Minimal invasive LASER-resection vs. radiotherapy as primary treatment of early glottic cancer. A population-based study with, up to 16 years follow up of survival, rate of laryngectomy and voice function.

BACKGROUND: Early glottic cancer can be treated with laser resection or radiotherapy. In an earlier study, we found that voice function after laser resection was inferior to that after radiotherapy. OBJECTIVES: This study was designed to determine if reduced margins at laser resection improved voice function without impairing oncologic results. METHOD: A total of 268 patients with previously untreated T1-T2 glottic carcinoma were studied. They were primarily treated with either radiotherapy (n = 119) or laser resection (n = 149). Survival, need for additional treatment (radiotherapy and/or total layngectomi) and voice function was compared. RESULT: Median follow up time was 7 years with range 0.5-16.6. There was no difference in the overall survival (p = .065) or disease-specific survival. (p = .126). After radiotherapy 32/119 patients and after laser resection 57/149 patients had recurrence. Total rate of laryngectomy was 24% in the radiotherapy group, and 8% in the laser resection group (p = .001). Voice analysis (T1A) showed more roughness in the radiotherapy group, otherwise no difference. CONCLUSIONS: By reducing the surgical margins, we have achieved a better voice function (T1A) but more patients have needed repeated laser excisions and some have also needed supplementary radiotherapy. The risk of laryngectomy and survival were apparently not affected.

How older adults relate to their own voices: a qualitative study of subjective experiences of the aging voice.

AIM: The aim of this study was to investigate how otherwise healthy older adults with self-assessed voice problems relate to their voice and voice changes. METHOD: Focus groups were conducted at an activity center to identify how older adults reflect on their own voice and the aging voice in general. The interviews were audio recorded and transcribed. The analysis was done using thematic content analysis. RESULTS: The analysis resulted in three main themes: "communicational aspects of the aging voice," "consequences of deteriorating vocal and communicative capacity," and "attitudes, strategies, and ideas". The participants considered voice to be an important communication tool and presented what could be interpreted as awareness regarding their voice. Voice changes were considered a natural part of aging. This attitude was also an important reason why the participants had not sought medical care for their voice problems. The participants discussed ideas concerning extended voice use to maintain a functioning voice when aging. Simultaneously, voice changes due to aging were considered to have a negative effect on communication and social participation. CONCLUSIONS: The voice is important for older adults, and an insufficient voice can affect communication and social participation. Information about aging voice and voice exercises, for example from speech language pathologists, could be of interest among older adults. Further studies on the voice of older adults are needed regarding how they experience their voice and the general aspects of a healthy aging voice.

Immune delineation of laryngeal papilloma reveals enhanced neutrophil associated gene profile.

Laryngeal papilloma (LP) is a rare benign disease, caused by recurrent multisite papillomas that are referred to as recurrent respiratory papillomatosis (RRP). RRP is caused primarily by two types of human papillomavirus (HPV): HPV6 and HPV11. The immune dysregulation within the microenvironment of the lesions has been shown to likely play a role in the development of RRP. The present study aimed at analyzing the transcriptional profile of immune response genes and cancer-related genes in the LP microenvironment. We used the NanoString® nCounter® analysis system to study expression of 730 genes among seven paired samples of LP and healthy laryngeal (HL) tissue. qRT-PCR and flow cytometric analysis was performed to confirm identified transcripts and follow-up scores of infiltrating immune cells, respectively. In total, 113 differentially expressed transcripts were detected of which 37 showed increased expression levels and 76 decreased expression levels in the LP samples compared to the HL samples (fold change ≥ 2). Transcripts with increased expression levels included S100As (A7, A8, and A12), CEACAM1, neutrophil activation associated cytokines (IL8), chemokines (CXCL6), and IL receptors, e.g., IL4R. Transcripts with decreased expression in LP were associated with innate and adaptive immunity. Overall, HPV6 and 11 were present in 67% and 33% of the patients, respectively. There was a significant increase in neutrophils and a significant decrease in CD8+ T cells in LP. LP samples display an immune profile characterized by enhanced expression of neutrophilic markers and significantly reduced T cell-associated markers.

Prevalence of Voice Disorders in the General Population, Based on the Stockholm Public Health Cohort.

OBJECTIVE: To investigate the prevalence of voice disorders in the general population. STUDY DESIGN: Analysis of data from the Stockholm Public Health Cohort. METHODS: A public health survey was distributed to an open cohort of 114,538 adults >18 years of age in the area of Stockholm County, Sweden. The survey included one question about voice problems, estimating the extent of occurrence of voice problems, excluding voice problems during colds/upper airway infections. The question was tested for validity and reliability in n = 166 voice healthy individuals and n = 183 patients with benign voice lesions. The construct validity was tested against two established self-assessment questionnaires. The question was established to correspond to tiring, strain, and hoarseness. Prevalence of voice problems and correlations with age, gender, occupation, hearing, smoking, and socio-economic status were calculated. RESULTS: The overall prevalence of voice disorders in the entire group was estimated to 16.9%, where 15.5% voice problems were rated to occur to a small extent and 1.4% to a great extent. Women were significantly more prone to report voice problems than men. The highest ratings of a great extent of voice problems were found in both women and men >85 years of age. As for occupation, the highest prevalence of voice problems was found in teaching and service occupations. CONCLUSIONS: The prevalence of voice problems was estimated to 16.9% in the entire group. Women reported significantly more voice problems than men and voice problems were significantly more common in ages >65. This study of self-reported voice problems in a general population is one of the largest of its kind.

Absolute or relative voice rest after phonosurgery: a blind randomized prospective clinical trial.

OBJECTIVES: The first aim, was to compare participant compliance with postoperative voice rest advice in two groups. The second aim was to compare vocal function and recovery in the short-term, seven days post-surgery and in the long-term, 3-6 months post-surgery. DESIGN: Preliminary randomized prospective blind clinical trial. METHODS: Twenty patients scheduled for surgery for benign vocal fold lesions were randomized into seven days of absolute or relative voice rest. Compliance with voice rest advice was monitored with a voice accumulator for seven days following surgery. Vocal recovery was tracked through (a) self-perceived vocal function, (b) perceptual assessments of voice recordings and (c) visual assessment of high resolution and high speed digital imaging (d) vocal stamina and reaction to vocal loading, explored with a vocal loading task. RESULTS: The absolute voice rest group phonated significantly less than the relative voice rest group during seven days post-surgery, but they were not silent. The absolute voice rest group self-reported more difficulty with compliance than the relative voice rest group. The relative voice rest group coped with significantly more vocal loading at long-term check-up. In the short-term the absolute voice rest group improved morphological recovery to a significant degree, however relative voice rest renders superior long-term recovery. CONCLUSIONS: Absolute voice rest is difficult to comply with. Neither short-term, nor long-term vocal recovery differed significantly between groups. Within-group comparisons showed significant improvements in vocal stamina, immediate recovery from vocal loading and self-assessments of voice problems only for the group with recommended relative voice rest.

Voice and swallowing after total laryngectomy.

BACKGROUND: Voice and swallowing problems are often seen in patients with advanced larynx cancer, after total laryngectomy (TL) and chemo/radiotherapy. The aim of this study was to determine the occurrence of voice and swallowing problems in patients who have been laryngectomised and investigate if these symptoms were related to age, time after TL, radiotherapy and TNM-classification. In addition, we studied how often the patients changed their voice prostheses and the need of therapeutic interventions after TL. METHODS: Forty-five patients were included in the study and completed the Swedish version of the Sydney Swallow Questionnaire and the Voice Handicap Index-T. RESULTS: Swallowing problems were reported by 89% of the patients and moderate-to-severe voice handicap was reported by 66%. Most of the subjects who had dysphagia also presented voice problems (rs = 0.67 p ≤ .01). Additional therapeutic interventions to manage problems with voice and/or swallowing after TL were required in 62% of the patients. CONCLUSIONS: Swallowing and voice problems after TL are common. Thus, the preoperative information and assessment of these functions, as well as the treatment and the post-operative rehabilitation should be evaluated and optimised to provide better functional results after treatment of advanced larynx cancer.

Recovery From Heavy Vocal Loading in Women With Different Degrees of Functional Voice Problems.

TYPE OF STUDY: This is a longitudinal, case-control clinical trial. OBJECTIVES: This study aims to track recovery time following a vocal loading task (VLT) imposing vocal fatigue and to explore if patients with functional dysphonia (FD) are worse affected by vocal loading, and if these patients take longer than others to recover. METHODS: Fifty (n = 50) female participants in four vocal subgroups on a spectrum of everyday vocal loading and functional voice complaints, including n = 20 patients with FD, took part in a clinical VLT, inflicting vocal fatigue through loud speech in ambient noise. Short-term recovery was explored through self-assessment of unspecified voice problems every 15 minutes for 2 hours following loading. Long-term recovery was tracked through self-assessments of specific voice symptoms during 3 days following vocal loading. Effects of heavy vocal loading were evaluated through voice recordings, long-time-average spectrum, perceptual assessments, and assessments of digital imaging performed pre- and post vocal loading. RESULTS: Patients with FD did not return to baseline for unspecified voice problems within 2 hours of vocal loading and were worse affected by vocal loading than other groups. Women with high everyday vocal loading with no voice complaints identified vocal loading more evidently than other groups. Long-term recovery took 7-20 hours for all groups. CONCLUSIONS: Short-term recovery is slower for patients with FD and these patients are worse affected by a VLT than others.

The Pharyngoesophageal Segment After Total Laryngectomy.

OBJECTIVE: The aim of the present study was to characterize the pharyngoesophageal segment in laryngectomees who rated themselves as functional tracheoesophageal speakers. METHODS: Voice perceptual assessment, high-resolution videomanometry of swallowing and phonation, and high-speed camera recording during phonation provided information about the anatomy and function of the pharyngoesophageal segment. RESULTS: Fourteen patients were included in the study. The voice assessments presented high intra/inter-listener reliability. We found a significant correlation between roughness and poor voice quality, hyperfunction and poor intelligibility, and poor voice quality, long time since the operation, and old age. High-resolution videomanometry during phonation revealed decreasing mean pressures from the distal esophagus to the pharynx and confirmed low resting pressures at the pharyngoesophageal segment and low esophageal peristaltic contraction pressures after laryngectomy in comparison to normal subjects. The neoglottis shape was mainly circular and presented a strong mucosal wave in most of the patients on the high-speed camera recording. CONCLUSIONS: Perceptual voice assessment and high-speed camera recordings provided baseline information about voice characteristics and vibration regularity of the neoglottis. Additionally, the quantitative measures obtained with high-resolution videomanometry may have clinical applicability as reference data in voice rehabilitation after total laryngectomy.

Long-Time Voice Accumulation During Work, Leisure, and a Vocal Loading Task in Groups With Different Levels of Functional Voice Problems.

OBJECTIVE: The study aimed to examine the vocal behavior and self-assessed vocal health in women with varying everyday vocal load and functional voice problems, including patients with functional dysphonia, in three conditions: work, leisure, and a vocal loading task (VLT). STUDY DESIGN: This is a longitudinal controlled, clinical trial. METHODS: Fifty (n = 50) female subjects were tracked during 7 days' voice accumulation accompanied by a voice health questionnaire, containing general assessments with visual analogue scale and specific voice health questions. Subjects were divided into four vocal subgroups according to everyday vocal load and functional vocal complaints. Accumulation time was divided into three conditions: a VLT, work, and leisure. The following behavioral parameters were measured: (1) relative phonation time (%), (2) phonatory sound pressure/voice level (dB sound pressure level), (3) ambient noise level (dB sound pressure level), and (4) phonatory fundamental frequency (Hz). RESULTS: Patients with functional dysphonia reported significantly higher specific voice problems across conditions and worse general voice problems during work and leisure than other groups. Women with high everyday vocal load and voice complaints showed higher phonation times and fundamental frequency during work than voice healthy controls. They also reported the highest incidence of general voice problems in the VLT. CONCLUSIONS: Vocal loading relates to prolonged phonation time at high fundamental frequencies. Patients with functional dysphonia experience general and specific voice problems permanently, whereas women with everyday vocal load and voice complaints recover during leisure. This may explain why the latter group does not seek voice therapy.

Viral load and mRNA expression of HPV type 6 among cases with recurrent respiratory papillomatosis.

OBJECTIVES/HYPOTHESIS: To determine viral load of human papillomavirus type 6 (HPV6), physical state of HPV6-DNA, and transcription level of HPV6 E7-mRNA in laryngeal papilloma and in adjacent healthy mucosa. STUDY DESIGN: Case series. METHODS: A papilloma biopsy was collected from each of 25 adult patients with respiratory recurrent papillomatosis. From 14 of the 25 patients, we first collected a biopsy from healthy mucosa of the false vocal fold and another from the papilloma. Quantity of HPV6 and E7-mRNA was measured by polymerase chain reaction. RESULTS: For the papilloma, the median load of HPV6 was 41 copies/cell, and the lowest amount was 5.4 copies/cell. Human papillomavirus type 6 was detected in 50% (7/14) of the healthy mucosa, with a median of 1.1 copies/cell, and the highest amount was 6.6 copies/cell. Overall, viral load was higher in papilloma than in healthy mucosa (P < 0.05). The average HPV6 E2/E7-DNA ratio was 1.3, indicating an episomal state. Human papillomavirus type 6-mRNA was detected in all HPV6-DNA-positive samples. The transcription median ratio of HPV6-mRNA/HPV6-DNA was 1.5 in papilloma and 3.8 in healthy mucosa. CONCLUSION: The amount of HPV6-DNA was consistently higher in the papilloma than in healthy mucosa. The transcription level of HPV6 E7 mRNA was similar in the papilloma and in normal mucosa. We suggest that interfering with replication of HPV6 and suppression of HPV6 to fewer than five copies/cell may be curative.

Treatment of cricopharyngeal dysfunction: a comparative pilot study.

BACKGROUND: Cricopharyngeal dysfunction is a narrowing at the level of the upper oesophageal sphincter caused by failed or incomplete sphincter opening as a result of lack of pharyngoesophageal coordination or reduction in the muscular compliance of the upper oesophageal sphincter. Oropharyngeal dysphagia is a typical symptom. Videomanometry allows direct comparison of pressure readings with dynamic anatomy during swallowing. METHODS: This is a prospective randomized pilot study that compares the effect of balloon dilatation and laser myotomy in cricopharyngeal dysfunction. We used videomanometry as an objective measure and the Swedish version of Sydney Swallowing Questionnaire as patient's self-assessment at baseline and 1 and 6 months after treatment. RESULTS: The UES sagittal diameter increased from 5.6 mm pre-operatively to 8.4 mm 6 months post-operatively with no differences between treatment groups. Preoperative mean Sydney Swallowing Questionnaire score was 770 and 6 months post-operative score 559, with no difference between the treatments in our cohort. CONCLUSION: Cricopharyngeal dysfunction treatment by either laser myotomy or balloon dilatation improved upper oesophageal sphincter opening during at least 6 months. TRIAL REGISTRATION: ISRCTN84905610, date: 081214.

Design of a clinical vocal loading test with long-time measurement of voice.

OBJECTIVES: The aim of this study was to design a clinical vocal loading task (VLT) and to track vocal loading and recovery in voice-healthy subjects. STUDY DESIGN: Pilot study. METHODS: Voice-healthy subjects (six female, five male) took part in a controlled VLT in the voice clinic. The VLT was designed to induce vocal fatigue. The subjects read aloud while making themselves heard through ambient speech-babble aired at 85 dB sound pressure level (SPL). Reading was terminated by the subjects when or if they felt any discomfort from the throat. The subjects wore a voice accumulator and filled out a voice activity questionnaire 1 day preceding and for 2 days following the VLT. Expert panels assessed vocal quality and laryngeal physiology from recordings. RESULTS: The subjects endured the VLT for 3-30 minutes. All subjects perceived vocal loading in the VLT. All subjects raised the fundamental frequency and SPL of their speech during the VLT. No match was shown between assessment of voice quality and laryngeal physiology. The subjects showed phonation quotients of 64-82% in the task. Measurements of phonation threshold pressure (PTP) were unstable and were not used. Self-perceived vocal loading receded after 24 hours. CONCLUSIONS: An authentic vocal load was simulated through the chosen method. Onset and recovery from self-perceived vocal loading was traceable through the voice activity questionnaire. The range of endurance in the VLT was an unexpected finding, indicating the complexity of vocal loading.

Teachers' voice use in teaching environments: a field study using ambulatory phonation monitor.

OBJECTIVES: This case-control designed field study examines the vocal behavior in teachers with self-estimated voice problems (VP) and their age- and school-matched voice healthy (VH) colleagues. It was hypothesized that teachers with and teachers without VP use their voices differently regarding fundamental frequency, sound pressure level (SPL), and in relation to the background noise. METHODS: Teachers with self-estimated VP (n = 14; two males and 12 females) were age and gender matched to VH school colleagues (n = 14; two males and 12 females). The subjects, recruited from an earlier study, had been examined in laryngeal, vocal, hearing, and psychosocial aspects. The fundamental frequency, SPL, and phonation time were recorded with an Ambulatory Phonation Monitor during one representative workday. The teachers reported their activities in a structured diary. The SPL (including teachers' and students' activity and ambient noise) was recorded with a sound level meter; the room temperature and air quality were measured simultaneously. The acoustic properties of the empty classrooms were measured. RESULTS: Teachers with VP behaved vocally different from their VH peers, in particular during teaching sessions. The phonation time was significantly higher in the group with VP, and the number of vibratory cycles differed between the female teachers. The F0 pattern, related to the vocal SPL and room acoustics, differed between the groups. CONCLUSION: The results suggest a different vocal behavior in subjects with subjective VP and a higher vocal load with fewer possibilities for vocal recovery.

How do teachers with self-reported voice problems differ from their peers with self-reported voice health?

OBJECTIVES: This randomized case-control study compares teachers with self-reported voice problems to age-, gender-, and school-matched colleagues with self-reported voice health. The self-assessed voice function is related to factors known to influence the voice: laryngeal findings, voice quality, personality, psychosocial and coping aspects, searching for causative factors of voice problems in teachers. METHODS: Subjects and controls, recruited from a teacher group in an earlier questionnaire study, underwent examinations of the larynx by high-speed imaging and kymograms; voice recordings; voice range profile; audiometry; self-assessment of voice handicap and voice function; teaching and environmental aspects; personality; coping; burnout, and work-related issues. The laryngeal and voice recordings were assessed by experienced phoniatricians and speech pathologists. RESULTS: The subjects with self-assessed voice problems differed from their peers with self-assessed voice health by significantly longer recovery time from voice problems and scored higher on all subscales of the Voice Handicap Index-Throat. CONCLUSIONS: The results show that the cause of voice dysfunction in this group of teachers with self-reported voice problems is not found in the vocal apparatus or within the individual. The individual's perception of a voice problem seems to be based on a combination of the number of symptoms and of how often the symptoms occur, along with the recovery time. The results also underline the importance of using self-assessed reports of voice dysfunction.

Speaker's comfort in teaching environments: voice problems in Swedish teaching staff.

OBJECTIVES: The primary objective of this study was to examine how a group of Swedish teachers rate aspects of their working environment that can be presumed to have an impact on vocal behavior and voice problems. The secondary objective was to explore the prevalence of voice problems in Swedish teachers. METHOD: Questionnaires were distributed to the teachers of 23 randomized schools. Teaching staff at all levels were included, except preschool teachers and teachers at specialized, vocational high schools. The response rate was 73%. RESULTS: The results showed that 13% of the whole group reported voice problems occurring sometimes, often, or always. The teachers reporting voice problems were compared with those without problems. There were significant differences among the groups for several items. The teachers with voice problems rated items on room acoustics and work environment as more noticeable. This group also reported voice symptoms, such as hoarseness, throat clearing, and voice change, to a significantly higher degree, even though teachers in both groups reported some voice symptoms. Absence from work because of voice problems was also significantly more common in the group with voice problems--35% versus 9% in the group without problems. CONCLUSION: We may conclude that teachers suffering from voice problems react stronger to loading factors in the teaching environment, report more frequent symptoms of voice discomfort, and are more often absent from work because of voice problems than their voice-healthy colleagues.

Throat related symptoms and voice: development of an instrument for self assessment of throat-problems.

BACKGROUND: Symptoms from throat (sensation of globus; frequent throat clearing; irritated throat) are common in patients referred to voice clinics and to ENT specialists. The relation to symptoms of voice discomfort is unclear and in some cases patients do not have voice problems at all. Instruments for patients' self-reporting of symptoms, and assessment of handicap, such as the Voice Handicap Index (VHI), are in common use in voice clinics. Symptoms from throat are however only marginally covered. PURPOSE: To develop and evaluate an instrument that could make the patients' estimation of symptoms from the throat possible. Further to facilitate the consideration of the relation between throat- and voice problems with the Throat subscale together with a Swedish translation of the Voice Handicap Index. Finally to try the VHI with the Throat subscale: the VHI-T, for test-retest reliability and validity. METHODS: A subscale with 10 throat related items was developed for appliance with the VHI. The VHI was translated to Swedish and retranslated to English. The questionnaire was tried in two phases on a total of 23+144 patients and 12+58 voice healthy controls. The reliability was calculated with Cronbach's alpha, ICC and Pearson's correlation coefficient. The validity was estimated by independent T-test. RESULTS: The difference in VHI-T scores between the patients and the voice-healthy controls was significant (p = < 0,01) and there was a good correlation of the test- retest occasions. The reliability testing of the entire questionnaire showed an alpha value of r = 0,90 and that for the Throat subscale separately a value of r = 0,87 which shows a high degree of reliability. CONCLUSIONS: For the estimation of self-perceived throat and voice problems the scale on throat related problems together with the present Swedish translation of the Voice Handicap Index, (VHI) the VHI-Throat, proves to be a valid and reliable instrument. The throat subscale seems to help revealing a category of symptoms that are common in our patients. These are symptoms that have not earlier been possible to cover with the questionnaires designed for use in the voice clinic.

Fluorescence investigations to classify malignant laryngeal lesions in vivo.

BACKGROUND: The extent of surgical resection for malignant laryngeal lesions influences voice quality. An instrument to estimate histopathologic grading of dysplasia in vivo may spare normal tissue without increasing the risk of local failure. METHODS: Laryngeal lesions (N = 39; 21 after administration of delta-aminolevulinic acid (ALA)) were investigated with laser-induced fluorescence, and the results correlated to histopathologic grading in 4 groups: non/mild dysplasia (I), moderate dysplasia (II), severe dysplasia/cancer in situ (III), and carcinoma. RESULTS: At 337-nm excitation, there were differences in the fluorescence ratio I(431)/I(390) between groups I/III and carcinoma. Following 405-nm excitation, I(500 nm) group I differed significantly from group III and cancer. The sensitivity for the fluorescence method was 89%, and the specificity was 100%. CONCLUSIONS: There are differences in the in vivo tissue fluorescence between tissue with different gradings of dysplasia and carcinoma.