Diagnosis of unilateral recurrent laryngeal nerve paralysis: Laryngeal electromyography, subjective rating scales, acoustic and aerodynamic measures

OBJECTIVE/HYPOTHESIS: To determine whether specific laryngeal electromyography (LEMG) patterns in patients with unilateral vocal fold paralysis/paresis (UVFP) are related to etiology of injury, time from onset of injury, patient perception of symptom severity, acoustic measures, and laryngeal aerodynamic measures. STUDY DESIGN: This is a retrospective review of 75 patients. METHODS: Each patient received LEMG, acoustic and aerodynamic testing, and a subjective rating scale assessment (the Glottal Closure Index). Statistical analysis by groups were performed using both χ and single-factor analysis of variance testing. RESULTS: An iatrogenic etiology was associated with poor tone on LEMG (P = .05). Those individuals evaluated after 3 months after onset demonstrated more nascent units, a sign of reinnervation, compared with individuals evaluated before 3 months (P \u3c .02). Individuals with fewer normal motor units on LEMG had significantly higher mean translaryngeal air flows (P = .044). Individuals with poor recruitment had significantly shorter maximum phonation times (P = .034) and higher mean flows (P = .044). Individuals with better laryngeal tone as noted on LEMG had significantly lower mean flows (P = .06). CONCLUSIONS: Specific LEMG patterns are related to the etiology of the UVFP and time course since recurrent laryngeal nerve injury. LEMG appears to reflect vocal fold muscle tone as seen on laryngeal function studies. In combination, these studies provide a cohesive assessment of laryngeal function in patients with UVFP. © 2006 The American Laryngological, Rhinological and Otological Society, Inc

Perceived vocal fatigue and effort in relation to laryngeal functional measures in paresis patients

Objectives/Hypothesis To determine if differences in objective measures of laryngeal function can meaningfully explain different levels of self-perceptions of effort or fatigue in patients with vocal fold paresis. Study Design A retrospective chart review of 72 patients with vocal fold paresis diagnosed using laryngeal electromyography, who had either been observed (n=21), treated only by injection (n=24), or treated only by surgery (n=27). Methods Before and after treatment/observation, patients\u27 subjective ratings of severity of vocal effort and fatigue were assessed using the Glottal Function Index. Laryngeal function was assessed using maximum phonation time and translaryngeal flow. Results None of the variables demonstrated a significant linear change across time. Post hoc Tukey analyses following analysis of variance (ANOVA) found significant differences in flow among three groups, those rating symptoms of effort as no problem, moderate problem, or severe problem. Post hoc Tukey analyses following ANOVA found significant differences in the amount that flow changed among three groups, those demonstrating no difference, minor differences, or major differences in ratings of effort before and after treatment. Conclusions Changes in reported symptom severity of effort were related to changes in translaryngeal midvowel flow that were not explained by passage of time. Level of Evidence 4. Laryngoscope, 124:1631-1637, 2014 © 2013 The American Laryngological, Rhinological and Otological Society, Inc

Evidence of return of function in patients with vocal fold paresis

Unilateral vocal fold paresis (UVFP) patients were examined over time for achievement of partial or full functional return or no functional return in the extent of arytenoid movement, clarity of laryngeal articulation, maximum phonation time (MPT), and flow. Effects of treatment type and initial laryngeal electromyography (EMG) results were examined. A retrospective chart review was completed for patients a year or less after onset evaluated between April 1999 and December 2005 and treated between 2 and 20 months after onset. Twenty-one individuals were evaluated (11 males, age: 34-89 years) and subsequently treated (10 by injection and 11 by thyroplasty). Evidence of full functional return was found for the extent of arytenoid movement in 25% of individuals, for clarity of laryngeal articulation in 71%, for MPT in 58%, and for flow in 50%. No evidence of functional return was found for the extent of arytenoid movement in 33% of the individuals, for clarity of laryngeal articulation in 8%, for MPT in 32%, and for flow in 22%. All pairs of outcome measures showed poor agreement in the level to which they functionally returned. More individuals with signs of reinnervation demonstrated MPTs with full functional return than expected. Patients with UVFP, even after treatment and at least 12 months postinjury did not demonstrate full functional return for all measures. Differences across measures in the percentage of individuals demonstrating each level of function and the lack of agreement of function level between measures within individuals suggest the need to use multiple outcome measures. © 2010 The Voice Foundation

Using laryngeal electromyography to differentiate presbylarynges from paresis

Purpose: Differential diagnosis of patients over 64 years of age reporting hoarseness is challenging. Laryngeal electromyography (LEMG) was used to determine the status of the recurrent and superior laryngeal nerves. The authors hypothesized that individuals with hoarseness but normal LEMG would have measures similar to those of patients from previous studies with presbylarynges and significantly different from those of patients with abnormal LEMG. Method: A retrospective chart review of acoustic, aerodynamic, endoscopic, and self-rating measures was completed for 52 individuals over 64 years of age reporting moderate to severe hoarseness. Results: Individuals with normal LEMG had measures similar to those of patients from previous studies diagnosed with presbylarynges. The group with LEMG abnormalities was subcategorized by specific nerve(s) affected. Significant differences were found for measures between presbylarynges and unilateral but not bilateral paresis groups. Several endoscopic findings were observed more often than expected in the presbylarynges group. Using electromyography as a gold standard, the presence of any impairment in arytenoid movement had the most sensitivity (77%) in making the diagnosis of paresis, and the absence of any impairment had the most specificity (67%) in making the diagnosis of presbylarynges. Conclusion: LEMG may be useful in differentially diagnosing hoarseness in older patients, especially to distinguish between bilateral paresis and presbylarynges. © American Speech-Language-Hearing Association

Perceived vocal fatigue and effort in relation to laryngeal functional measures in paresis patients

Objectives/Hypothesis To determine if differences in objective measures of laryngeal function can meaningfully explain different levels of self-perceptions of effort or fatigue in patients with vocal fold paresis. Study Design A retrospective chart review of 72 patients with vocal fold paresis diagnosed using laryngeal electromyography, who had either been observed (n=21), treated only by injection (n=24), or treated only by surgery (n=27). Methods Before and after treatment/observation, patients\u27 subjective ratings of severity of vocal effort and fatigue were assessed using the Glottal Function Index. Laryngeal function was assessed using maximum phonation time and translaryngeal flow. Results None of the variables demonstrated a significant linear change across time. Post hoc Tukey analyses following analysis of variance (ANOVA) found significant differences in flow among three groups, those rating symptoms of effort as no problem, moderate problem, or severe problem. Post hoc Tukey analyses following ANOVA found significant differences in the amount that flow changed among three groups, those demonstrating no difference, minor differences, or major differences in ratings of effort before and after treatment. Conclusions Changes in reported symptom severity of effort were related to changes in translaryngeal midvowel flow that were not explained by passage of time. Level of Evidence 4. Laryngoscope, 124:1631-1637, 2014 © 2013 The American Laryngological, Rhinological and Otological Society, Inc

Long-Term Voice Change in Presbylarynges Patients With and Without Intervention

PURPOSE: To explore long-term patient experience of treated and untreated presbylarynges patients two or more years after their previous clinic visit by their responses to a probe about the changes in voice (better, stable, or worse) and standardized rating scales either by phone or from clinic records. Congruences of rating differences between visits and probe responses were assessed. METHODS: Thirty-seven participated prospectively and seven retrospectively. Better, stable, or worse probe responses and treatment follow-through were obtained. Self-rating scales, completed verbally or obtained from charts, were compared to the previous visit so differences between visits could be converted to be congruent with probe responses. RESULTS: After a mean of 4.6 years, 44% (63% untreated) reported stable, 36% (38% untreated) worse, and 20% (89% untreated) better. Significantly greater proportions of untreated reported better/stable probe responses while treated reported worse (χ2; P = 0.038). Significantly better means for all ratings were found at follow-up for those with better probe responses, but mean ratings were not significantly worse for those with worse probe response. No significant congruences of rating differences between visits and probe responses were found. In untreated reporting stable probe response, a significantly greater proportion of those with previous clinic ratings within normal limits (WNL) maintained ratings WNL at follow-up (z-statistic; P = 0.0007). CONCLUSIONS: Ratings WNL at the initial evaluation, especially voice-related quality of life and effort, were found to still be WNL after several years. Little congruence was found between rating differences and probe responses, especially for worse, suggesting need for developing more sensitive rating scales

Perceptual ratings of vocal characteristics and voicing features in untreated patients with unilateral vocal fold paralysis

This study used visual analog scales to obtain perceptual ratings of features of voice production in subjects with unilateral vocal fold paralysis (UVFP), including clarity of laryngeal articulation, consistency of loudness across the utterance and the voiced/voiceless distinction. Recordings of repeated /i/, /isi/, and /izi/ from subjects diagnosed with UVFP and control subjects were randomly re-recorded, and then rated by five listeners. Significant differences in ratings (Smirnov test, p \u3c 0.01) were found between groups for aphonia , severity , clarity of articulation , overall loudness , consistency of loudness and amount of effort . Four of five raters agreed on the accuracy of /s/ or /z/ productions for only 54% of the samples from the subjects with UVFP. Voiceless and voiced cognates were equally likely to be rated as inaccurate. Results suggested that these variables were sensitive to changes in voice production resulting from paralysis, and may be useful in measuring treatment outcomes and spontaneous recovery of function. Learning outcomes: As a result of reading this manuscript the reader will (1) gain an understanding of types of perceptual scales and how to develop the set of vocal characteristics to be used in distinguishing patients with UVFP and those without, (2) learn which vocal characteristics listeners are able to use to successfully distinguish between patients with UVFP and those without and (3) understand the possible role for perceptual ratings in tracking changes in vocal characteristics in subjects over time following treatment or spontaneous recovery of function. © 2004 Elsevier Inc. All rights reserved

Perceptual ratings of vocal characteristics and voicing features in untreated patients with unilateral vocal fold paralysis

This study used visual analog scales to obtain perceptual ratings of features of voice production in subjects with unilateral vocal fold paralysis (UVFP), including clarity of laryngeal articulation, consistency of loudness across the utterance and the voiced/voiceless distinction. Recordings of repeated /i/, /isi/, and /izi/ from subjects diagnosed with UVFP and control subjects were randomly re-recorded, and then rated by five listeners. Significant differences in ratings (Smirnov test, p \u3c 0.01) were found between groups for aphonia , severity , clarity of articulation , overall loudness , consistency of loudness and amount of effort . Four of five raters agreed on the accuracy of /s/ or /z/ productions for only 54% of the samples from the subjects with UVFP. Voiceless and voiced cognates were equally likely to be rated as inaccurate. Results suggested that these variables were sensitive to changes in voice production resulting from paralysis, and may be useful in measuring treatment outcomes and spontaneous recovery of function. Learning outcomes: As a result of reading this manuscript the reader will (1) gain an understanding of types of perceptual scales and how to develop the set of vocal characteristics to be used in distinguishing patients with UVFP and those without, (2) learn which vocal characteristics listeners are able to use to successfully distinguish between patients with UVFP and those without and (3) understand the possible role for perceptual ratings in tracking changes in vocal characteristics in subjects over time following treatment or spontaneous recovery of function. © 2004 Elsevier Inc. All rights reserved

Effects of Participation in a Structured Choral Program on the Voice of Older Adults

OBJECTIVES: To examine the effects of short-term and long-term engagement with structured choral singing on vocal function and quality of life outcomes in older adults. METHODS: Two groups of older adult singers over 55 years, one with fewer than 4 semesters and one with 4 or more semesters singing in a chorale, were assessed at 3 time points: baseline, after 1 semester of singing, and either after 1 semester of rest or after 1 semester of rest and 1 semester more of singing. Acoustic and aerodynamic measures, voice-related quality of life ratings, and measures of singing accuracy were obtained. Percent change between time points were calculated to determine three outcomes: improvement, lack of change, or worsening of measures across time. RESULTS: Long-term average spectrum (LTAS), difference in first and second harmonics and estimated subglottic pressure were significantly more likely to improve after a semester of singing with less experience singers, and LTAS continued to improve after a semester of rest. Flow was significantly more likely to improve with more singing experience after a semester of singing. Aerodynamic variables consistently changed in more experienced singers and improvement was maintained over the three visits. No significant changes occurred over time for singing accuracy for any singer type. Self-perception of singing voice continued to improve with more singing experience. CONCLUSIONS: This study demonstrated that for older adults in good health, regular singing provided a mechanism for maintaining speaking voice over time

Treatment effectiveness for aging changes in the larynx

© 2017 The American Laryngological, Rhinological and Otological Society, Inc. Objectives: To compare the effectiveness of injection augmentation and bilateral thyroplasty surgery in managing age-related changes of the larynx. Study Design: Retrospective chart review of patients treated with bilateral thyroplasty and/or injection augmentation. Methods: We evaluated 22 patients before and after treatment using: 1) normalized glottal gap area and normalized true vocal fold width from endoscopic images; 2) patient self-rating questionnaires; and 3) acoustic and aerodynamic measures. Results: Thyroplasty surgery resulted in 38% of patients demonstrating less bowing compared to 33% after injection, and 63% demonstrated less supraglottic activity compared to 43% after injection (P = 0.09). Change in mean Voice-Related Quality of Life (V-RQOL) scores was 25.5 after thyroplasty compared to −16.4 after injection (P \u3c 0.05). Those exhibiting a greater than 20 change in V-RQOL after treatment were significantly more likely to report swallowing symptoms pretreatment. Conclusion: Patients postinjection did not rate themselves on any questionnaires as significantly better compared to pretreatment, whereas patients post-thyroplasty rated themselves as significantly improved on all questionnaires. Patients post-thyroplasty rated their voices as significantly closer to their best voice than patients postinjection. Likewise, 64% of patients who had thyroplasty surgery reported a significant treatment effect compared to 33% for injection augmentation. Level of Evidence: 4. Laryngoscope, 127:2572–2577, 2017