Patient reported voice handicap and auditory-perceptual voice assessment outcomes in patients with COVID-19.

PURPOSE: The purpose of this study is to compare patient-reported voice handicap and auditory-perceptual measures of voice between healthy individuals and COVID-19 patients, as well as to investigate the effect of clinical factors on voice quality. METHODS: COVID-19 patients (n = 138) and 90 healthy controls were included in the study. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) was used to grade voice samples based on overall severity, roughness, breathiness, strain, pitch, and loudness. The Voice Handicap Index-10 was completed by all participants (VHI-10). Physical (pVHI), emotional (eVHI) and functional (fVHI) subscores were calculated. Clinical data were collected (disease stage, CT grade, neutrophil/lymphocyte ratio, CRP, and symptoms). RESULTS: A statistically significant difference between patient and control groups in VHI-10 and CAPE-V scores was detected (p < 0.001). Except eVHI, total score and all subscale scores were higher in patients with COVID-19 as the pVHI was the most affected (η2 = 0.324) subscale. All scores of CAPE-V were significantly worse in patients with COVID-19 as highest impact of COVID-19 was on breathiness (η2 = 0.518). Pre-existing pulmonary comorbidity, dyspnoea and N/L was significantly associated with the VHI-10 overall score (ßpc = 4.27, ßdyspnoea = 5.69 and ßnl = 0.25). The overall severity of CAPE-V was significantly dependent on dyspnoea and pulmonary comorbidity (ßdyspnoea = 11.25, ßpc = 10.12). VHI ≥4 and CAPE-V overall severity ≥11 were good indicators of COVID-19 related dysphonia. CONCLUSIONS: COVID-19 causes patient-reported voice handicap and deteriorates auditory-perceptual measures of voice. COVID-19 related voice impairment was mainly associated with the decreased respiratory capacity.

COVID-related dysphonia and persistent long-COVID voice sequelae: A systematic review and meta-analysis.

PURPOSE: Dysphonia is a common symptom due to the coronavirus disease of the 2019 (COVID-19) infection. Nonetheless, it is often underestimated for its impact on human's health. We conducted this first study to investigate the global prevalence of COVID-related dysphonia as well as related clinical factors during acute COVID-19 infection, and after a mid- to long-term follow-up following the recovery. METHODS: Five electronic databases including PubMed, Embase, ScienceDirect, the Cochrane Library, and Web of Science were systematically searched for relevant articles until Dec, 2022, and the reference of the enrolled studies were also reviewed. Dysphonia prevalence during and after COVID-19 infection, and voice-related clinical factors were analyzed; the random-effects model was adopted for meta-analysis. The one-study-removal method was used for sensitivity analysis. Publication bias was determined with funnel plots and Egger's tests. RESULTS: Twenty-one articles comprising 13,948 patients were identified. The weighted prevalence of COVID-related dysphonia during infection was 25.1 % (95 % CI: 14.9 to 39.0 %), and male was significantly associated with lower dysphonia prevalence (coefficients: -0.116, 95 % CI: -0.196 to -0.036; P = .004) during this period. Besides, after recovery, the weighted prevalence of COVID-related dysphonia declined to 17.1 % (95 % CI: 11.0 to 25.8 %). 20.1 % (95 % CI: 8.6 to 40.2 %) of the total patients experienced long-COVID dysphonia. CONCLUSIONS: A quarter of the COVID-19 patients, especially female, suffered from voice impairment during infection, and approximately 70 % of these dysphonic patients kept experiencing long-lasting voice sequelae, which should be noticed by global physicians.

Outcome of new- onset dysphonia in COVID-19 patients in a single tertiary centre

Introduction: Ever since coronavirus disease 2019 (COVID-19) was first identified in December 2019, it has infected millions of people and resulted in more than 6.86 million deaths worldwide. Numerous novel manifestations have emerged ensuing COVID-19 and even though a full 2-year period has passed, the ongoing pandemic remains a conundrum, especially to the healthcare system. Dysphonia, or a disorder of the voice, is among the novel manifestations that have emerged. Aim of the study: To outline the outcome of new-onset dysphonia presentation in COVID-19 patients in a single tertiary centre. Case study: We aim to discuss the clinical presentation and outcome of the 3 cases that we managed in our centre to help understand the course and outcome of new- onset dysphonia among COVID-19 patients. Result and discussion: We found that despite its viral origin, dysphonia in COVID-19 patients persisted for longer compared to other viral-induced dysphonia. New-onset dysphonia is a possible silent manifestation of COVID-19.

Pareto-Optimized AVQI Assessment of Dysphonia: A Clinical Trial Using Various Smartphones

Multiparametric indices offer a more comprehensive approach to voice quality assessment by taking into account multiple acoustic parameters. Artificial intelligence technology can be utilized in healthcare to evaluate data and optimize decision-making processes. Mobile devices provide new opportunities for remote speech monitoring, allowing the use of basic mobile devices as screening tools for the early identification and treatment of voice disorders. However, it is necessary to demonstrate equivalence between mobile device signals and gold standard microphone preamplifiers. Despite the increased use and availability of technology, there is still a lack of understanding of the impact of physiological, speech/language, and cultural factors on voice assessment. Challenges to research include accounting for organic speech-related covariables, such as differences in conversing voice sound pressure level (SPL) and fundamental frequency (f0), recognizing the link between sensory and experimental acoustic outcomes, and obtaining a large dataset to understand regular variation between and within voice-disordered individuals. Our study investigated the use of cellphones to estimate the Acoustic Voice Quality Index (AVQI) in a typical clinical setting using a Pareto-optimized approach in the signal processing path. We found that there was a strong correlation between AVQI results obtained from different smartphones and a studio microphone, with no significant differences in mean AVQI scores between different smartphones. The diagnostic accuracy of different smartphones was comparable to that of a professional microphone, with optimal AVQI cut-off values that can effectively distinguish between normal and pathological voice for each smartphone used in the study. All devices met the proposed 0.8 AUC threshold and demonstrated an acceptable Youden index value.

Self-perception of Voice Handicap in COVID 19 Patients.

Voice abnormalities were reported in patients during the course of COVID-19 infection. This study aims to evaluate the effect of COVID 19 infection on the self-perception of voice handicap in positive COVID 19 patients in addition to investigating the factors that might correlate with voice handicap if present. Voice handicap index-10 was filled in by 200 patients that were confirmed to be COVID 19 positive based on the RT-qPCR and symptomatology of the disease. The result showed that about 65.5% had mild degree of COVID 19 and 27.5% had moderate degree. Dysphonia was reported by 19% of the patients when questioned about voice symptoms. Dysphonia was detected in 35% of them by auditory perceptual assessment. Symptoms of Dyspnea, dysphonia, headache were significantly correlated with total and subtotal scores of Voice handicap index. COVID 19 infection has a negative impact on some of the patients? self- perception of voice handicap on the functional, physical and emotional domains. Age and degree of COVID 19 severity were correlating with the patients? self -perception of voice handicap.

Vocal Disorders in Patients with COVID 19 in Egypt.

COVID-19 is considered a respiratory disease which has many symptoms associated with the larynx and the lungs infections. COVID-19 has wide spectrum of clinical features starting from mild symptoms to severe illness. Otolaryngological symptoms as nasal obstruction, loss of smell, taste dysfunction, sore throat, sticky mucus, and dysphagia are common in COVID-19 patients. Other vocal symptoms as dysphonia and phonesthenia are common in COVID-19 patients. The aim of this study is to detect the occurrence of vocal symptoms in COVID-19 patients in Egypt and to investigate the videolaryngoscopic findings associated with these symptoms. A total number of 106 patients diagnosed with COVID-19 were randomly assessed for vocal symptoms. The following epidemiological and clinical data were collected: age, gender, smoking consumption, general symptoms, otolaryngological and vocal symptoms as dysphonia and phonesthenia. Auditory perceptual assessment of voice and videolaryngoscopic examination were done. The occurrence of dysphonia and phonesthenia were observed in COVID -19 patients. Of the 106 patients, 84 patients (79%) were dysphonic, 20 (18.8%) patients were phonesthenic. The correlation of the different otolaryngological symptoms with dysphonia and phonesthenia were reported. A significant correlation was found between dysphonic patients and rhinorrhea, taste dysfunction, sore throat, and cough. A significant correlation was found between phonesthenic patients and allergic rhinitis. Videolaryngoscopic findings were detected in COVID-19 patients. Vocal fold congestion was found in 42 patients (39.6%), benign vocal fold swellings was found in 18 patients (16.9%), ventricular hypertrophy was found in 6 patients (0.05%), unilateral vocal fold immobility was found in 14 patients (13.2%), and vocal fold congestion associated with ventricular fold hypertrophy was found in 20 patients (18.8%).There was significant correlation of dysphonia and phonesthenia with vocal fold congestion (P value:0.001, P value:0.039 respectively).There was a significant correlation between cough and vocal fold congestion (P value: 0.000). Benign vocal fold swellings were associated with 18 patients (16.9%), but it was not statistically significant (P value: 0.931). Dysphonia and phonesthenia were observed in patients with mild to moderate COVID-19.The vocal symptoms were associated with different laryngoscopic findings, in which, vocal fold congestion was the commonest.

Comparison of Voice Therapy Outcomes: Clinic vs Telehealth.

BACKGROUND: Voice therapy provides patients with valuable exercises and techniques to optimize vocal behaviors and improve their ability to communicate effectively and efficiently. These sessions were typically held by speech-language pathologists (SLPs) in clinic. During the COVID-19 pandemic, SLPs were provisionally able to provide billable voice therapy services in telehealth format. There is a lack of existing research studies comparing outcomes based on the format of voice therapy. METHODS: A retrospective chart review was performed on 101 patients who underwent voice therapy at a large academic institution in order to compare outcomes between clinic, telehealth, and mixed voice therapy formats. Demographics, dysphonia etiology, duration of symptoms, number of therapy sessions, and pre- and postvoice therapy scores using reflux symptom index (RSI), voice handicap index (VHI-10), consensus auditory-perceptual evaluation of voice (CAPE-V), and Grade, Roughness, Breathiness, Asthenia, Strain (GRBAS) scoring were collected. Statistical comparisons were performed using Fisher's exact test and analysis of covariance. RESULTS: There were no statistically significant differences in pre- to postvoice therapy RSI, VHI-10, CAPE-V, or GRBAS scores based on format of voice therapy, after adjustment for number of therapy sessions received. There were no differences in these outcomes when comparing voice therapy by etiology of dysphonia. CONCLUSIONS: Overall, these data support the effectiveness of the telehealth voice therapy format. It is a promising platform for greater patient access to therapy. All formats of voice therapy were effective in improving key measures of voice perception.

Otolaryngologic Symptom Severity Post SARS-CoV-2 Infection.

OBJECTIVE(S): To assess laryngologic symptomatology following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and determine whether symptom severity correlates with disease severity. METHODS: Single-institution survey study in participants with documented SARS-CoV-2 infection between March 2020 and February 2021. Data acquired included demographic, infection severity characteristics, comorbidities, and current upper aerodigestive symptoms via validated patient reported outcome measures. Primary outcomes of interest were scores of symptom severity questionnaires. Coronavirus disease of 2019 (COVID-19) severity was defined by hospitalization status. Descriptive subgroup analyses were performed to investigate differences in demographics, comorbidities, and symptom severity in hospitalized participants stratified by ICU status. Multivariate logistical regression was used to evaluate significant differences in symptom severity scores by hospitalization status. RESULTS: Surveys were distributed to 5300 individuals with upper respiratory infections. Ultimately, 470 participants with COVID-19 were included where 352 were hospitalized and 118 were not hospitalized. Those not hospitalized were younger (45.87 vs. 56.28 years), more likely female (74.17 vs. 58.92%), and less likely white (44.17 vs. 52.41%). Severity of dysphonia, dyspnea, cough, and dysphagia was significantly worse in hospitalized patients overall and remained worse at all time points. Cough severity paradoxically worsened in hospitalized respondents over time. Dyspnea scores remained abnormally elevated in respondents even 12 months after resolution of infection. CONCLUSIONS: Results indicate that laryngologic symptoms are expected to be worse in patients hospitalized with COVID-19. Dyspnea and cough symptoms can be expected to persist or even worsen by 1-year post infection in those who were hospitalized. Dysphagia and dysphonia symptoms were mild. Nonhospitalized participants tended to have minimal residual symptoms by 1 year after infection.

Case report of recurrent respiratory papillomatosis

Recurrent respiratory papillomatosis is a chronic disease caused by the human papillomavirus and can affect both children and adults. Although it is a benign disease, papilloma growth can cause severe, sometimes life-threatening airway obstruction. We report the case of a 28-year-old male patient who was admitted to the hospital with a fever and prolonged cough. A computed tomography (CT) scan showed solid and cavitated nodules in his right lung and solid nodules on his vocal cords. Bronchoscopy demonstrated polypoid lesions on his vocal cords. Histopathological study of the lesions confirmed a diagnosis of respiratory papillomatosis.Copyright © 2022 Biomedpress.

Transjugular Approach for Recurrent Intracranial Glomus Vagale Tumors: An Ideal Approach to Preserve Hearing and Facial Nerve Function

Lateral skull base paragangliomas (glomus tumors) are rare skull base tumors arising from neuroendocrine cells. These benign tumors can be locally aggressive with potential for intracranial extension and significant morbidity as they compromise cranial nerve structures. Treatment is highly patient dependent. Herein, we present a case of recurrent glomus vagale paraganglioma requiring a multidisciplinary transjugular and transcervical approach for complete resection. A 64-year-old male was referred to the neurotology clinic in 2019 for a left skull base tumor causing progressive dysphonia and dysphagia. Exam revealed left true vocal fold weakness and no other abnormalities. Hearing was normal on the left. Magnetic resonance imaging (MRI) revealed a large hyperintense lesion of the left jugular foramen with intracranial cerebellopontine angle extension and normal flow through the sigmoid sinus and jugular vein. The patient elected for surgical removal and near-total resection was achieved via retrosigmoid craniotomy. A small portion was intentionally left in the jugular foramen to preserve the intact eleventh cranial nerve, internal jugular vein, and sigmoid sinus. Surgical pathology confirmed glomus paraganglioma. Postoperative radiation was strongly recommended, but the patient was lost to follow-up due to the COVID-19 pandemic. The patient re-presented in late 2021 with worsened dysphonia and dysphagia. Exam confirmed left true vocal fold immobility consistent with vagal nerve paralysis and a new finding of left tongue weakness consistent with hypoglossal nerve injury. MRI revealed recurrence of the lesion to dimensions larger than original presentation and complete occlusion of the sigmoid-jugular system. Hearing and facial nerve function remained fully intact, thus a transjugular approach with hearing preservation and complete surgical resection was utilized. After combined retrosigmoid and transcervical incision, the transjugular approach was utilized to resect the sigmoid sinus, the tumor of the jugular foramen, and the intracranial extension. The ear canal and facial nerve canal were preserved. The sigmoid sinus was ligated with surgical clips and the jugular vein was ligated with suture thread. Intracranially, the hypoglossal nerve was identified and preserved, and the vagus nerve was seen eroded by tumor. Pathology confirmed recurrent paraganglioma. Postoperatively, the patient recovered well but continues to endorse persistent dysphonia. His treatment plan includes radiation and thyroplasty. Multiple surgical approaches for the treatment of skull base paragangliomas have been reported including infratemporal types A to D, among others. This report identifies a rare case of recurrent paraganglioma which necessitated removal via transjugular approach. While uncommon in skull base surgery, this approach allowed identification and preservation of important neck and skull base structures (e.g., facial nerve, ear canal, spinal accessory nerve) while achieving complete gross resection. Radiation techniques have become popular alternatives for treatment of glomus tumors of the skull base due to high levels of surgery-related adverse events. Thus, skull base surgeons should be aware of the utility of the transjugular surgical technique for patients with intact hearing and facial nerve function who seek removal of intracranial jugular foramen tumors.

How Does Long Term Use of Surgical Face Mask Affect the Voice in Normophonic Subjects?

OBJECTIVES: To assess the effects of the longterm-use of surgical face mask (SFM) on acoustic and auditory-perceptual voice parameters in normophonic subjects without any known risk factor related to voice disorders. MATERIALS AND METHODS: Of 73 normophonic subjects who were previously included in a couple of studies before the COVID-19 outbreak, 25 people (18 female and 7 male) who were free of any known risk factor related to voice disorders during the outbreak were re-evaluated to assess the long-term effect of SFM on voice by using acoustic (mean F0, Jitter-local, Shimmer-local, Cepstral Peak Prominence (CPP), Noise to Harmonic Ratio (NHR), maximum phonation time (MPT)) and auditory-perceptual (Consensus Auditory-Perceptual Evaluation of Voice, CAPE-V) parameters and those data found in SFM period were compared with the previous (preSFM) data. MPT and acoustic data were analyzed by PRAAT software. RESULTS: It was seen that the mean F0 value presented a significant increase, while Jitter-local and Intensity values revealed a significant decrease in females after 2 years pass with SFM use (average 22.52 ± 0.18 months).In males, only a significant decrease in Jitter-local was detected. CONCLUSIONS: This study is the first longitudinal investigation on the effects of SFM use on acoustic and auditory-perceptual measures of voice. The data in this study, revealed that long-term use of SFM would not appear to be negatively affecting the acoustic parameters of the voice in normophonic subjects (particularly females) without any related risk factors such as tobacco use, reflux, and etc.

Examining Use and Effectiveness of Teletherapy for Patients with Dysphonia.

OBJECTIVE(S)/HYPOTHESIS: Virtual therapy (teletherapy) for patients with dysphonia has become ubiquitous in the COVID-19 era. However, barriers to widespread implementation are evident, including unpredictable insurance coverage attributed to limited evidence supporting this approach. In our single-institution cohort, our objective was to show strong evidence for use and effectiveness of teletherapy for patients with dysphonia. STUDY DESIGN: Single institution, retrospective cohort study. MATERIAL AND METHODS: This was an analysis of all patients referred for speech therapy with dysphonia as primary diagnosis from 4/1/2020 to 7/1/2021 and in whom all therapy sessions were delivered in a teletherapy format. We collated and analyzed demographics and clinical characteristics and adherence to the teletherapy program. We assessed changes in perceptual assessments and vocal capabilities (GRBAS, MPT), patient-reported outcomes (V-RQOL), and metrics of session outcomes (complexity of vocal tasks, carry-over of target voice) pre- and post-teletherapy using student's t test and chi-square test. RESULTS: Our cohort included 234 patients (mean [SD] age 52 [20] years) residing a mean (SD) distance of 51.3 (67.1) miles from our institution. The most common referral diagnosis was muscle tension dysphonia (n = 145, 62.0% patients). Patients attended a mean (SD) of 4.2 (3.0) sessions; 68.0% (n = 159) of patients completed four or more sessions and/or were deemed appropriate for discharge from teletherapy program. Statistically significant improvements were seen in complexity and consistency of vocal tasks with consistent gains in carry-over of target voice for isolated tasks and connected speech. CONCLUSIONS: Teletherapy is a versatile and effective approach for treatment of patients with dysphonia of varying age, geography, and diagnoses.

Chronic voice disorder after coronavirus disease 2019 infection and its treatment using the cricothyroid visor maneuver: a case report.

BACKGROUND: Regarding human coronavirus, the severe acute respiratory syndrome coronavirus 2 pandemic, the novelty of disease, and consequently the lack of studies, the etiology of dysphonia in patients with coronavirus disease 2019 is still unknown and needs to be investigated. The purpose of the current study is to investigate the effect of a new manual therapy technique, cricothyroid visor maneuver, on muscle tension dysphonia symptoms for a patient who had experienced dysphonia symptoms due to the coronavirus disease 2019 infection. CASE PRESENTATION: A 55-year-old retired Iranian teacher who was diagnosed with muscle tension dysphonia by an otolaryngologist participated in this study. Fifty days before being referred to an otolaryngologist, he was diagnosed with coronavirus disease 2019 on the basis of the results of a standard laboratory test, namely real-time polymerase chain reaction. Treatment was provided in ten sessions. Pre- and post-treatment audio recordings of sustained vowels, selected sentences, and connected speech samples were submitted for auditory perceptual and acoustic analysis to assess the effects of the treatment program. Also, videolaryngostroboscopy voice quality perceptions by the patient, both before and after therapy, were assessed. The reduction in all features of the Consensus Auditory-Perceptual Evaluation of Voice was observed. The results of acoustic assessment showed that jitter (35.13%) and shimmer (20.48%) decreased; moreover, the harmonics-to-noise ratio (1.17%), cepstral peak prominence smoothed (28.53%) and maximum phonation time (15.5%) increased after treatment sessions. The scores of four parameters of Stroboscopy Examination Rating Form (SERF) form changed after cricothyroid visor maneuver therapy. Also, the visual analog scales score at the pre-treatment assessment was 40, and increased to 90 at the post-treatment assessment. CONCLUSIONS: The effectiveness of cricothyroid visor maneuver therapy on dysphonia associated with coronavirus disease 2019 was investigated in the current study. This case study has highlighted chronic dysphonia after coronavirus disease 2019 infection, and suggests that the cricothyroid visor maneuver therapy approach may have positive outcomes for patients with muscle tension dysphonia with this background.

Effect of FFP2/3 Masks on Voice Range Profile Measurement and Voice Acoustics in Routine Voice Diagnostics.

INTRODUCTION: Voice diagnostics including voice range profile (VRP) measurement and acoustic voice analysis is essential in laryngology and phoniatrics. Due to COVID-19 pandemic, wearing of 2 or 3 filtering face piece (FFP2/3) masks is recommended when high-risk aerosol-generating procedures like singing and speaking are being performed. Goal of this study was to compare VRP parameters when performed without and with FFP2/3 masks. Further, formant analysis for sustained vowels, singer's formant, and analysis of reading standard text samples were performed without/with FFP2/3 masks. METHODS: Twenty subjects (6 males and 14 females) were enrolled in this study with an average age of 36 ± 16 years (mean ± SD). Fourteen patients were rated as euphonic/not hoarse and 6 patients as mildly hoarse. All subjects underwent the VRP measurements, vowel, and text recordings without/with FFP2/3 mask using the software DiVAS by XION medical (Berlin, Germany). Voice range of singing voice, equivalent of voice extension measure (eVEM), fundamental frequency (F0), sound pressure level (SPL) of soft speaking and shouting were calculated and analyzed. Maximum phonation time (MPT) and jitter-% were included for Dysphonia Severity Index (DSI) measurement. Analyses of singer's formant were performed. Spectral analyses of sustained vowels /a:/, /i:/, and /u:/ (first = F1 and second = F2 formants), intensity of long-term average spectrum, and alpha-ratio were calculated using the freeware praat. RESULTS: For all subjects, the mean values of routine voice parameters without/with mask were analyzed: no significant differences were found in results of singing voice range, eVEM, SPL, and frequency of soft speaking/shouting, except significantly lower mean SPL of shouting with FFP2/3 mask, in particular that of the female subjects (p = 0.002). Results of MPT, jitter, and DSI without/with FFP2/3 mask showed no significant differences. Further mean values analyzed without/with mask were ratio singer's formant/loud singing, with lower ratio with FFP2/3 mask (p = 0.001), and F1 and F2 of /a:/, /i:/, /u:/, with no significant differences of the results, with the exception of F2 of /i:/ with lower value with FFP2/3 mask (p = 0.005). With the exceptions mentioned, the t test revealed no significant differences for each of the routine parameters tested in the recordings without and with wearing a FFP2/3 mask. CONCLUSION: It can be concluded that VRP measurements including DSI performed with FFP2/3 masks provide reliable data in clinical routine with respect to voice condition/constitution. Spectral analyses of sustained vowel, text, and singer's formant will be affected by wearing FFP2/3 masks.

Long-term laryngological sequelae and patient-reported outcomes after COVID-19 infection.

PURPOSE: We examine prevalence, characteristics, quality of life (QOL) assessments, and long-term effects of interventions for laryngeal dysfunction after recovery from COVID-19 infection. MATERIALS AND METHODS: 653 patients presenting to Yale's COVID clinic from April 2020 to August 2021 were identified retrospectively. Patients with PCR-positive COVID-19 who underwent evaluation by fellowship-trained laryngologists were included. Patient demographics, comorbidities, intubation/tracheostomy, strobolaryngoscopy, voice metrics, and management data were collected. Patient-reported QOL indices were Dyspnea Index (DI), Cough Severity Index (CSI), Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), and Reflux Symptom Index (RSI). RESULTS: 57 patients met inclusion criteria: 37 (64.9 %) were hospitalized for COVID-19 infection and 24 (42.1 %) required intubation. Mean duration between COVID-19 diagnosis and presentation to laryngology was significantly shorter for patients who were intubated compared to non-intubated (175 ± 98 days versus 256 ± 150 days, respectively, p = 0.025). Dysphonia was diagnosed in 40 (70.2 %) patients, dysphagia in 14 (25.0 %) patients, COVID-related laryngeal hypersensitivity in 13 (22.8 %), and laryngotracheal stenosis (LTS) in 10 (17.5 %) patients. Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms and 2 (11.8 %) patients reported resolution. VHI scores decreased for patients who reported symptom improvement. 7 (70 %) patients with LTS required >1 procedural intervention before symptom improvement. Improvement across QOL indices was seen in patients with LTS. CONCLUSIONS: Laryngeal dysfunction commonly presents and is persistent for months after recovery from COVID-19 in non-hospitalized and non-intubated patients. Voice therapy and procedural interventions have the potential to address post-COVID laryngeal dysfunction.

Dysphonia Severity Index and Consensus Auditory-Perceptual Evaluation of Voice Outcomes, and Their Relation in Hospitalized Patients with COVID-19.

OBJECTIVES: This study aimed to compare the results of the Dysphonia Severity Index (DSI) and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) between patients hospitalized with COVID-19 and healthy subjects, as well as to investigate the correlation between DSI and CAPE-V. STUDY DESIGN: Cross-sectional survey. MATERIAL AND METHODS: Eighty subjects, 40 COVID-19 patients (with a mean age of 41.2± 5.41) and 40 healthy subjects (with a mean age of 44.50± 3.50) participated in this study. Assessments included the DSI for aerodynamic-acoustic measurement and the Persian version of Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) for evaluating auditory-perceptual voice quality. Data were analyzed by means of the independent t-test and Pearson correlation at the 5% significance level. RESULTS: The results showed COVID-19 patients got significantly lower score in DSI compared to healthy subjects (P < 0.05). Moreover, the patients with COVID-19 had higher scores in all categories of voice production (severity, roughness, loudness, pitch, strain and breathiness) than the healthy group (P < 0.05). Comparing the result of the two voice assessments in each group revealed that there was a greater negative significant correlation in the diseased group (r p: -0.68, P: 0.001) than in the healthy group (r p: -0.37,P: 0.049). CONCLUSIONS: Hospitalized COVID-19 patients experience deviations in the voice quality and acoustic-aerodynamic features of their voice. Also, the results of this study showed the patient group had higher perceptual dysphonia and lower voice quality compared to the healthy group. Further studies are recommended to determine the relationship between objective and subjective voice evaluation in patients with COVID-19 after recovery.

Rehabilitation of intubated COVID-19 patients in a Singapore regional hospital with early intensive care unit and sustained post-intensive care unit rehabilitation

Background: A proportion of patients with COVID-19 become critically ill, but few studies describe the functional outcomes and rehabilitation process of these patients. Objective(s): To describe the complications encountered and functional outcomes of critically ill COVID-19 patients requiring intubation and subsequent intensive care unit (ICU) management and rehabilitation. Method(s): Retrospective case note review was conducted on all patients requiring intubation and ICU admission and subsequently discharged from our hospital from February 15, 2020 to May 1, 2020. Demographics, preexisting medical conditions, complications encountered in ICU, ICU and General Ward Length of Stay, number of therapy sessions delivered, nutritional data, and functional outcomes on discharge were collected from electronic medical records and entered in a deidentified database. Result(s): Most patients developed significant breathlessness affecting post-ICU rehabilitation, a few patients developed ICU associated delirium while no patient developed ICU-associated weakness. All patients survived and could walk 20 m within 12 days post-extubation. Conclusion(s): Early ICU and sustained post-ICU rehabilitation of critically ill, intubated COVID-19 patients is feasible. Further studies could look into the outcomes of this group of patients, in particular the effect of nutrition and pulmonary training on functional outcomes. We strongly recommend an interdisciplinary rehabilitation team approach in managing critically ill COVID-19 patients. Copyright © The Author(s) 2022.

An occurrence of immune-mediated necrotizing myopathy following treatment of polymyositis in a Filipino female: A case report

Background: Necrotizing myopathy has been previously described but was not included in the Peter and Bohan criteria until 2004, when immune-mediated necrotizing myopathy (IMNM) was distinguished from polymyositis (PM) based on immunologic and histopathologic differences. IMNM is currently a well-recognized autoimmune myopathy and represents up to 20% of these cases. Case: A 60-year- old female with biopsy-proven PM achieved sustained clinical remission with Rituximab. Her co-morbid conditions include hypertension, diabetes mellitus, and dyslipidemia. The patient noted a recurrence of gradual progressive, proximal muscle weakness and easy fatigability after receiving her first mRNA Covid-19 vaccine. Four months after onset of symptoms, CK Total was 9600 U/L. Rituximab was administered and muscle weakness and total CK levels (1247 U/L) improved within 10 days. She was prescribed rosuvastatin and fenofibrate for dyslipidemia within 7 days of completing the rituximab course. Two weeks later, proximal muscle weakness recurred. She became wheelchair-bound and experienced dysphonia. MMT score was 2/5 in proximal muscles and total CK total increased to 19,935 U/L. The patient received Methylprednisolone 500 mg IV once a day for 3 days. She had a good response with resolution of dysphonia and improvement of MMT to 4/5 on shoulder abduction and hip flexion on the 6th hospital day. She was discharged on oral methylprednisolone at 1 mg/kg/day. Muscle biopsy was consistent with an immune-mediated necrotizing myopathy, revealing necrotic fibers, intracellular macrophages, fatty infiltrates, irregular staining patterns on NADH stain with no evidence of endomysial inflammation, perifascicular atrophy, ragged red fibers, or rimmed vacuoles. Antibodiy against 3-hydoxy- 3- methylglutarylcoenzymeA reductase (HMGCR) result is pending but the other myositis-specific antibodies are negative.(including anti-SRP). Conclusion(s): IMNM is an autoimmune myopathy associated with anti-HMGCR and anti-SRP antibodies that clinically present similarly to polymyositis. The temporal occurrence of worsening muscle weakness with initiation of statin therapy make statin toxic myopathy or immune mediated necrotizing myopathy as diagnostic considerations. This case emphasizes the need to re-evaluate the etiology of new onset muscle weakness in patients with idiopathic inflammatory myopathy and highlights the role of myositis-specific antibodies and muscle biopsy in confirming the diagnosis.

Relationships Between Sense of Coherence, Self-perception of Voice and Work Environment Among Teachers.

OBJECTIVE: to analyze the relationship between sense of coherence and sociodemographic data, remote physical work environment, and self-perception of symptoms, vocal handicap and vocal fatigue in teachers. METHODS: Seventy eight teachers pertaining to the municipal education network of a Brazilian capital city participated in the study, during the period of social isolation by COVID-19. An online questionnaire was applied with sociodemographic and physical remote work environment questions, the Sense of Coherence Scale (SOC-13), the Brazilian Dysphonia Screening Tool (Br-DST), the Vocal Fatigue Index (VFI), and the Vocal Handicap Index (VHI-10). Descriptive analysis, bivariate and multivariate Logistic regression models were performed to check the proportion of teachers with high and low SOC among the different categories of independent variables. Student's t test and Mann Whitney test were used to compare SOC, IDV, and VFI scores between the groups, and Hedge's g test was used to access the effect size. The total scores of SOC, VHI and VFI were correlated using Pearson's Correlation Coefficient. All tests adopted a 5% significance level. RESULTS: Male teachers and those over 45 years old were, respectively, 6.79 (95%CI = 1.16-39.58) and 5.27 (95%CI = 1.40-19.76) times more likely to present a high SOC. The variables associated with a lower chance of presenting high SOC were vocal restriction (OR = 0.21; 95%CI = 0.06-0.79) and voice-related physical discomfort (OR = 0.13; 95%CI = 0.02-0.78). Regarding the remote work environment, in bivariate analysis, teachers who were dissatisfied with air quality (OR = 0.08; 95%CI = 0.01-0.65), temperature (OR = 0.11; 95%CI = 0.01-0.92), and noise (OR = 0.25; 95%CI = 0.61-0.99) were less likely to have high SOC. Higher values of SOC are associated with lower self-perception of vocal fatigue and voice handicap (P < 0,001). CONCLUSION: The way individuals face stressful situations interferes with the self-perception of their voice and their work environment. The relationship between the sense of coherence and voice perception is relevant to favor programs to promote vocal health and stress management in teachers.