Vocal cord dysfunction diagnosis may be improved by a screening check list.

BACKGROUND: Many patients with vocal cord dysfunction (VCD), with or without asthma, receive inappropriate treatment because they are misdiagnosed as having difficult-to-control asthma alone. We developed a clinical screening check list designed to aid the diagnosis of VCD. METHODS: A prospective observational study involving 80 patients aged ≥18 years, diagnosed with severe asthma. After anamnesis and physical examination, physicians completed a check list with 6 questions to identify VCD, for which the answer "yes" counted one point. Then patients underwent spirometry and laryngoscopy. On the basis of the laryngoscopic findings, we created three patient groups: VCD (vocal cord adduction during inspiration, n = 14); unconfirmed VCD (inconclusive findings, n = 29); and control (normal findings, n = 37). We attempted to determine whether any of those groups were associated with the responses to individual questions or sets of questions on the check list. RESULTS: The proportion of affirmative answers to the question "Does pulmonary auscultation reveal wheezing, predominantly in the cervical region, and/or stridor?" was significantly higher for the VCD group than for the other two groups (P = 0.006), notably in elderly patients. The variable "4 or more affirmative answers" was more common in VCD and unconfirmed VCD groups in comparison to controls (P = 0.022). CONCLUSIONS: A finding of wheezing or stridor on auscultation of the cervical region is suggestive of vocal cord dysfunction, especially in elderly patients, and such dysfunction can be confirmed through laryngoscopy. Our VCD screening check list proved to be useful in the screening of VCD among patients with severe asthma.

Laryngeal and respiratory patterns in patients with paradoxical vocal fold motion.

The purposes of this study were to determine the differences in spirometric measures obtained from patients with endoscopically-documented paradoxical vocal fold motion (PVFM) and to compare them to a group of normal subjects without endoscopically-documented paradoxical vocal fold motion during non-provocative breathing and following speech. Thirty eight subjects with documented paradoxical vocal fold motion using transnasal flexible laryngoscopy (TFL) and no history of asthma and 21 normal subjects with documented normal breathing patterns and normal findings on endoscopy underwent flow-volume loop studies. Endoscopic judgments of vocal fold motion from three breathing conditions were made by two observers. The results of the endoscopic judgments indicate that paradoxical motion occurs whether breathing through the nose or mouth in the PVFM subjects, mainly after speaking and inhalation. In addition, the spirometry results indicated that the inspiratory measure of FIVC%, FVC% and FIV(0.5)/FIVC were significantly lower in the PVFM group compared to the normal subjects. The data supports the hypothesis that in patients with PVFM, inspiratory spirometric values play a role in identifying patients with PVFM. The finding of vocal fold closure following a speech utterance in the majority of the PVFM subjects but not in the normal control group warrants further investigation.

Laryngeal sensory deficits in patients with chronic cough and paradoxical vocal fold movement disorder.

OBJECTIVES/HYPOTHESIS: Although the diagnostic accuracy of paradoxical vocal fold movement disorder and chronic cough has improved, the underlying pathophysiology remains relatively unknown. We hypothesize that one potential etiological factor in these patients is an aberrant laryngeal sensory response and sought to determine if respiratory retraining in addition to antireflux therapy alters this aberrant response. STUDY DESIGN: Retrospective, outcomes. METHODS: Sixteen patients who had been on at least 3 months of twice-daily proton pump inhibitors with no subjective improvement in their primary complaint of cough, self-reported symptoms of gastroesophageal and laryngopharyngeal reflux, and concurrent paradoxical vocal fold movement (PVFM) were included in the current study. In addition to continuing twice daily pharmacological therapy, subjects underwent a course of respiratory retraining. Outcome measures including the Reflux Symptom Index (RSI), transnasal flexible laryngoscopy, and laryngopharyngeal sensory discrimination thresholds were obtained prior to and following a course of respiratory retraining. RESULTS: Mean bilateral laryngeal sensory response improved significantly after combined respiratory retraining and aggressive proton pump inhibitor therapy (P = .01). In addition, mean RSI score decreased significantly following treatment (P = .02). Specifically, 13 of 16 patients experienced improved sensory response, corresponding with patient reports of improved PVFM symptoms following treatment. CONCLUSIONS: Aberrant laryngeal sensation was identified in patients with PVFM and chronic cough. This response, however, normalized following a limited course of respiratory retraining, corresponding with improved patient symptoms.

Measuring quality of life in dysphonic patients: a systematic review of content development in patient-reported outcomes measures.

To review existing patient reported outcomes measures (PROMs) used in dysphonic populations to assess the procedures used in their development and the extent to which these meet current development standards for content generation and psychometric evaluation. The study is a systematic review. A systematic review of Medline, Cumulative Index to Nursing & Allied Health, and Health and Psychosocial Instruments databases was completed using voice, quality of life, and PROMs as keywords. We identified all patient or parent-reported questionnaires measuring quality of life associated with voice disorders from the review findings. Questionnaires were appraised for adherence to international guidelines for the development and evaluation of PROMs as outlined by the Scientific Advisory Committee of the Medical Outcome Trust. Nine PROMs fulfilled the inclusion criteria. The quality of these questionnaires was variable with regard to instrument development and none met all of the current, recommended criteria. Of the nine questionnaires, the Voice Symptom Scale underwent the most rigorous development process. Furthermore, many instruments have been augmented to allow for proxy administration, failing to address quality of life-related issues specific to the target population. Instrument development is often overlooked when attempting to quantify patient reported outcomes in dysphonic patients. Careful instrument development procedures are required to ensure that PROMs are valid, reliable, and responsive. Our review suggests that the deficits in psychometric properties of the current voice-related PROMs may be, at least in part, due to deficits in the development process. Furthermore, these data suggest the potential utility of a novel PROM adhering to rigorous international standards to better ensure that clinicians appreciate the variables most relevant to patients with voice disorders and address some of the psychometric shortcomings of the currently used questionnaires.

The characterization of the vibrato in lyric and sertanejo singing styles: acoustic and perceptual auditory aspects.

The vibrato is one of the embellishments most frequently used in the singing voice and it can be found in different singing styles, among those, lyric and Sertanejo (Brazilian country western-like singing style). Considering these two styles, the objective of the present study was to analyze the production of vibrato in the singing voice in the lyric and sertanejo genres from an acoustic and perceptual viewpoint. Twenty male singers-10 classical (operatic) singers and 10 sertanejo singers-reportedly in perfect laryngeal health, served as subjects for this study. Digital recording of the subjects' voices was performed. For each phonation, acoustic analysis was carried out together with comparison of overtones and vibrato rate and extension measurements. The results have shown that the mean values for vibrato rate and extent in lyric singers were 4.55-6.25 Hz and 0-54-1.66 semitone, respectively, whereas for sertanejo they were 5.0-6.56 Hz and 0.54-0.95 semitone. In the spectrogram, there was regularity in terms of frequency oscillation in the lyric genre whereas in the sertanejo style there was no regularity.

Paradoxical vocal fold motion: a sensory-motor laryngeal disorder.

OBJECTIVES: The purpose of this study is to determine the laryngeal sensitivity (LS) thresholds and the ratings of laryngopharyngeal reflux symptoms in patients with paradoxical vocal fold motion (PVFM). METHODS: This is a chart review following Institutional Review Board approval of 75 patients from January 2006 to June 2007. The patients were diagnosed with PVFM following case history, transnasal flexible laryngoscopy and spirometric testing. The data analyzed consisted of the reflux symptom index (RSI) and laryngopharyngeal sensitivity (LS). Laryngeal sensitivity and RSI were graded according to mild, moderate, or severe. RESULTS: There were 12 (16%) patients with normal RSI scores, 37 patients (49.3%) with moderate RSI (RSI 11-22), and 26 patients (34.7%) with severe RSI (RSI >22). The right LS was normal in 11 patients (14.7%), moderately impaired in 16 patients (21.3%), and severely impaired in 48 (64%) patients. The left LS showed normal sensation in 11 patients (14.7%), moderately impaired LS in 13 patients (17.3%), and severe impairment in 51 patients (68%). Only one patient had both normal sensation and normal RSI, and 70.4% of patients had abnormal RSI and sensation thresholds. CONCLUSIONS: Patients diagnosed with PVFM had a high prevalence of symptoms related to LPR and markedly reduced LS. These findings suggest that PVFM may be triggered by reduced peripheral sensation or laryngeal inflammation.

Correlatos perceptivos e acústicos dos ajustes supraglóticos na disfonia / Perceptive and acoustic correlates of supraglottis adjustments in dysfonia

OBJETIVO: avaliar os correlatos perceptivo-auditivos (ajustes supraglóticos) e acústicos (formantes) da qualidade vocal de indivíduos disfônicos com alterações glóticas, atendidos em ambulatório de fonoaudiologia de uma instituição hospitalar da cidade de São Paulo. MÉTODOS: o grupo estudado foi representado por amostras de voz de 20 indivíduos disfônicos com idades variadas entre 30 e 65 anos do sexo feminino (atendidos em um hospital da cidade de São Paulo) e julgamentos perceptivo-auditivos da qualidade vocal por amostras avaliadas previamente por um grupo de juízes em atividade clínica. As amostras foram exploradas quanto à freqüência dos três primeiros formantes (F1, F2 e F3). Os valores foram considerados de forma qualitativa (comparados aos dados da análise perceptivo-auditiva) e quantitativa (teste Qui-quadrado). RESULTADOS: os ajustes de qualidade vocal mais freqüentes foram laringe baixa, mandíbula fechada, lábios arredondados, corpo de língua abaixado, corpo de língua retraído, labiodentalização. Diferenças estatisticamente significantes foram encontradas para os valores de freqüência de F1 para os vocábulos "cata" (864 Hz) e "gata" (814 Hz), p=0 e F3 para os vocábulos "cata" (2598 Hz) e "gata" (2660 Hz), p=0,17 dos indivíduos do grupo estudado em relação aos valores de referência para o Português-Brasileiro. CONCLUSÃO: os ajustes de qualidade vocal identificados encontraram correspondência com a diminuição dos valores de F1 e F3 indicando tendências de ajustes do trato vocal.

PURPOSE: to evaluate auditory perception (supraglottic adjustments) and acoustic (formants) of vocal quality in dysphonic individuals with glotic disorders, attended in a clinic a hospital in the city of São Paulo. METHODS: the studied was represented by voice samples taken form from 20 dysphonic people aged between 30 and 65 of the female gender (attended in a hospital in the city of Sao Paulo) and the auditory perception judgment of the vocal quality was represented by samples previously evaluated by active judges in clinic activity. The samples were explored as for the frequency of the first three formants (F1, F2 and F3). The values were considered as for their quality (compared to the data of auditory perception analysis) and their quantity (Qui-square test) RESULTS: the more frequent adjustments of vocal quality were low larynx, closed jaw, lip rounding, lowered tongue body, retracted tongue body, labiodentalization. Statistically meaningful differences were found for the frequency value of F1 for the syllables "cata" (864 Hz) and "gata" (814Hz), p=0 and F3 for the syllables "cata" (2598 Hz) and "gata"(2660 Hz), p=0.17 for the subjects of the group studied with relation to the values of reference for Portuguese-Brazilian language. CONCLUSION: the identified adjustments of vocal quality met correspondence with the reducing of values of F1 and F3 indicating trends for vocal treat adjustments.