Review of management of laryngopharyngeal reflux disease.

This review was conducted according to the Patient/problem Intervention Comparison Outcome (PICO) Statements. Some studies reported that 10-30% of patients consulting in ENT come with presenting symptoms of laryngopharyngeal reflux (LPR), but the exact prevalence of LPR is still unknown. Management has not changed in 20 years despite a significant increase in the number of publications on epidemiology, clinical presentation, diagnosis and treatment. The development of hypopharyngeal-esophageal multichannel intraluminal impedance pH monitoring (HEMII-pH) and saliva pepsin detection now allow a new multidimensional diagnostic approach associating clinical scores to HEMII-pH and saliva pepsin detection. This new approach may enable personalized treatment according to LPR profile on HEMII-pH (acid, non-acid, mixed; upright, recumbent reflux episodes). Updated treatment of LPR could consist in a 3-month association of dietary measures, proton pump inhibitors, alginate and magaldrate, followed by treatment adaptation.

Guidelines of clinical practice for the management of swallowing disorders and recent dysphonia in the context of the COVID-19 pandemic.

Procedures putting healthcare workers in close contact with the airway are particularly at risk of contamination by the SARS-Cov-2 virus, especially when exposed to sputum, coughing, or a tracheostomy. In the current pandemic phase, all patients should be considered as potentially infected. Thus, the level of precaution recommended for the caregivers depends more on the type of procedure than on the patient's proved or suspected COVID-19 status. Procedures that are particularly at high risk of contamination are clinical and flexible endoscopic pharyngo-laryngological evaluation, and probably also video fluoroscopic swallowing exams. Voice rehabilitation should not be considered urgent at this time. Therefore, recommendations presented here mainly concern the management of swallowing disorders, which can sometimes be dangerous for the patient, and recent dysphonia. In cases where they are considered possible and useful, teleconsultations should be preferred to face-to-face assessments or rehabilitation sessions. The latter must be maintained only in few selected situations, after team discussions or in accordance with the guidelines provided by health authorities.

The development of new clinical instruments in laryngopharyngeal reflux disease: The international project of young otolaryngologists of the International Federation of Oto-rhino-laryngological Societies.

INTRODUCTION: To analyze the epidemiological characteristics of placebo controlled randomized trials (RCTs) that evaluated the effectiveness of medical treatments over placebo in laryngopharyngeal reflux (LPR). MATERIAL AND METHODS: PubMed, Cochrane database, and Scopus were assessed for subject headings using the PRISMA recommendations. Placebo RCTs published between 1990 and 2018 describing clinical evolution throughout LPR treatment were extracted and analyzed for evidence-based level, number of patients, inclusion and exclusion criteria, gender, age, symptoms and signs used as therapeutic outcomes, and treatment schemes. RESULTS: The database search identified 15 placebo RCTs with a total of 763 patients. The mean age of patients was 48.59 years and 52.68% of patients were female. Among the 15 placebo RCTs, 9 have demonstrated a partial or total superiority of a medical treatment over placebo. Most of authors based the LPR diagnosis on symptoms and signs without additional examination. Our analysis reveals an important heterogeneity between studies with regard to the diagnosis criteria, treatment schemes and signs and symptoms used as therapeutic outcomes. Many commonly reported signs and symptoms related to LPR were not used as therapeutic outcomes. Half of the authors did not prescribe diet and behavioral changes along the treatment. CONCLUSION: The controversy in the RCTs about the superiority of medical treatment over placebo in LPR disease is probably due to discrepancies in the diagnosis method, exclusion criteria, therapeutic schemes and the lack of comprehensive tools for the assessment of signs and symptoms. In this context, the LPR Study Group of Young-Otolaryngologists of the International Federations of Oto-Rhino-Laryngological Societies developed two new instruments to precisely assess signs and symptoms throughout the treatment. These two instruments could be used in future trials comparing medical treatment over placebo in LPR disease.

International consensus (ICON) on assessment of oropharyngeal dysphagia.

OBJECTIVE: To present international recommendations regarding the proper evaluation of oropharyngeal dysphagia (OD), both objectively and subjectively (self-evaluation). METHODS: Following a thorough review of the literature, 5 experts in the field from 4 different continents answered separately a questionnaire regarding the work-up of OD. Individual answers were presented and discussed during the world ENT conference that was held in Paris in June 2017. This article will present the recommendations issued from that meeting. RESULTS: For the initial objective assessment of OD, it is recommended to perform either a functional endoscopic evaluation of swallowing (FEES) or a videofluoroscopic swallowing study (VFSS). FEES is the more popular investigation given its increased ease of use and accessibility. When evaluating for the presence of aspiration during the objective evaluation of OD, it is recommended to perform either a FEES or a VFSS. In this case, FEES is the favored investigation given its likely increased sensitivity. In order to highlight the presence of oropharyngeal food residue following the deglutition process, it is recommended to perform either a FEES or a VFSS; FEES likely being the more sensitive investigation while VFSS allows a better quantification of the amount of pharyngeal residue. Is it also recommended to objectify the quality of the deglutition process by means of a score during the objective evaluation of OD. Finally, it is recommended to utilize a self-evaluation questionnaire during research studies exploring the deglutition process.

[Evaluation of quality of life and swallowing in patients with cancer of the oropharynx treated with assisted transoral robotic surgery]. / Evaluation de la qualité de vie et de la déglutition des patients atteints d'un cancer de l'oropharynx traités par chirurgie transorale assistée par robot.

OBJECTIVES: To present the preliminary results of the qualiit of life and quality of swallowing in a series of 15 patien! treated with oropharyngectomy by transoral robotic-assisted (CTAR) (robot da Vinci, Intuitive Surgical ). MATERIALS AND METHODS: A prospective monocentric non-randomized study of 15 patients with cancer of the oropharynx. Were analyzed: demographics, quality of life questionnaires (QLQ-C30 and H&N 35 EORTC) and quality of swallowing questionnairex (MDADI, DHI and EAT 10) with an average of 1 year after the end of the treatment. RESULTS: Fifteen patients (10 males and 5 females), mean age of 65 years (47-73 years) were included. The tumours were classified as: cT1: 4; cT2: 10 cT3: 1. Five of the 15 patients received postoperative chemoradiotherapy as histo-pathological studies showed multiple metastatic cervical lymph nodes +/- capsular rupture. For the analysis of the quality of life and quality of swallowing, the patients were divided into two groups. Group A included patients who underwent CTARs and group B, patients operated by CTAR with adjuvant chemoradiotherapy. At 12 months of the procedure, all patients had a deglutition considered as normal without feeding tube nor tracheostomy. With the three scales used, the quality of swallowing was satisfactory for all patients. It was better for patients in group A than for patients in group B. In terms of quality of life, the EORTC QLQ-C30 scale showed our patients had a high rate of satisfaction scale in "health and overall quality of life". For the EORTC H&N35 questionnaire, mean scores for "specific symptoms" were also low except for the following three items "dry mouths", "sticky saliva" and "sexuality problem". The first two items were statistically more frequent (p = 0.02 and p = 0.001) in group B patients. CONCLUSION: After transoral robotic-assisted oropharyngectomy, patients have a good quality of life and swallowing. Postoperative chemoradio-therapy compromises the quality of swallowing. Multicentric studies are required to confirm these preliminary results.

[Understanding the use of self-evaluation questionnaires when assessing a patient's swallowing capacity and performing follow-up activities]. / Intérêt des echelles d'autoévaluation dans le bilan et le suivi des troubles de la déglutition.

The purpose of this study was to examine the possibility of improving the assessment protocol of dysphagia and show the interest of adding a self-assessment evaluation scale to the traditional functional assessment of the swallowing process. We have a comparison of the assessment of 30 dysphagic patients with two different scales (DHI and EAT-10). Results show that the self-evaluation scales selected led to quantitative data comparable to the objective results of the COLP-FR-G functional assessment tool. We may therefore conclude that the patients' own feelings do not differ from the results of the clinical dysphagia severity assessment. Results also highlight that both scales provide similar information in terms of content and also reflect the evolution of objective data. The EAT-10 scale, by its simplicity and limited number of questions, could be proposed as a screening test in neurological patients and geriatric population, where the DHI scale, with its three subdomains (physical, functional and emotional), would be a complementary tool for the functional swallowing evaluation. Indeed, in order to evaluate dysphagia, the association of DHI, EAT-10 and COLP-FR-G offers several advantages. This protocol is convenient and rapid to administrate, it takes the diversity of etiologies into account and its score is easy to transmit to the patients' medical practitioners. Consequently, its use in the assessment of swallowing functions should be encouraged as a consistent part of the clinical practice.

[A perceptual study of question and assertive modalities after vertical partial laryngectomies]. / Etude perceptive des modalités interrogatives et assertives après laryngectomies partielles verticales.

OBJECTIVES: Our study concerns the perception of the contrast between assertives and question modalities in patients having undergone a cordectomy or a vertical partial laryngectomy. MATERIAL AND METHODS: Four patients (2 cordectomies and 2 vertical partial laryngectomies), age from 57 to 66 year old (average 61; median 61) were included. They were recorded while producing logatomes, constituents and sentences in the assertive and question modalities. Perceptual evaluation was analysed using Praat software. The assessors (consisting of 8 French native auditors, 4 men and 4 women) evaluated 80 stimuli. RESULTS: Our results show a good average rate of modality recognition with a good intelligibility for these patients. The more frequent errors were in the vertical partial laryngectomies group who had more unpredictable modulations. CONCLUSION: Our small sample does not allow us to generalize but our first observations tend to show that these patients have a good capability in producing question and assertive modalities.

The contribution of supraglottic laryngeal adjustments to voice: phonetic evidence from Arabic.

In this study, we provide nasendoscopic observations illustrating phonetic contrasts in Arabic that require supraglottic laryngeal adjustments, and demonstrate how the laryngeal constrictor mechanism contributes to phonetic descriptions of phonation. Arabic has two pharyngeal consonants (voiceless and voiced). We show, among others, that these two consonants possess auditory features of whisperiness and creaky voice, respectively, and are always produced with supraglottic constriction similar but more marked than during whispery or creaky [i]. However, during modal [i], the epilaryngeal space is wide open. We outline a revised model of laryngeal constriction where 'voice' is controlled to a large degree by supraglottic as well as glottic mechanisms. Some hypotheses are also proposed concerning the possible muscular synergies that induce these supraglottic gestures.

[Evolution of voice assessment and quality of life after endoscopic laser cordectomy]. / Evolution de la voix et de la qualité de vie après cordectomie au laser CO2 par voie endoscopique.

OBJECTIVES: Endoscopic laser cordectomy is a minimally invasive surgical technique for Tis, T1 and selected T2 glottic carcinoma. The purpose of the study was to evaluate prospectively pre-operatively and 3 months after surgery i) acoustic and perceptual parameters, ii) quality of life through a self evaluation (VHI) test. METHODS: A prospective longitudinal evaluation of 13 male patients, shared-out onto 3 surgical procedures (cordectomy type I, grouped type II and III, and type V). Patients were recorded before and at 1 and 3 months after surgery. The parameters recorded were; acoustic parameters (F0, Jitter, Shimmer), Maximum Phonation Time (MPT), perceptual evaluation using the GRBAS scale and the self evaluation scale with the Voice Handicap Index (VHI). RESULTS: No statistics could be done because of the limited number of patients in each group. Perceptual and self evaluation data showed a favorable progression between 1 and 3 months for patients in group Type I, II and III cordectomy. Evolution of acoustic parameters is more difficult to analyze. The voice of the Cordectomy type V group remains whispery at 3 months after surgery. CONCLUSION: The quality of voice is a very important criterion for the patients. During the first 3 months after laser cordectomy, the perceptual vocal function and the self evaluation improves. But for the acoustic data, 3 months is probably too short to objectively quantify an improvement especially after type V cordectomy.

[Epidermoid carcinoma of piriform sinus after chemo-radiotherapy: acoustic evaluation and voice handicap]. / Carcinomes épidermoïdes du sinus piriforme traités par chimio-radiothérapie : analyse acoustique et handicap vocal.

OBJECTIVE: The aim of this prospective investigation was to analyse the voice and the vocal handicap for patients who received concomitant chemoradiation therapy in piriform sinus epidermoid carcinoma (T2, T3). MATERIAL AND METHODS: This study included two males populations: Twelve patients aged from 48 to 71 years old were evaluated between 6 and 30 months after the end of chemo-radiotherapy and ten normal subjects, matched in age. The evaluation consisted in firstly a vocal recording (vowel and text) allowing an objective acoustic analysis (temporal and frequential parameters) and a perceptive evaluation of the voice quality by means of GRBAS scale. Secondly an evaluation of the quality of life by means of the voice handicap index (VHI). RESULTS: The acoustic parameters of instability for the fundamental frequency (FO) and the maximum phonation time of the patients were statistically different (p <0.05) related to the normal subjects. On the other hand, the FO (patients - 130 Hz, subjects = 121 Hz) as well as the speech rate (patients = 142 words/mn, subject = 148 words/mn) were not statistically different. The perspective indexes showed a deterioration of the vocal quality while the handicap expressed was minor. CONCLUSION: This preliminary study showed the interest of evaluations of the vocal function and the quality of life after chemo-radiotherapy for piriform sinus carcinomas allowing patients to conserve a phonation and eventually the propose a speech therapy.

[Quality of life after oropharyngectomy]. / Qualité de vie après buccopharyngectomie transmandibulaire.

OBJECTIVE: The purpose of this study was to assess direct or non-direct links between functional abilities of the patient evaluated objectively and his quality of life after oropharyngectomy, a surgery capable of engendering bad functional outcomes. METHODS: Praxies and speech were examined in 16 patients at 3, 6, 9 or 12 months after surgery and 2 self-evaluation questionnaires were proposed: One about health related quality of life of cancer patients (EORTC QLQ-C30 and H&N35) and, the other about oral communication handicap (VHI). RESULTS AND CONCLUSION: A correlation between quality of life and objective functional abilities can not always be found. Self-evaluation questionnaires might be a complementary approach in order to guide management in patient care after oropharyngectomy.

[Dysphonia: current methods of evaluation]. / Méthodes actuelles d'évaluation des dysphonies.

OBJECTIVES: The aim of this review article was to provide an update on current techniques for evaluation of dysphonia in routine clinical practice. MATERIALS AND METHODS: Recent medical and other scientific literature was reviewed and pertinent current theories concerning the physiology of laryngeal function described. RESULTS: Perceptual voice quality evaluation by a professional jury of listeners is still considered to be the most reliable and complete means of evaluating pathologic voice, even though it is difficult to perform in routine and the results lack reproducibility. The objective evaluation of the vocal fundamental frequency and its variations and the spectral characteristics of voice has the advantage of being simple to perform, reproducible and quantifiable. However, automatic measurements need to be analyzed with precaution for severe dysphonia, the computer algorithms being designed for voices retaining a certain periodicity. Aerodynamic measurements are quantifiable and reproducible and provide information as to the quality of laryngeal function as a transducer of aerodynamic energy into acoustic energy. Videostroboscopy and electroglottography provide information as to the quality of the laryngeal vibrations, the source of sound production. CONCLUSIONS: All of these types of analysis are complementary, informing as to different aspects of vocal quality and laryngeal function. No one measurement alone can diagnose or characterize dysphonia.

[Evaluation of the handicap by means of the EORTC scale in partial glossectomies]. / Evaluation du handicap au moyen des échelles de l'EORTC pour les glossectomies partielles.

OBJECTIVES: Different treatments for tongue cancer are more and more efficient but there are heavy functional and aesthetic sequels. The aim of this study was to evaluate the quality of life after partial glossectomy and to adapt the rehabilitation program after surgery. METHODS: Our population of 16 patients (5 females and 11 males), who underwent partial glossectomy, had to quote the auto questionnaire on quality of life (EORTC QOL-C30) and the specific head and neck cancer scale (H&N35). RESULTS: In our population, the patient's satisfaction for the global quality of life was 71%; the functioning scale was 83%, and the mean rate of generic symptoms was 13%. On the contrary, the specific Head & Neck symptom rate was high, with 76% of complains. CONCLUSIONS: The QOL scale could be considered as a good tool for patients to express their difficulties in daily life. It is a reliable and reproducible tool for a follow up study of patients. It allows proposing specific rehabilitation procedures in the post operative period.

[Perceptive evaluation of substitution voices: the I(I) NFVo rating scale]. / Evaluation perceptive des voix de substitution: l'echelle I(I)NFVo.

OBJECTIVES: Evaluation of a perceptual specific rating scale for specific severe non laryngeral dysphonia. MATERIAL AND METHOD: 113 speech samples from substitution voices were scored perceptually according to the IINFVo scale: overall quality impression (I), impression of Intelligibility (I), additive and unnecessary noise (N), speech fluency (F) and presence of voiced segments (Vo). Each parameter was scored on a visual analogue scale from 0 (minimally deviant) to 10 (maximally deviant substitution voicing). These samples were presented to semi-professional jury-members (second grade speech therapy students) and professional jury-members (phoniatricians and speech therapists, specialised in the oncological field). RESULTS: Interindividual agreement between semi-professionals was moderate (0.57-0.68). Interindividual agreement between professionals was higher (0.82-0.86). These figures are similar or even better compared to the classical perceptual evaluation scale for laryngeal speech (GRBAS). CONCLUSION: Our study suggests that the I(I)NFVo rating scale is suitable for perceptual evaluation of substitution voicing and consistency results are comparable with the classical perceptual rating scale (GRBAS).

[Diagnosis of non-organic dysphonia in adult]. / Diagnostic d'une dysphonie non organique de l'adulte.

Non organic dysphonia or functional voice disorders are the consequence of a vocal misuse or overuse with inefficient oral communication. Any stage of voice production can be altered. A review of physiopathological, aerodynamic and biomechanical mechanisms will help to understand the onset of dysphonia. Organic lesions as a consequence of functional voice disorders are frequent but the link is not easy to establish. It is important to look for various physiologic, anatomic, environmental, behavioural and infectious factors that could induce or aggravate non organic dysphonia, as they can benefit from specific treatment. A thorough functional and organic assessment is the first step of the rehabilitation process, taking into account the patient's expectations about his voice handicap.

[Quality of life before and after thyroplasty for vocal fold paralysis]. / Qualité de vie avant et après thyroplastie pour paralysie laryngée unilatérale.

OBJECTIVES: The aim of our prospective study was to evaluate the vocal handicap in relation with the quality of life in patients with unilateral vocal fold paralysis (UVFP), before and after thyroplasty with Montgomery implant (type I). METHODS: Ten patients had to file the VHI questioner before and three months after thyroplasty. The 30 items of the Voice Handicap Index scale are sub-divided in 3 categories referring to "Functional", "Physical" and "Emotional" dimensions. RESULTS: Before thyroplasty, the global score and the 3 sub-scales rating are high reflecting severe impairment in speech communication (VHI total = 65,9/120, F = 25.7/40, E = 19.9/40, P = 20.8/40). Three months after thyroplasty, a significant improvement is found predominantly in the field of functional and emotional evaluation, corresponding to an improved quality of social life (VHI total = 20,9/120, F = 6.3/40, E = 3.6/40, P = 10.6/40). CONCLUSION: These results show the interest in using the autoevaluation VHI scale as a complementary evaluation associated to perceptual, acoustic and aerodynamic evaluation to objectify the functional improvement in voice quality after thyroplasty.

Implementation of the European Laryngological Society (ELS) basic protocol for assessing voice treatment effect.

OBJECTIVES: 93 patients with various kinds of organic benign voice pathology (vocal fold nodules, polyp, Reinke's oedema, unilateral paralysis, sulcus/scar) and/or with muscle tension dysphonia, were evaluated before and after their voice treatment (phonosurgery with voice therapy, antireflux medication, or voice therapy alone) in order to check the clinical relevance of a basic multidimensional protocol for assessing functional results of voice treatments, as developed by the Committee on Phoniatrics of the ELS. MATERIAL AND METHOD: The protocol has been used in different university voice clinics. It comprises 5 dimensions: Perception: Grade, Breathiness and Roughness from the GRBAS-scale, rated by two experienced judges: a phoniatrician/laryngologist and a speech therapist. Acoustics: Jitter % and Shimmer % computed on a /a:/, at comfortable loudness and pitch. Also Fo-range and softest possible intensity. Videostroboscopy: Glottal closure, regularity, mucosal wave and symmetry, rated separately. Phonation quotient: computed by dividing the vital capacity (ml) by the maximum phonation time (s) (best value of 2x3 trials). Self rating by the patient: voice quality in itself and general social/occupational handicap due to the voice problem rated separately. RESULTS: Results show that, at group level, the overall effects for each parameter indicate a significant improvement after treatment. However, the correlations between the pre/post changes for the different parameters are weak (low redundancy). CONCLUSION: The assessment of voice pathology needs to be multidimensional, as these multidimensional informations about voice changes lead to a better understanding of the actual way in which a treatment works.

[Montgomery thyroplasty implant under local anesthesia for unilateral laryngeal paralysis]. / Thyroplastie avec implant de Montgomery sous anesthésie locale dans les paralysies laryngées unilatérales.

OBJECTIVES: Based on an inception cohort of 63 patients with unilateral vocal fold paralysis consecutively treated with thyroplasty and Montgomery's implant under local anesthesia during the years 1997-2002, we recorded i) morbidity and mortality, ii) evolution of dysphonia and swallowing impairment and iii) a prospective analysis of selected speech and voice parameters in an attempt to determine their evolution during the first 12 postoperative months and to search for potential statistical relationships with the following variables (age, gender, side of the paralysis, etiology of the paralysis, time between onset of paralysis and thyroplasty, position of the paralyzed true vocal fold, nerve involved, associated pneumonectomy, prior intracordal injection of autologous fat and surgeon). RESULTS: The overall complication rate was 8%. Minor complications occurred in 6.5% of the patients and included 4 cases of laryngeal edema successfully treated with oral steroids. Major complications occurred in 1.5% of the patients. Intralaryngeal hematoma requiring temporary tracheotomy was the major complication. Swallowing was improved in 93.5% of the patients. Immediate improvement of speech and voice was noted in all. Secondary degradation of speech and voice occurred in one patient. At revision thyroplasty lateral displacement of the implant was noted and successfully repositioned. At one month post-operatively, the values of maximum phonation time, speech rate, group phrasing standard deviation of the fundamental frequency, jitter and shimmer were statistically improved while the fundamental frequency did not vary significantly. At 12 months post-operatively the noise to harmonic ratio was improved while the other parameters remained stable. No significant statistical relationship was found between the post-operative speech and voice parameters and the variables under analysis. CONCLUSION: Based on the current series and a review of the medical literature, thyroplasty with Montgomery's implant under local anesthesia appears to be an easy, effective and safe procedure that might be used in all patients with unilateral laryngeal nerve paralysis.

[Intelligibility of French consonants after partial supra-cricoid laryngectomy]. / Etude de l'intelligibilité des consonnes du français après laryngectomie partielle supra-cricoïdienne.

INTRODUCTION: The purpose of this study was to determine what patterns of perceptual confusions characterize the voice of patients after supracricoïd partial laryngectomy (SCPL) by the identification tests of French consonants. We evaluated the voicing distinction. METHODS: Ten male patients were recorded 18 months after SCPL. Audio recordings of the 16 French consonants in a syllabic context (CV) produced by each talker with three repetitions were presented to three expert listeners. The listeners transcribed their responses using an open-response paradigm. Listeners' pooled responses were converted to confusion matrices. RESULTS: Voicing features were altered with a shift of voiced consonants towards voiceless consonants (24%), predominantly for stop consonants. CONCLUSION: Consonant articulation appears to impose certain constraints on voicing ability of SCPL patients, since voiced consonants are predominantly perceived as voiceless consonants. Presumably, this poor voicing ability is the direct consequence of the mechanical properties of the neoglottis that are far different from those of the vocal folds. Moreover, assessing consonant identification and intelligibility should help to improve voice therapy and efficiency of speech.