[Inducible laryngeal obstruction: detection and management]. / Obstruction laryngée induite : détection et prise en charge.

Inducible laryngeal obstruction (ILO) is a phenomenon of paradoxical upper airway closure during breathing causing respiratory distress and a noisy breathing. It most often appears during maximal exertion but can also be induced by inhalation of irritants, pharyngolaryngeal reflux or stressful situations. It can sometimes be confused with an acute asthma attack. The gold standard investigation is a videolaryngoscopy during ergometry which can confirm the diagnosis, allowing appropriate treatment. The aim of this article is to describe the pathophysiology of ILO and to discuss paraclinical examinations and treatment options.

L'obstruction laryngée induite (ILO) est un phénomène de fermeture paradoxale des voies aériennes supérieures pendant la respiration qui provoque une détresse respiratoire et une symptomatologie bruyante. Elle apparaît le plus souvent pendant un effort maximal mais peut aussi être liée à l'inhalation de produits irritants, à un reflux pharyngolaryngé ou au stress. Elle peut parfois être confondue avec une crise d'asthme en phase aiguë. L'examen de choix est la vidéolaryngoscopie d'effort, qui permet de confirmer le diagnostic et de choisir le traitement approprié. Le but de cet article est de décrire la physiopathologie de l'ILO et de discuter des examens paracliniques et traitements proposés.

VoiceS: voice quality after transoral CO2 laser surgery versus single vocal cord irradiation for unilateral stage 0 and I glottic larynx cancer-a randomized phase III trial.

BACKGROUND: Surgery and radiotherapy are well-established standards of care for unilateral stage 0 and I early-stage glottic cancer (ESGC). Based on comparative studies and meta-analyses, functional and oncological outcomes after both treatment modalities are similar. Historically, radiotherapy (RT) has been performed by irradiation of the whole larynx. However, only the involved vocal cord is being treated with recently introduced hypofractionated concepts that result in 8 to 10-fold smaller target volumes. Retrospective data argues for an improvement in voice quality with non-inferior local control. Based on these findings, single vocal cord irradiation (SVCI) has been implemented as a routine approach in some institutions for ESGC in recent years. However, prospective data directly comparing SVCI with surgery is lacking. The aim of VoiceS is to fill this gap. METHODS: In this prospective randomized multi-center open-label phase III study with a superiority design, 34 patients with histopathologically confirmed, untreated, unilateral stage 0-I ESGC (unilateral cTis or cT1a) will be randomized to SVCI or transoral CO2-laser microsurgical cordectomy (TLM). Average difference in voice quality, measured by using the voice handicap index (VHI) will be modeled over four time points (6, 12, 18, and 24 months). Primary endpoint of this study will be the patient-reported subjective voice quality between 6 to 24 months after randomization. Secondary endpoints will include perceptual impression of the voice via roughness - breathiness - hoarseness (RBH) assessment at the above-mentioned time points. Additionally, quantitative characteristics of voice, loco-regional tumor control at 2 and 5 years, and treatment toxicity at 2 and 5 years based on CTCAE v.5.0 will be reported. DISCUSSION: To our knowledge, VoiceS is the first randomized phase III trial comparing SVCI with TLM. Results of this study may lead to improved decision-making in the treatment of ESGC. TRIAL REGISTRATION: ClinicalTrials.gov NCT04057209. Registered on 15 August 2019. Cantonal Ethics Committee KEK-BE 2019-01506.

Oral diadochokinesis and associated oro-facial function in young and old German mother-tongue speakers: A cross-sectional study.

OBJECTIVES: The aims of this study were to compare oral diadochokinesis and to test associations with oro-facial functional parameters in healthy young and old German speakers. BACKGROUND: Oral diadochokinesis is a key component in the concept of oro-facial hypofunction and relates to tongue and lip motor function but may depend on the linguistic background. MATERIALS AND METHODS: Healthy German speakers with a minimum of 20 teeth were recruited to form a young (<60 years) and an older group (≥60 years). Oral diadochokinesis was assessed as the number of repetitions/s for the monosyllables /pa/, /ta/ and /ka/ to evaluate movement capacity of the lip, the anterior region of the tongue and the posterior region of the tongue, respectively. Maximum voluntary lip force, maximum voluntary bite force, masticatory performance, maximum voluntary tongue pressure, xerostomia and swallowing function were assessed with validated instruments. Results are presented as median (IQR). RESULTS: Sixty participants formed the younger group (n = 35, 30.0 years [24.0-49.0]) and the older group (n = 25, 64.0 years [62.0-72.0]). Counts/s of /ta/ were different between age groups (younger group: 6.0 vs older group: 5.4) but not for syllables /pa/ (younger group: 6.0 vs older group: 5.8) and /ka/ (younger group: 5.6 vs older group: 5.0). The oral diadochokinesis with /pa/ was overall associated with maximum voluntary lip force; oral diadochokinesis performed with /ta/ was associated with tongue pressure, and oral diadochokinesis with /ka/ with swallowing function. Masticatory performance was not associated with oral diadochokinesis but with maximum voluntary bite force, xerostomia and with maximum voluntary tongue pressure. CONCLUSIONS: The published thresholds for oral diadochokinesis should be reconsidered in non-Japanese mother-tongue speakers. However, they still play an important role in the overall concept of oro-facial functional assessment.

Voluntary increase of acoustic middle ear impedances with simultaneous sound attenuation associated with mild hyperacusis (VIMH).

BACKGROUND: Acoustic impedances, as measured with tympanometers, change with the pressure in the middle ears, or reflexively as a response to a range of stimuli. A few persons are able to influence their acoustic impedances voluntarily. AIMS/OBJECTIVES: To describe this phenomenon and its clinical consequences. MATERIAL AND METHODS: Presentation of five case reports with measurements of the acoustic impedances, hearing thresholds, and otoacoustic emissions (TEOAE) in the relaxed state and while the change in acoustic impedance was invoked. RESULTS: All five subjects were able to voluntarily increase the acoustic impedance of their ears for short periods of time. While the change was active, TEOAE levels decreased by 0.8-9.7 dB and a mild transient conductive hearing loss in the low frequencies occurred. Four out of the five subjects reported a mild hyperacusis when the voluntary change was not invoked and showed unusual features in their acoustically evoked reflex. CONCLUSIONS AND SIGNIFICANCE: Subjects who can control their acoustic impedances voluntarily seem to have an increased prevalence of mild hyperacusis. Our results suggest interference of the voluntary control with the acoustic stapes reflex as a mechanism and we propose to name this phenomenon 'Voluntary Impedance increase with Mild Hyperacusis', or VIMH.

Encouragement to Increase the Use of Psychosocial Skills in the Diagnosis and Therapy of Patients With Functional Dysphonia.

Clinicians believe that psychosocial factors play a causal role in the etiology of many forms of functional dysphonia (FD). But for decades, all attempts to confirm such causation have failed. This paper aims to show the logic of this failure, to discuss the possibilities of employing psychology in therapy nonetheless, and to encourage clinicians to use their psychosocial knowledge and skills. The failure to confirm psychic and social factors as causal in the etiology of FD is basically a consequence of a principal shortcoming of evidence-based medicine (EBM). As the gold standard for validity, reliability, and objectivity in medical research, EBM is based on calculability and hence the processing of quantitative data. But life paths and life situations are best or sometimes only expressible in qualitative, experiential, and idiographic terms. Thus EBM-guided evaluation undervalues most psychosocial studies. This report of an experienced multidisciplinary voice team proposes alternative pathways for integrating psychosocial knowledge into the diagnosis and the treatment of FD. The difference between the fields of activity of psychotherapists and speech-language pathologists is discussed, and the latter group is shown the potential benefits of using more of their psychosocial knowledge and skills.

Functional hoarseness in children: short-term play therapy with family dynamic counseling as therapy of choice.

Children with nonorganic voice disorders (NVDs) are treated mainly using direct voice therapy techniques such as the accent method or glottal attack changes and indirect methods such as vocal hygiene and voice education. However, both approaches tackle only the symptoms and not etiological factors in the family dynamics and therefore often enjoy little success. The aim of the "Bernese Brief Dynamic Intervention" (BBDI) for children with NVD was to extend the effectiveness of pediatric voice therapies with a psychosomatic concept combining short-term play therapy with the child and family dynamic counseling of the parents. This study compares the therapeutic changes in three groups where different procedures were used, before intervention and 1 year afterward: counseling of parents (one to two consultations; n = 24), Brief Dynamic Intervention on the lines of the BBDI (three to five play therapy sessions with the child plus two to four sessions with the parents; n = 20), and traditional voice therapy (n = 22). A Voice Questionnaire for Parents developed by us with 59 questions to be answered on a four-point Likert scale was used to measure the change. According to the parents' assessment, a significant improvement in voice quality was achieved in all three methods. Counseling of parents (A) appears to have led parents to give their child more latitude, for example, they stopped nagging the child or demanding that he/she should behave strictly by the rules. After BBDI (B), the mothers were more responsive to their children's wishes and the children were more relaxed and their speech became livelier. At home, they called out to them less often at a distance, which probably improved parent-child dialog. Traditional voice therapy (C) seems to have had a positive effect on the children's social competence. BBDI seems to have the deepest, widest, and therefore probably the most enduring therapeutic effect on children with NVD.

Psychogenic aphonia: no fixation even after a lengthy period of aphonia.

BACKGROUND: Although psychogenic aphonia is considered to be a conversion disorder, aphonic patients are primarily treated symptomatically. This is because it is considered of overriding importance to elicit a voice quickly to avoid fixation of the aphonia. The aim of this study was to show that, for patients exhibiting the symptom of voicelessness, not eliciting the voice immediately will not lead to a permanent aphonia. METHODS: Between February 2000 and May 2006, aphonia was diagnosed in 22 patients. Effects of short-term psychodynamic psychotherapeutic intervention and voice therapy were studied in a follow-up of three years, on average. RESULTS: Twenty one patients recovered their voices; 6 even before their first medical examination, 13 after an average of 12 weeks and 2 patients after 2 and 3 years respectively. One patient who has been in psychiatric therapy for years, as a result of having suffered serious abuse, failed to regain her voice. CONCLUSIONS: Even after a lengthy period of aphonia a complete recovery of the voice function is possible in nearly all cases. Countertransference phenomena in therapists are discussed as the possible reason why they usually decide on treatment aimed primarily at dealing with the symptoms.

Randomized controlled trial on single dose steroid before thyroidectomy for benign disease to improve postoperative nausea, pain, and vocal function.

OBJECTIVE: To evaluate the effects of a single preoperative dose of steroid on thyroidectomy outcomes. BACKGROUND: Nausea, pain, and voice alteration frequently occur after thyroidectomy. Because steroids effectively reduce nausea and inflammation, a preoperative administration of steroids could improve these thyroidectomy outcomes. METHODS: Seventy-two patients (men = 20, women = 52) undergoing thyroidectomy for benign disease were included in this randomized, controlled, 2 armed (group D: 8 mg dexamethasone, n = 37; group C: 0.9% NaCl, n = 35), double-blinded study (clinical trial number NCT00619086). Anesthesia, surgical procedures, antiemetics, and analgesic treatments were standardized. Nausea (0-3), pain (visual analog scale), antiemetic and analgesic requirements, and digital voice recording were documented before and 4, 8, 16, 24, 36, and 48 hours after surgery. Patients were followed-up 30 days after hospital discharge. RESULTS: Baseline characteristics were similar among the 2 treatment groups. Nausea was pronounced in the first 16 hours postoperatively (scores were <0.3 and 0.8-1.0 for group D and C, respectively (P = 0.005)), and was significantly lower in group D compared with group C during the observation period (P = 0.001). Pain diminished within 48 hours after surgery (visual analog scale 20 and 35 in group D and C, respectively (P = 0.009)). Antiemetic and analgesic requirements were also significantly diminished. Changes in voice mean frequency were less prominent in the dexamethasone group compared with the placebo group (P = 0.015). No steroid-related complications occurred. CONCLUSION: A preoperative single dose of steroid significantly reduced nausea, vomiting, and pain, and improved postoperative voice function within the first 48 hours (most pronounced within 16 hours) after thyroid resection; this strategy should be routinely applied in thyroidectomies.

The use of polydimethylsiloxane for injection laryngoplasty.

BACKGROUND: Injuries of the recurrent laryngeal nerve with consecutive vocal cord paralysis is a typical complication in chest, esophageal, thyroideal, and neck surgery. Glottic insufficiency secondary to such a lesion can be treated by endolaryngeal vocal cord augmentation (injection laryngoplasty). Many different substances have been used, often showing complications or disadvantages. This study reports on the use of injectable polydimethylsiloxane (PDMS), with special regard to the long-term results. METHODS: In this prospective study, 21 patients with unilateral vocal cord paralysis underwent injection laryngoplasty using PDMS at a volume of 0.5-1.0 ml. Preoperatively, 6 weeks and 12 months after the injection the following parameters concerning patients' voice were evaluated: Glottic closure by videolaryngostroboscopy, maximum phonation time, voice range, voice dynamic, jitter, shimmer, noise-to-harmonic-ratio, and roughness, breathiness, and hoarseness (RBH). In addition, patients were asked to give their own evaluation of how satisfied they felt with their voice and of the handicaps it caused them. RESULTS: Postoperatively an improvement was evident in all the parameters that were investigated, and this significant improvement was still in evidence for most of the parameters more than one year after the injection. In our study no complications were observed more than one year after injection. CONCLUSION: PDMS is a safe substance for injection laryngoplasty in unilateral vocal cord paresis. Objective and subjective parameters confirm its effectiveness. It is suitable for obtaining satisfying results in the reestablishment of the patient's voice and communication ability.

Vocal cord dysfunction: dealing with aggressivity.

QUESTIONS UNDER STUDY: Vocal cord dysfunction (VCD) is characterised by recurrent attacks of paradoxical adduction of the vocal cords during inspiration, accompanied clinically by dyspnoea attacks with inspiratory stridor lasting between minutes and hours. The aim of the study is to evaluate the self-perception of patients suffering from VCD and how they deal with aggressivity. METHODS: The Giessen Test (GT) and the Picture Frustration Test (PFT) were used on 6 patients with VCD. RESULTS: Five variables show significant differences between the patients with VCD and the values of the normative groups. VCD-patients show an idealized image of themselves, ie relaxed, open, sociable, and capable of devotion. They do not reject accusations against them by others and rarely make self-criticism. In conflicts they behave passively, thus blocking their expression of aggressivity. CONCLUSIONS: In many cases organic disposition and trigger stimuli are thought to be responsible for provoking dyspnoea attacks in VCD. However, the self-perception of patients and their way of dealing with aggressivity strongly suggests that psychosocial factors play a great role in the development of VCD. This requires not only symptom-orientated therapy but also psychological counselling.

An update in thinking about nonorganic voice disorders.

OBJECTIVE: To describe and evaluate psychosocial factors in nonorganic voice disorders (NVDs). Nonorganic voice disorders are presumed to be the result of increased muscular tension that is caused to varying extents by vocal misuse and emotional stress. It is therefore necessary to include both of these in the diagnosis and treatment of patients with voice disorders. DESIGN: Clinical survey. SETTING: Academic tertiary referral center. PATIENTS: To evaluate psychosocial factors in NVDs, a sample of 74 patients with NVDs was examined psychologically using the Giessen Test and Picture Frustration Test. The results were compared with a control group of 19 patients with an organic dysphonia (vocal cord paralysis). MAIN OUTCOME MEASURES: Six scales of the Giessen Test (social response, dominance, control, underlying mood, permeability, and social potency), 3 reaction types of the Picture Frustration Test (obstacle dominance, ego defense, and need persistence), and 3 aggression categories of the Picture Frustration Test (extrapunitivity, intropunitivity, and impunitivity). RESULTS: The most striking significant difference between the 2 groups was that in conflict situations, patients with NVDs sought a quick solution or expected other people to provide one, which prevented them from understanding the underlying causes of the conflict. CONCLUSIONS: Only if the psychosocial aspects are taken into account can patients with NVD be offered a therapy that treats the causes of the voice disorder. It must be decided individually whether and when a voice training approach or a more psychological-psychotherapeutical approach is preferable.

Endoscopic resection of laryngeal and tracheal lesions using the microdebrider.

CONCLUSION: Endoscopic resection of laryngeal and tracheal lesions using the microdebrider is a safe, accurate and reliable method. OBJECTIVE: The microdebrider is an important tool for endoscopic nasal and sinus surgery and over the last few years a powered blade with a long shaft has been developed for endoscopic laryngeal and tracheal surgery. The aim of this non-randomized prospective study was to determine the advantages and disadvantages of the microdebrider for treating patients with different laryngeal and tracheal pathologies. MATERIAL AND METHODS: The laryngeal microdebrider was used under endoscopic control in 37 patients. In 29 cases a benign laryngeal lesion was removed endoscopically. In four patients debulking of a malignant obstructive endolaryngeal tumor was performed in order to avoid a tracheotomy. In four cases a bulky obstructing endotracheal lesion was removed. RESULTS: All laryngotracheal lesions could be removed, and this was facilitated by the use of angled rigid telescopes and the laryngeal blade. No traumatic lesions to normal laryngeal tissue occurred as a result of use of the microdebrider and no postoperative endolaryngeal bleeding was observed. The histological diagnosis of the biopsies taken with the microdebrider was accurate in every case. In three of the four cases with obstructive laryngeal malignancies, a tracheotomy was avoided until definitive therapy was undertaken. Normal breathing was restored in all patients with endotracheal lesions.

Stress and distress in non-organic voice disorder.

Non-organic voice disorders are characterised by an impaired voice sound, and/or reduced vocal capacity, and/or laryngeal sensory disturbances, all in the absence of causal organic laryngeal pathology. Psychogenic causes, a "psychological disequilibrium", and an increased tension of the laryngeal muscles are presumed to be one end of the spectrum of possible factors leading to the development of the disorder. In making a diagnosis, perceptive and acoustic methods for voice analysis are used in addition to the ENT-examination and the laryngostroboscopy. An assessment of the degree to which the patient feels him/herself subjectively affected by the voice disorder also plays an important role. If the history reveals any indication of psychosocial stress or conflict, the patient is offered psychological consultations. These conflicts seem less often to be deep rooted psychopathological problems but rather daily anxieties, failures, injuries, annoyances, disappointments regarding the sufferer him/herself and others, the non-fulfillment of desires, feelings of inadequacy and of lack of self-confidence. The patients may find it difficult to speak about conflicts and feelings, and they follow social conventions to an excessive extent. In frustrating situations patients tend to react aggressively towards themselves rather than towards others and are too quick in seeking a solution to any problem that may arise. The role of the voice as a "barometer of emotion", where a disorder may be regarded as a sign of emotional stress, has to be taken into consideration before starting a therapy: If the non-organic voice disorder is obviously due to vocal misuse and muscle tension, a more symptom-orientated voice therapy may be favoured. If psychosocial stress seems to play a greater role, additional counseling may be necessary. Only by using this approach can the patient be offered a therapy which goes into the causes and thereby addresses the whole person.

Comparison of 3 bonded lingual appliances by auditive analysis and subjective assessment.

The aim of this prospective study was to compare for the first time the influences of lingual appliances of different dimensions on sound performance and oral comfort. The study group comprised 12 subjects (10 women, 2 men; mean age, 33.96 years). Their sound production was recorded by means of a digital audio tape recorder before, 10 minutes after, and 24 hours after placement of the different appliances for semiobjective assessment by 3 blinded speech professionals. This was followed by supplementary subjective ratings of sound performance and oral comfort by the patients. All lingual appliances induced significant impairment in sound performance and oral comfort. However, they varied significantly with respect to the degree of impairment. The smaller the appliance, the less pronounced the impairments it induced. The smallest changes were induced by a bonded canine-to-canine retainer, followed by customized lingual brackets and prefabricated lingual brackets. By using lower-profile customized brackets, the orthodontist can significantly enhance patient comfort and significantly reduce impairments of sound performance in comparison with prefabricated brackets with larger dimensions. Before placing a lingual appliance, however, patients should be briefed on possible effects such as impaired sound production and decreased oral comfort.

Speech performance in lingual orthodontic patients measured by sonagraphy and auditive analysis.

Esthetically appealing, externally invisible, lingually applied orthodontic brackets are in increasing demand. Because the brackets are placed lingually, however, they appear to cause some problems with respect to speech. This study is the first to present a prospective evaluation of the articulation of 23 patients with lingual brackets by means of an innovative combination of test methods. An acoustic, objective evaluation of articulation measured by digital sonagraphy was related to a semiobjective auditive evaluation by 10 speech professionals, to a semiobjective auditive evaluation by close contacts of the patients, and to a subjective auditive evaluation by the patients themselves, the latter 2 using standardized questionnaires. The tests were performed before (T1), within 24 hours after (T2), and 3 months (+/- 1 week) after (T3) the start of therapy. In comparison with the initial findings, a significant deterioration in articulation was recorded with all test methods at T2 and T3. Using a new combination of methods, our investigations show the need for detailed briefing of patients about the extent and duration of changes in speech resulting from lingual brackets.

Intra- and intersubject comparison of cochlear implant systems using the Esprit and the Tempo+ behind-the-ear speech processor.

A patient with bilateral profound deafness was implanted with a Nucleus CI24M cochlear implant (CI) and used an Esprit behind-the-ear (BTE) speech processor. Thirteen months later, the implant had to be removed because of a cholesteatoma. As the same electrode could not be reinserted, a Medel combi40s CI was implanted in the same ear, and the patient used a Tempo+ BTE processor. After 1 year of use of the Combi40s/Tempo+ system, speech recognition was better and was rated better subjectively than with the CI24M/Esprit system. Speech recognition and subjective ratings were also assessed for two matched groups of nine CI users each, using either an Esprit or a Tempo+ processor. On average, speech recognition scores were higher for the group of Tempo+ users, but the difference was not statistically significant. Users of the Esprit processors rated their device higher in terms of cosmetic appearance and comfort of wearing.

Changes of voice and articulation in children with cochlear implants.

OBJECTIVE: The different speech sounds are formed by the primary voice signal and by the shape of the articulation tract. With this mechanism, specific overtones, the formants, are generated for each vowel. The objective of this study was to investigate the fundamental frequency (F0) of the voice signal and the first three formants (F1-F3) as a parameter of the articulation in prelingually deafened children at different timepoints after cochlear implantation (CI) compared with children with normal speech development. METHODS: Using the Kay CSL 4300B, the fundamental frequency and the formants F1-F3 of the Swiss-German vowel /a/ were investigated at different timepoints after CI in 20 prelingually deafened children aged 3.8-10.2 years by means of spectrographic and linear predictive coding (LPC) analysis. RESULTS: Children who had been operated before their fourth birthday showed no significant deviation in their fundamental frequency from age- and sex-matched peers, whereas a significant difference was documented in children who were older at the time of implantation. The first formant was very stable in every child and showed only discrete deviations from the normal range. The second and third formants, however, developed a broader scatter, but there was no systematic deviation of these formants to higher or lower values. The F1:F2 ratio was normal in children who were implanted at the age of up to 4 years and more centralized in children who were older at the time of implantation, as is known from the hearing impaired. CONCLUSIONS: Our results indicate that prelingually deaf children who receive a cochlear implant before their fourth birthday attain a better acoustic control over their speech, normalizing their fundamental frequencies and improving their articulatory skills.