dysfunction. A subset of vocal cord dysfunction leads to dysphonia, as opposed to dyspnea, secondary to abnormal laryngeal muscle spasms (vocal cord closure is less severe). OnabotulinumtoxinA injections may be helpful for spasmodic dysphonia and for treating dyspnea in certain cases, although evidence is limited.

[The diagnosis and treatment progress of vocal fold leukoplakia]

Vocal fold leukoplakia is a descriptive diagnosis, and can be divided into simple hyperplasia, precancerous lesions(with atypical hyperplasia) and invasive carcinoma according to pathological types. Because of a close relationship with the laryngeal carcinoma, knowing the risk factors and treatment methods of vocal fold leukoplakia has grate significance in preventing the malignant change and recurrence. This paper summarizes the recent progress in clinical diagnosis and treatment of vocal cord leukoplakia, mainly including risk factors, means of examination, treatment and prognosis.

Effect of Interventional Ultrasound in the Treatment of Postthyroidectomy Vocal Cord Dysfunction: A Preliminary Exploratory Study

PURPOSE

To explore the efficacy of interventional ultrasound treatment for hoarseness caused by nondisconnected recurrent laryngeal nerve injury after thyroidectomy.

MATERIALS AND METHODS

In this retrospective study, we analysed the clinical data of 21 patients who underwent interventional ultrasound therapy (ultrasound-guided injection of a Diprospan and saline mixture) for postthyroidectomy hoarseness at our hospital between August 1, 2023, and January 31, 2024 (the Diprospan group) and randomly selected 21 patients who did not receive any treatment for postthyroidectomy hoarseness during the same period as the control group. The average vocal cord activity improvement time for the Diprospan group was calculated and compared with that of untreated patients from previous studies. Vocal cord activity improvement rates were assessed at 1, 2, and 3 mo after thyroidectomy, and changes in the voice handicap index (VHI) and the subjective listening perception scale (GRBAS) scores before and after treatment were evaluated. Additionally, the efficacy was compared between patients treated within 2 wk (timely intervention group, TI group) and those treated 2 wk after thyroidectomy (delayed intervention group, DI group) to explore the impact of treatment timing on outcomes.

RESULTS

In the Diprospan group, the average vocal cord activity improvement time was 44.6 ± 4.7 d for those treated within 2 wk after thyroidectomy and 17.7 ± 1.5 d for those treated 2 wk after thyroidectomy, both of which were significantly shorter than the 6 mo to 1 y reported in the literature. The improvement rates at 1, 2, and 3 mo after thyroidectomy were significantly greater in the Diprospan group than in the control group (0.0% vs. 28.6%, 23.8% vs. 81.0%, 33.3% vs. 90.5%, p < 0.05). The VHI score (72.6 ± 21.2 vs. 12.6 ± 24.7, p < 0.001) and GRBAS score (12.0 vs. 0.0, p < 0.001) significantly improved after treatment. Compared with the DI group, the TI group also showed faster voice recovery (19.8 ± 5.8 d vs. 14.0 ± 2.6 d, p < 0.05). No treatment-related adverse reactions were observed.

CONCLUSION

Interventional ultrasound is a safe and effective treatment for hoarseness after thyroidectomy, as it effectively improves vocal cord mobility and accelerates voice recovery.