As multidisciplinary cancer treatment evolves, strategies to identify patients needing early rese... more As multidisciplinary cancer treatment evolves, strategies to identify patients needing early resection/salvage are necessary. Some have suggested that vocal cord function after organ-preservation treatment may be an indicator. A retrospective review was performed of patients presenting with fixed or impaired vocal cord function at a tertiary center. Local recurrence rates were examined in patients with and without improved/normal mobilization after treatment. Sixty-nine patients met the inclusion criteria, with 35 patients having vocal cord fixation and 34 patients with impaired mobility. After treatment, 44 patients had normalization of vocal cord function, while 25 patients did not, with 2-year local control rates of 70% and 77%, p = .23, respectively. No difference in local control was found between patients with normalized/improved cord function (n = 53) and those who remained the same/worsened (n = 16; p = .81). Therapy-induced changes in vocal cord mobility did not correlate with local recurrence. Other criteria are needed to identify patients most likely to benefit from early surgical resection/salvage after organ preservation.
Objective. To identify factors related to the health care spending of patients with laryngeal dis... more Objective. To identify factors related to the health care spending of patients with laryngeal disorders.
OBJECTIVE: We sought to explore whether nausea and vomiting are predictive of entrapment. STUDY D... more OBJECTIVE: We sought to explore whether nausea and vomiting are predictive of entrapment. STUDY DESIGN AND SETTING: We retrospectively evaluated the data regarding orbital floor fractures in children younger than 19 years old presenting at a tertiary care center from 1990 to 2001. Zygomatic, naso-orbital ethmoid, and displaced orbital rim fractures were excluded from our analysis. Data on the fracture type, signs and symptoms, ocular mo-tility, surgical repair, and resolution of diplopia were also collected. RESULTS: Twenty-nine orbital floor fractures were identified. One fourth of the children had nausea/ vomiting, and half had trapdoor fractures. Seventeen percent of patients had entrapment of the inferior rectus. The positive predictive value of nau-sea/vomiting with a trapdoor fracture for entrap-ment was 83.3% (P 0.002, Fisher exact test). Half the patients required surgical intervention, most commonly for diplopia or gaze restriction. Gaze impairment did not resolve in 2 patients. CONCLUSION: Patients with trapdoor fractures who present with nausea/vomiting are at a high risk of inferior rectus entrapment and poor outcome. (Oto-laryngol Head Neck Surg 21003;129:000-000) (Otolaryngol Head Neck Surg 2003;129:43-7.)
OBJECTIVE: To compare the quality-of-life (QOL) benefit received from cochlear implants (CIs) and... more OBJECTIVE: To compare the quality-of-life (QOL) benefit received from cochlear implants (CIs) and hearing aids (HAs) among hearing-impaired adults. STUDY DESIGN: Health-related questionnaire. METHODS: Twenty-seven CI users compared to control group of 54 HA users, both older than 49. Questionnaires for the pre-rehab state (without HA or CI use) and post-rehab state (after HA or CI for 12 months) were mailed 2 weeks apart. RESULTS: Twenty-six (96.3%) CI and 30 (55.6%) HA users responded (P < 0.001, chi-square). Compared to HA patients, CI users showed twice as much overall QOL improvement (P 0.082, multiple linear regression) as HA users. Multivariate analysis of variance showed greater QOL benefit in CI than HA users across the physical, psychological, and social subdomains (P 0.03). CONCLUSION: Cochlear implants provide at least comparable benefit for those with profound hearing loss as hearing aids bring for those with less severe hearing loss. (Otolaryngol Head Neck Surg 2004; 131:413-22.)
We report the results of a survey designed to investigate audiologic referral patterns of primary... more We report the results of a survey designed to investigate audiologic referral patterns of primary care physicians and, more specifically, their referral of patients for hearing aids and cochlear implants. Three hundred internal medicine and family medicine physicians were identified from a referral basin of a tertiary care center and chosen randomly to be faxed questionnaires concerning their views about patients with hearing loss, hearing loss screening and referral practices, and availability of local resources. Of the 260 physicians who received a questionnaire, 85 (32.7%) responded. Of their communities (60% of which had populations of fewer than 50,000), 82.4% had an otolaryngologist and 40% had access to an academic center. Although 97.6% of the responding physicians indicated that hearing loss affected patients' quality of life, only 60% assessed patients for hearing loss. "Lack of time " and "morepressing issues " were the most common reasons given for not evaluating patients for hearing loss. Although 76physicians (89.4%) said they were aware of cochlear implants, only 22 (25.9%) had referred patients for implant evaluation. Lack of referral most commonly resulted from uncertainties about "where to refer" and "which patients were potential candidates. " The results of this survey suggest that a large percentage of primary care physicians do not routinely test for hearing impairment in adults.
This study evaluates how extraesophageal reflux affects membranous vocal fold healing in a canine... more This study evaluates how extraesophageal reflux affects membranous vocal fold healing in a canine model. We created membra-nous vocal fold injuries in the animals and randomly assigned them to topical application of acid and pepsin at pH 2 or pH 6 or of normal saline solution every other day for 12 days. The experimental vocal folds were compared to uninjured, control vocal folds troni animals painlessly sacrificed for other reasons. Hematoxylin and eosin. flbronectin. and procollagen I staining were performed for histologic analysis. The injured specimens had three times greater cellular infiltrate (p< .001, analysis of variance) and twice as much fibronectin and procollagen I ip < .001. analysis of variance) as did the speeimens from the control animals. No significant differencesor trends were identified for cellular infiltrate, fibronectin. or procollagen I within the injured groups (p> .05. Bonferroni /-test). Acute wound healing did not appear to be influenced by the presence of acid and pepsin at pH 2 or 6 as compared to saline solution.
Objectives: We undertook to explore the relationship between non-neoplastic voice disorders and p... more Objectives: We undertook to explore the relationship between non-neoplastic voice disorders and patients' quality of life. Methods: A PubMed search (1966 to 2003) for the terms Voice Handicap Index (VHI), Short Form-36 (SF-36), voice disorders, voice quality, treatment outcome, voice outcome, quality of life, and questionnaires was performed. Raw data were obtained whenever possible. Studies were analyzed by meta-analysis techniques. Results: Of 54 VHI studies identified, 11 were excluded, and of 21 SF-36 studies, 7 were excluded for incomplete data, non-English language, measuring malignant disease, or duplicate publication. Patients with neurologic and inflammatory or traumatic laryngeal disease had worse VHI scores than controls, and those with neurologic laryngeal disease had the most severe impairment (p < .001, Kruskal-Wallis analysis of variance; p < .05, Dunn's method of multiple comparisons). Those with neurologic laryngeal disease had worse SF-36 subdomain scores than did controls in 6 of 8 subdomains (p < .03, Kruskal-Wallis analysis of variance; p < .05, Dunn's method of multiple comparisons). Both patients with neurologic disease and patients with inflammatory or traumatic laryngeal disorders had changes in SF-36 subdomains similar to those of patients with other chronic disease states. Conclusions: Non-neoplastic voice disorders adversely impact patients' voice-related and general quality of life, and neurologic voice disorders have the greatest impact.
Objectives/Hypothesis: To examine the role of HPV status in the etiology, prognosis, and treatmen... more Objectives/Hypothesis: To examine the role of HPV status in the etiology, prognosis, and treatment of head and neck squamous cell carcinoma in early larynx malignancies. Study Design: Retrospective. Methods: Thirty-eight cases of T1 or carcinoma in situ (CIS) laryngeal lesions were examined for the presence of human papilloma virus (HPV) using an inclusive polymerase chain reaction (PCR)/hybridiza-tion technique capable of identifying 37 HPV subtypes. Results: HPV DNA was detected in 6 (16%) of the 38 lesions, representing HPV types 16, 26, 31, 39, and 52, and p16 tumor suppressor protein expression was confirmed in 10 representative cases. This HPV prevalence is higher than that noted in many previous laryngeal cancer studies, possibly due to the relatively large panel of subtypes screened for in this study. Identification of HPV-26, which has been associated with uterine cervical cancer, in an early laryn-geal cancer specimen represents the first evidence of this subtype in a laryngeal carcinoma. Consistent with reports focusing on head and neck squamous cell carcinoma (HNSCC) arising from other subsites within the upper aerodigestive tract, patients with HPV-positive laryngeal carcinomas were of younger age and were somewhat less likely to have a history of tobacco use, although the latter of the two findings did not reach statistical significance. Conclusions: Our findings emphasize the presence of a broad spectrum of HPV types in a relevant proportion of early laryngeal cancers, and together with evidence of an association of HPV tumor status with a more favorable clinical course, provide a rationale for the routine HPV testing of small larynx lesions.
Owing to their vasodilatory effects, the phosphodiesterase-5 inhibitors have become widely used f... more Owing to their vasodilatory effects, the phosphodiesterase-5 inhibitors have become widely used for the treatment of erectile dysfunction. Among the reported adverse events of these agents are epistaxis, variceal bleeding, intracranial hemorrhage, and hemorrhoidal bleeding. We report a case of vocal fold hemorrhage that occurred after vardenafi l use in a 31-year-old man who was a professional singer.
Objectives. To determine patient compliance with voice rest and the impact of voice rest on quali... more Objectives. To determine patient compliance with voice rest and the impact of voice rest on quality of life (QOL). QOL impact on a 100-mm visual analog scale (VAS), and communication methods were collected from 84 participants from 2 academic voice centers. Results. Of 84 participants, 36.9% were men, 63.1% were women, and 64.3% were singers. The mean age of participants was 47.2 years. The mean duration of voice rest was 8.8 days (range, 3-28), and the median was 7 days. Overall compliance was 34.5%. Postoperative voice rest patients were more compliant than non-postoperative patients (42.4% vs 16.0%, P = .04, c 2). Voice rest had an impact on QOL (mean ± SD, 68.5 ± 27.7). Voice rest also had a greater impact on singers than nonsingers (mean VAS 77.2 vs 63.6, P = .03, t test) and on those age <60 years than those age ≥60 years (mean VAS 74.4 vs 46.7, P < .001, t test). More talkative patients and those with longer periods of voice rest had worse QOL scores (Spear-man correlation = 0.35, P = .001 and Spearman correlation = 0.24, P = .03, respectively). Restrictions in personal and social life were noted in 36.9% of patients, 46.4% were unable to work, 44.0% felt frustrated, and 38.1% reported feeling handicapped while on voice rest. Conclusions. Given poor patient compliance and the significant impact of voice rest on QOL, further studies are warranted to examine the efficacy of voice rest and factors that may contribute to patient noncompliance with treatment.
OBJECTIVES: 1) Evaluate the prevalence and quality-of-life impact of voice and swallowing problem... more OBJECTIVES: 1) Evaluate the prevalence and quality-of-life impact of voice and swallowing problems in the elderly; 2) determine treatment trends and barriers to treatment. STUDY DESIGN: Cross-sectional study of independent-living residents in two retirement communities. Prevalence of dysphonia and dysphagia, voice-related quality of life (VRQOL), 7-point Likert scale of dysphagia severity, Center for Epidemiologic Studies Depression (CES-D) scale, and barriers to treatment were collected. Spearman correlation and ANOVA statistics were performed. RESULTS: A total of 248 residents responded with a mean age of 82.4 years; 19.8 percent had dysphonia, 13.7 percent dysphagia, and 6 percent both. Respondents with more severe swallowing difficulty had greater impairment on the VRQOL (P 0.04, Spearman correlation 0.4). Respondents with both dysphonia and dysphagia had greater depression scores than those with neither symptom (mean CES-D score 15.5 vs 9.9, P 0.009, ANOVA, P 0.05, Bonferroni t test). Only 22.4 percent and 20.6 percent had sought treatment for dysphonia and dysphagia, respectively. Being unaware of treatment options and viewing voice and swallowing trouble as a normal part of aging were the most common reasons for not seeking treatment. CONCLUSIONS: Voice and swallowing problems are common in the elderly, but they are not realizing potential treatment benefits .
OBJECTIVE: To understand how primary care physicians manage patients with dysphonia and the barri... more OBJECTIVE: To understand how primary care physicians manage patients with dysphonia and the barriers they face when evaluating patients for voice problems. STUDY DESIGN: Cross-sectional survey. SETTING: Primary care community. SUBJECTS AND METHODS: A total of 933 internal and family medicine physicians were randomly selected from a database of physicians in a referral basin of a tertiary care medical center and mailed a questionnaire. Questions concerned physician comfort level in recognizing an abnormal voice, their view of the quality of life impact of dysphonia, frequency of evaluating patients for voice problems, barriers to the evaluation of voice problems , reasons for referral, and common treatments prior to referral. RESULTS: A total of 271 physicians responded, for a response rate of 29.0 percent. Of those who responded, 36.5 percent routinely evaluate their patients for voice problems. Reasons for not evaluating patients for voice problems were patients not complaining about hoarseness, more pressing issues, not feeling comfortable assessing patients for voice problems, and time constraints. Chronic voice changes and not being able to understand patients' speech were the most common reasons for referral. Reflux and allergy treatment were common treatment modalities prior to re-ferral. A total of 67.5 percent of respondents were interested in learning more about voice problems. CONCLUSION: Primary care physicians face limitations with respect to evaluating patients for voice problems. Otolaryngologists must continue outreach efforts and collaboration with primary care colleagues in order to enhance the screening for voice problems.
Introduction. Teachers have an increased prevalence of voice disorders that result in reduced act... more Introduction. Teachers have an increased prevalence of voice disorders that result in reduced activities, missed workdays, and occupation changes. However, only a small fraction of these teachers have sought professional help for their disorders. The purpose of this study was to elucidate some of the barriers to care that teachers may face. Study Design. Cross-sectional survey. Methods. One thousand subjects were randomly selected from a list of 95, 364 Kindergarten–12 teachers in North Carolina. Teachers were mailed a 43-item survey, with domains including demographics, personal voice health, and barriers to care using a five-point Likert scale. Results were tabulated, and statistical analysis was performed using the chi-square test. Results. Two hundred forty-three responses were received; 237 were complete. Twenty-two percent were currently hoarse. Fifty-eight percent had been hoarse at one point. Twenty-three percent had missed work for hoarseness. Only one-third (32.6%) had sought professional help. Women and those older than 45 years were more likely to seek help (P < 0.001 and P ¼ 0.008, respectively). Fewer than half were aware of voice therapy or believed that a doctor could help. Thirty percent believed that hoarseness was normal in teaching. Conclusions. There are multiple barriers to care for the dysphonic teacher, including the lack of awareness of the availability of professional help. Further studies should evaluate teacher education and reducing barriers to care.
A B S T R A C T Objective: The prevalence of voice disorders reaches up to 23.4% in the pediatric... more A B S T R A C T Objective: The prevalence of voice disorders reaches up to 23.4% in the pediatric population and has a negative impact on quality of life. The objective of this study is to examine how pediatricians assess and manage patients with voice disorders and barriers they face when evaluating patients with dysphonia. Subjects and methods: The study was designed as a cross-sectional survey. Pediatricians who are members of the North Carolina Pediatric Society or Duke University affiliated physicians were selected to participate in the study. They were emailed a description of the study with a link to a questionnaire regarding comfort level in recognizing an abnormal voice, how often they assess for dysphonia, barriers to evaluation of voice problems, reasons for referral, and common treatments employed. Results: A total of 1125 physicians were sent a questionnaire and 72 replied for a response rate of 6.4%. Of those who responded, only 16.7% routinely assess patients for voice problems. The most common reasons for not assessing patients for dysphonia include patients not complaining of voice problems or parents not concerned, and being unsure of the best method or available treatment options. Referrals were most commonly made when speech could not be understood or when the voice problem coincided with other neurological symptoms. Allergy and reflux medications were often trialed prior to referral. The majority of responders felt that voice problems impacted quality of life and 84.7% were interested in more information regarding pediatric voice problems. Conclusion: Pediatricians encounter barriers in the assessment of voice problems in their patients. There is evidence from our study that they have interest in learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders.
OBJECTIVE: To evaluate the efficacy of voice therapy in the management of vocal fold polyps and c... more OBJECTIVE: To evaluate the efficacy of voice therapy in the management of vocal fold polyps and cysts. STUDY DESIGN AND SETTING: Retrospective review of vocal fold cysts and polyps undergoing voice therapy in a tertiary care center. Symptom resolution or persistence resulting in surgical intervention was the main outcome measure. RESULTS: Fifty-seven patients were identified, of which 49.1% achieved symptom resolution with voice therapy alone. Patients with complete glottal closure and muscle tension dysphonia did not have a better response than those with incomplete glottal closure and without muscle tension dysphonia (P 0.1, 2 , respectively). Patients with translucent polyps more commonly responded to voice therapy than fibrotic, hyaline, or hemorrhagic polyps, 81.8% versus 15.4% and 25.0% response rate, respectively (P 0.002, 2). CONCLUSIONS: Voice therapy is an effective treatment modality for vocal fold polyps and cysts. SIGNIFICANCE: A multidisciplinary approach including a trial of voice therapy is warranted.
Objectives: We developed and validated a disorder-specific health status instrument (Singing Voic... more Objectives: We developed and validated a disorder-specific health status instrument (Singing Voice Handicap Index; SVHI) for use in patients with singing problems. Methods: Prospective instrument validation was performed. Of 81 original items, those with poor statistical validity were eliminated, resulting in 36 items. The ability to discriminate dysphonic from normal singers, test-retest reliability, internal consistency, and construct validity were assessed. Results: We included 112 dysphonic and 129 normal singers, professional and nonprofessional, of classical, country, rock, choral, and gospel repertoire. Dysphonic singers had worse SVHI scores than normal singers (p <, .001, rank sum test). Test-retest reliability was high (Spearman correlation, 0.92; p < .001). Internal consistency demonstrated a Cron-bach's a of .97, and the correlation between the SVHI and self-rated singing voice impairment was .63 (p < .001, Spear-man correlation). Conclusions: The SVHI is a reliable and valid tool for assessing self-perceived handicap associated with singing problems .
OBJECTIVE: This study will determine factors that influence the self-perceived handicap associate... more OBJECTIVE: This study will determine factors that influence the self-perceived handicap associated with singing voice problems. STUDY DESIGN: A prospective cohort. SUBJECT AND METHODS: Singers presenting to a voice clinic prospectively completed the Singing Voice Handicap Index (SVHI) before evaluation and treatment. Demographic data, singing style, professional status, duration of symptoms, medical problems , and diagnosis were collected. Univariate and multivariate analysis was performed. RESULTS: One hundred seventy-one singers completed the SVHI. The duration of symptoms, being an amateur singer or singing teacher, benign vocal fold lesions, and neurologic voice disorders were associated with increased SVHI scores (P 0.05, multiple linear regression). Age greater than 50 years and gospel singing were predictive of increased SVHI scores only on univar-iate analysis (P 0.05, t test). CONCLUSION: Singers experience significant handicap as a result of their singing problems with certain factors associated with greater impairment. Targeting interventions at patients more severely affected may improve outcomes.
Voice disorders can have a drastic impact on the quality of life (QOL) of patients because they a... more Voice disorders can have a drastic impact on the quality of life (QOL) of patients because they adversely affect one of the most basic of facilities: communication. 1,2 Speech is a complex action requiring precise motor control of the upper digestive and respiratory tracts. Speech production relies on several highly integrated factors that Kantner and West 3 divided into (1) respiration, (2) phonation, (3) resonation, (4) articulation, and (5) neurologic integration. Speech begins with respiration, which provides power during exhalation to vibrate the vocal cords, called ''phonation,'' producing a complex tone. This tone is modified by the resonators: the pharyngeal, oral, and nasal cavities. It is then shaped by the movement of the tongue, soft palate, teeth, and lips during articula-tion to arrive at the end result, which is fully formed speech. 4 Voice disorders can be grouped into two main classes depending on the level of the defect: dysarthria and dysphonia. Dysarthria is caused by neurologic damage to the motor components of speech, which may involve any or all of the speech processes, including respiration, phonation, articulation, resonance, and prosody. Dysphonia refers to disordered sound production at the level of the larynx, classically seen as hoarseness. It may have a neurologic, structural, or functional etiology. It is important not to confuse either of these terms with aphasia, which is a disorder of language caused by neurologic damage. Voice disorders have varying lengths of duration and treatment options depending on the underlying etiology. THERAPEUTIC OPTIONS Standard voice therapy for dysphonia aims to rehabilitate the voice whenever possible , meaning to restore normal function. When that is not possible because of the underlying pathology, the aim is to achieve a voice that is as normal as possible, as
Objectives/Hypothesis: To determine the coprevalence of voice problems and hearing loss in the el... more Objectives/Hypothesis: To determine the coprevalence of voice problems and hearing loss in the elderly, to assess whether hearing loss is a risk factor for dysphonia, and to evaluate the quality-of-life impact of dysphonia and hearing loss among the elderly. Study Design: Cross-sectional study of independent living residents in two retirement communities. Methods: Main outcome measures include prevalence of dysphonia and hearing loss, Voice Related Quality of Life (VRQOL), Hearing Handicap Inventory for the Elderly–Screening Version (HHIE-S), and the Center for Epidemiologic Studies Depression (CES-D) scale. Relationships between continuous variables were analyzed with Spearman correlation, between categorical variables with chi-square, and between categorical and continuous variable with analysis of variance (ANOVA) on ranks. Results: A total of 248 residents responded with a mean age of 82.4 years. Of those, 19.8% had dyspho-nia, 50.0% had hearing loss, and 10.5% had both. Respondents with hearing loss were more likely to have dysphonia than those without hearing loss (odds ratio ¼ 2.31, 95% confidence interval, 1.19-4.47). Worse VRQOL scores were associated with more impairment on the HHIE-S (Spearman correlation ¼ À0.36, P < .001). Respondents with both dysphonia and hearing loss had greater depression scores than those with neither symptom (median CES-D score 13 vs. 8, P ¼ .03, ANOVA on ranks, Dunn's method, P < .05). Conclusions: Voice problems and hearing loss are common in the elderly, adversely impact quality of life, and require simultaneous management.
As multidisciplinary cancer treatment evolves, strategies to identify patients needing early rese... more As multidisciplinary cancer treatment evolves, strategies to identify patients needing early resection/salvage are necessary. Some have suggested that vocal cord function after organ-preservation treatment may be an indicator. A retrospective review was performed of patients presenting with fixed or impaired vocal cord function at a tertiary center. Local recurrence rates were examined in patients with and without improved/normal mobilization after treatment. Sixty-nine patients met the inclusion criteria, with 35 patients having vocal cord fixation and 34 patients with impaired mobility. After treatment, 44 patients had normalization of vocal cord function, while 25 patients did not, with 2-year local control rates of 70% and 77%, p = .23, respectively. No difference in local control was found between patients with normalized/improved cord function (n = 53) and those who remained the same/worsened (n = 16; p = .81). Therapy-induced changes in vocal cord mobility did not correlate with local recurrence. Other criteria are needed to identify patients most likely to benefit from early surgical resection/salvage after organ preservation.
Objective. To identify factors related to the health care spending of patients with laryngeal dis... more Objective. To identify factors related to the health care spending of patients with laryngeal disorders.
OBJECTIVE: We sought to explore whether nausea and vomiting are predictive of entrapment. STUDY D... more OBJECTIVE: We sought to explore whether nausea and vomiting are predictive of entrapment. STUDY DESIGN AND SETTING: We retrospectively evaluated the data regarding orbital floor fractures in children younger than 19 years old presenting at a tertiary care center from 1990 to 2001. Zygomatic, naso-orbital ethmoid, and displaced orbital rim fractures were excluded from our analysis. Data on the fracture type, signs and symptoms, ocular mo-tility, surgical repair, and resolution of diplopia were also collected. RESULTS: Twenty-nine orbital floor fractures were identified. One fourth of the children had nausea/ vomiting, and half had trapdoor fractures. Seventeen percent of patients had entrapment of the inferior rectus. The positive predictive value of nau-sea/vomiting with a trapdoor fracture for entrap-ment was 83.3% (P 0.002, Fisher exact test). Half the patients required surgical intervention, most commonly for diplopia or gaze restriction. Gaze impairment did not resolve in 2 patients. CONCLUSION: Patients with trapdoor fractures who present with nausea/vomiting are at a high risk of inferior rectus entrapment and poor outcome. (Oto-laryngol Head Neck Surg 21003;129:000-000) (Otolaryngol Head Neck Surg 2003;129:43-7.)
OBJECTIVE: To compare the quality-of-life (QOL) benefit received from cochlear implants (CIs) and... more OBJECTIVE: To compare the quality-of-life (QOL) benefit received from cochlear implants (CIs) and hearing aids (HAs) among hearing-impaired adults. STUDY DESIGN: Health-related questionnaire. METHODS: Twenty-seven CI users compared to control group of 54 HA users, both older than 49. Questionnaires for the pre-rehab state (without HA or CI use) and post-rehab state (after HA or CI for 12 months) were mailed 2 weeks apart. RESULTS: Twenty-six (96.3%) CI and 30 (55.6%) HA users responded (P < 0.001, chi-square). Compared to HA patients, CI users showed twice as much overall QOL improvement (P 0.082, multiple linear regression) as HA users. Multivariate analysis of variance showed greater QOL benefit in CI than HA users across the physical, psychological, and social subdomains (P 0.03). CONCLUSION: Cochlear implants provide at least comparable benefit for those with profound hearing loss as hearing aids bring for those with less severe hearing loss. (Otolaryngol Head Neck Surg 2004; 131:413-22.)
We report the results of a survey designed to investigate audiologic referral patterns of primary... more We report the results of a survey designed to investigate audiologic referral patterns of primary care physicians and, more specifically, their referral of patients for hearing aids and cochlear implants. Three hundred internal medicine and family medicine physicians were identified from a referral basin of a tertiary care center and chosen randomly to be faxed questionnaires concerning their views about patients with hearing loss, hearing loss screening and referral practices, and availability of local resources. Of the 260 physicians who received a questionnaire, 85 (32.7%) responded. Of their communities (60% of which had populations of fewer than 50,000), 82.4% had an otolaryngologist and 40% had access to an academic center. Although 97.6% of the responding physicians indicated that hearing loss affected patients' quality of life, only 60% assessed patients for hearing loss. "Lack of time " and "morepressing issues " were the most common reasons given for not evaluating patients for hearing loss. Although 76physicians (89.4%) said they were aware of cochlear implants, only 22 (25.9%) had referred patients for implant evaluation. Lack of referral most commonly resulted from uncertainties about "where to refer" and "which patients were potential candidates. " The results of this survey suggest that a large percentage of primary care physicians do not routinely test for hearing impairment in adults.
This study evaluates how extraesophageal reflux affects membranous vocal fold healing in a canine... more This study evaluates how extraesophageal reflux affects membranous vocal fold healing in a canine model. We created membra-nous vocal fold injuries in the animals and randomly assigned them to topical application of acid and pepsin at pH 2 or pH 6 or of normal saline solution every other day for 12 days. The experimental vocal folds were compared to uninjured, control vocal folds troni animals painlessly sacrificed for other reasons. Hematoxylin and eosin. flbronectin. and procollagen I staining were performed for histologic analysis. The injured specimens had three times greater cellular infiltrate (p< .001, analysis of variance) and twice as much fibronectin and procollagen I ip < .001. analysis of variance) as did the speeimens from the control animals. No significant differencesor trends were identified for cellular infiltrate, fibronectin. or procollagen I within the injured groups (p> .05. Bonferroni /-test). Acute wound healing did not appear to be influenced by the presence of acid and pepsin at pH 2 or 6 as compared to saline solution.
Objectives: We undertook to explore the relationship between non-neoplastic voice disorders and p... more Objectives: We undertook to explore the relationship between non-neoplastic voice disorders and patients' quality of life. Methods: A PubMed search (1966 to 2003) for the terms Voice Handicap Index (VHI), Short Form-36 (SF-36), voice disorders, voice quality, treatment outcome, voice outcome, quality of life, and questionnaires was performed. Raw data were obtained whenever possible. Studies were analyzed by meta-analysis techniques. Results: Of 54 VHI studies identified, 11 were excluded, and of 21 SF-36 studies, 7 were excluded for incomplete data, non-English language, measuring malignant disease, or duplicate publication. Patients with neurologic and inflammatory or traumatic laryngeal disease had worse VHI scores than controls, and those with neurologic laryngeal disease had the most severe impairment (p < .001, Kruskal-Wallis analysis of variance; p < .05, Dunn's method of multiple comparisons). Those with neurologic laryngeal disease had worse SF-36 subdomain scores than did controls in 6 of 8 subdomains (p < .03, Kruskal-Wallis analysis of variance; p < .05, Dunn's method of multiple comparisons). Both patients with neurologic disease and patients with inflammatory or traumatic laryngeal disorders had changes in SF-36 subdomains similar to those of patients with other chronic disease states. Conclusions: Non-neoplastic voice disorders adversely impact patients' voice-related and general quality of life, and neurologic voice disorders have the greatest impact.
Objectives/Hypothesis: To examine the role of HPV status in the etiology, prognosis, and treatmen... more Objectives/Hypothesis: To examine the role of HPV status in the etiology, prognosis, and treatment of head and neck squamous cell carcinoma in early larynx malignancies. Study Design: Retrospective. Methods: Thirty-eight cases of T1 or carcinoma in situ (CIS) laryngeal lesions were examined for the presence of human papilloma virus (HPV) using an inclusive polymerase chain reaction (PCR)/hybridiza-tion technique capable of identifying 37 HPV subtypes. Results: HPV DNA was detected in 6 (16%) of the 38 lesions, representing HPV types 16, 26, 31, 39, and 52, and p16 tumor suppressor protein expression was confirmed in 10 representative cases. This HPV prevalence is higher than that noted in many previous laryngeal cancer studies, possibly due to the relatively large panel of subtypes screened for in this study. Identification of HPV-26, which has been associated with uterine cervical cancer, in an early laryn-geal cancer specimen represents the first evidence of this subtype in a laryngeal carcinoma. Consistent with reports focusing on head and neck squamous cell carcinoma (HNSCC) arising from other subsites within the upper aerodigestive tract, patients with HPV-positive laryngeal carcinomas were of younger age and were somewhat less likely to have a history of tobacco use, although the latter of the two findings did not reach statistical significance. Conclusions: Our findings emphasize the presence of a broad spectrum of HPV types in a relevant proportion of early laryngeal cancers, and together with evidence of an association of HPV tumor status with a more favorable clinical course, provide a rationale for the routine HPV testing of small larynx lesions.
Owing to their vasodilatory effects, the phosphodiesterase-5 inhibitors have become widely used f... more Owing to their vasodilatory effects, the phosphodiesterase-5 inhibitors have become widely used for the treatment of erectile dysfunction. Among the reported adverse events of these agents are epistaxis, variceal bleeding, intracranial hemorrhage, and hemorrhoidal bleeding. We report a case of vocal fold hemorrhage that occurred after vardenafi l use in a 31-year-old man who was a professional singer.
Objectives. To determine patient compliance with voice rest and the impact of voice rest on quali... more Objectives. To determine patient compliance with voice rest and the impact of voice rest on quality of life (QOL). QOL impact on a 100-mm visual analog scale (VAS), and communication methods were collected from 84 participants from 2 academic voice centers. Results. Of 84 participants, 36.9% were men, 63.1% were women, and 64.3% were singers. The mean age of participants was 47.2 years. The mean duration of voice rest was 8.8 days (range, 3-28), and the median was 7 days. Overall compliance was 34.5%. Postoperative voice rest patients were more compliant than non-postoperative patients (42.4% vs 16.0%, P = .04, c 2). Voice rest had an impact on QOL (mean ± SD, 68.5 ± 27.7). Voice rest also had a greater impact on singers than nonsingers (mean VAS 77.2 vs 63.6, P = .03, t test) and on those age <60 years than those age ≥60 years (mean VAS 74.4 vs 46.7, P < .001, t test). More talkative patients and those with longer periods of voice rest had worse QOL scores (Spear-man correlation = 0.35, P = .001 and Spearman correlation = 0.24, P = .03, respectively). Restrictions in personal and social life were noted in 36.9% of patients, 46.4% were unable to work, 44.0% felt frustrated, and 38.1% reported feeling handicapped while on voice rest. Conclusions. Given poor patient compliance and the significant impact of voice rest on QOL, further studies are warranted to examine the efficacy of voice rest and factors that may contribute to patient noncompliance with treatment.
OBJECTIVES: 1) Evaluate the prevalence and quality-of-life impact of voice and swallowing problem... more OBJECTIVES: 1) Evaluate the prevalence and quality-of-life impact of voice and swallowing problems in the elderly; 2) determine treatment trends and barriers to treatment. STUDY DESIGN: Cross-sectional study of independent-living residents in two retirement communities. Prevalence of dysphonia and dysphagia, voice-related quality of life (VRQOL), 7-point Likert scale of dysphagia severity, Center for Epidemiologic Studies Depression (CES-D) scale, and barriers to treatment were collected. Spearman correlation and ANOVA statistics were performed. RESULTS: A total of 248 residents responded with a mean age of 82.4 years; 19.8 percent had dysphonia, 13.7 percent dysphagia, and 6 percent both. Respondents with more severe swallowing difficulty had greater impairment on the VRQOL (P 0.04, Spearman correlation 0.4). Respondents with both dysphonia and dysphagia had greater depression scores than those with neither symptom (mean CES-D score 15.5 vs 9.9, P 0.009, ANOVA, P 0.05, Bonferroni t test). Only 22.4 percent and 20.6 percent had sought treatment for dysphonia and dysphagia, respectively. Being unaware of treatment options and viewing voice and swallowing trouble as a normal part of aging were the most common reasons for not seeking treatment. CONCLUSIONS: Voice and swallowing problems are common in the elderly, but they are not realizing potential treatment benefits .
OBJECTIVE: To understand how primary care physicians manage patients with dysphonia and the barri... more OBJECTIVE: To understand how primary care physicians manage patients with dysphonia and the barriers they face when evaluating patients for voice problems. STUDY DESIGN: Cross-sectional survey. SETTING: Primary care community. SUBJECTS AND METHODS: A total of 933 internal and family medicine physicians were randomly selected from a database of physicians in a referral basin of a tertiary care medical center and mailed a questionnaire. Questions concerned physician comfort level in recognizing an abnormal voice, their view of the quality of life impact of dysphonia, frequency of evaluating patients for voice problems, barriers to the evaluation of voice problems , reasons for referral, and common treatments prior to referral. RESULTS: A total of 271 physicians responded, for a response rate of 29.0 percent. Of those who responded, 36.5 percent routinely evaluate their patients for voice problems. Reasons for not evaluating patients for voice problems were patients not complaining about hoarseness, more pressing issues, not feeling comfortable assessing patients for voice problems, and time constraints. Chronic voice changes and not being able to understand patients' speech were the most common reasons for referral. Reflux and allergy treatment were common treatment modalities prior to re-ferral. A total of 67.5 percent of respondents were interested in learning more about voice problems. CONCLUSION: Primary care physicians face limitations with respect to evaluating patients for voice problems. Otolaryngologists must continue outreach efforts and collaboration with primary care colleagues in order to enhance the screening for voice problems.
Introduction. Teachers have an increased prevalence of voice disorders that result in reduced act... more Introduction. Teachers have an increased prevalence of voice disorders that result in reduced activities, missed workdays, and occupation changes. However, only a small fraction of these teachers have sought professional help for their disorders. The purpose of this study was to elucidate some of the barriers to care that teachers may face. Study Design. Cross-sectional survey. Methods. One thousand subjects were randomly selected from a list of 95, 364 Kindergarten–12 teachers in North Carolina. Teachers were mailed a 43-item survey, with domains including demographics, personal voice health, and barriers to care using a five-point Likert scale. Results were tabulated, and statistical analysis was performed using the chi-square test. Results. Two hundred forty-three responses were received; 237 were complete. Twenty-two percent were currently hoarse. Fifty-eight percent had been hoarse at one point. Twenty-three percent had missed work for hoarseness. Only one-third (32.6%) had sought professional help. Women and those older than 45 years were more likely to seek help (P < 0.001 and P ¼ 0.008, respectively). Fewer than half were aware of voice therapy or believed that a doctor could help. Thirty percent believed that hoarseness was normal in teaching. Conclusions. There are multiple barriers to care for the dysphonic teacher, including the lack of awareness of the availability of professional help. Further studies should evaluate teacher education and reducing barriers to care.
A B S T R A C T Objective: The prevalence of voice disorders reaches up to 23.4% in the pediatric... more A B S T R A C T Objective: The prevalence of voice disorders reaches up to 23.4% in the pediatric population and has a negative impact on quality of life. The objective of this study is to examine how pediatricians assess and manage patients with voice disorders and barriers they face when evaluating patients with dysphonia. Subjects and methods: The study was designed as a cross-sectional survey. Pediatricians who are members of the North Carolina Pediatric Society or Duke University affiliated physicians were selected to participate in the study. They were emailed a description of the study with a link to a questionnaire regarding comfort level in recognizing an abnormal voice, how often they assess for dysphonia, barriers to evaluation of voice problems, reasons for referral, and common treatments employed. Results: A total of 1125 physicians were sent a questionnaire and 72 replied for a response rate of 6.4%. Of those who responded, only 16.7% routinely assess patients for voice problems. The most common reasons for not assessing patients for dysphonia include patients not complaining of voice problems or parents not concerned, and being unsure of the best method or available treatment options. Referrals were most commonly made when speech could not be understood or when the voice problem coincided with other neurological symptoms. Allergy and reflux medications were often trialed prior to referral. The majority of responders felt that voice problems impacted quality of life and 84.7% were interested in more information regarding pediatric voice problems. Conclusion: Pediatricians encounter barriers in the assessment of voice problems in their patients. There is evidence from our study that they have interest in learning more about dysphonia. Otolaryngologists must continue to provide outreach to pediatricians to enhance the screening and management of patients with voice disorders.
OBJECTIVE: To evaluate the efficacy of voice therapy in the management of vocal fold polyps and c... more OBJECTIVE: To evaluate the efficacy of voice therapy in the management of vocal fold polyps and cysts. STUDY DESIGN AND SETTING: Retrospective review of vocal fold cysts and polyps undergoing voice therapy in a tertiary care center. Symptom resolution or persistence resulting in surgical intervention was the main outcome measure. RESULTS: Fifty-seven patients were identified, of which 49.1% achieved symptom resolution with voice therapy alone. Patients with complete glottal closure and muscle tension dysphonia did not have a better response than those with incomplete glottal closure and without muscle tension dysphonia (P 0.1, 2 , respectively). Patients with translucent polyps more commonly responded to voice therapy than fibrotic, hyaline, or hemorrhagic polyps, 81.8% versus 15.4% and 25.0% response rate, respectively (P 0.002, 2). CONCLUSIONS: Voice therapy is an effective treatment modality for vocal fold polyps and cysts. SIGNIFICANCE: A multidisciplinary approach including a trial of voice therapy is warranted.
Objectives: We developed and validated a disorder-specific health status instrument (Singing Voic... more Objectives: We developed and validated a disorder-specific health status instrument (Singing Voice Handicap Index; SVHI) for use in patients with singing problems. Methods: Prospective instrument validation was performed. Of 81 original items, those with poor statistical validity were eliminated, resulting in 36 items. The ability to discriminate dysphonic from normal singers, test-retest reliability, internal consistency, and construct validity were assessed. Results: We included 112 dysphonic and 129 normal singers, professional and nonprofessional, of classical, country, rock, choral, and gospel repertoire. Dysphonic singers had worse SVHI scores than normal singers (p <, .001, rank sum test). Test-retest reliability was high (Spearman correlation, 0.92; p < .001). Internal consistency demonstrated a Cron-bach's a of .97, and the correlation between the SVHI and self-rated singing voice impairment was .63 (p < .001, Spear-man correlation). Conclusions: The SVHI is a reliable and valid tool for assessing self-perceived handicap associated with singing problems .
OBJECTIVE: This study will determine factors that influence the self-perceived handicap associate... more OBJECTIVE: This study will determine factors that influence the self-perceived handicap associated with singing voice problems. STUDY DESIGN: A prospective cohort. SUBJECT AND METHODS: Singers presenting to a voice clinic prospectively completed the Singing Voice Handicap Index (SVHI) before evaluation and treatment. Demographic data, singing style, professional status, duration of symptoms, medical problems , and diagnosis were collected. Univariate and multivariate analysis was performed. RESULTS: One hundred seventy-one singers completed the SVHI. The duration of symptoms, being an amateur singer or singing teacher, benign vocal fold lesions, and neurologic voice disorders were associated with increased SVHI scores (P 0.05, multiple linear regression). Age greater than 50 years and gospel singing were predictive of increased SVHI scores only on univar-iate analysis (P 0.05, t test). CONCLUSION: Singers experience significant handicap as a result of their singing problems with certain factors associated with greater impairment. Targeting interventions at patients more severely affected may improve outcomes.
Voice disorders can have a drastic impact on the quality of life (QOL) of patients because they a... more Voice disorders can have a drastic impact on the quality of life (QOL) of patients because they adversely affect one of the most basic of facilities: communication. 1,2 Speech is a complex action requiring precise motor control of the upper digestive and respiratory tracts. Speech production relies on several highly integrated factors that Kantner and West 3 divided into (1) respiration, (2) phonation, (3) resonation, (4) articulation, and (5) neurologic integration. Speech begins with respiration, which provides power during exhalation to vibrate the vocal cords, called ''phonation,'' producing a complex tone. This tone is modified by the resonators: the pharyngeal, oral, and nasal cavities. It is then shaped by the movement of the tongue, soft palate, teeth, and lips during articula-tion to arrive at the end result, which is fully formed speech. 4 Voice disorders can be grouped into two main classes depending on the level of the defect: dysarthria and dysphonia. Dysarthria is caused by neurologic damage to the motor components of speech, which may involve any or all of the speech processes, including respiration, phonation, articulation, resonance, and prosody. Dysphonia refers to disordered sound production at the level of the larynx, classically seen as hoarseness. It may have a neurologic, structural, or functional etiology. It is important not to confuse either of these terms with aphasia, which is a disorder of language caused by neurologic damage. Voice disorders have varying lengths of duration and treatment options depending on the underlying etiology. THERAPEUTIC OPTIONS Standard voice therapy for dysphonia aims to rehabilitate the voice whenever possible , meaning to restore normal function. When that is not possible because of the underlying pathology, the aim is to achieve a voice that is as normal as possible, as
Objectives/Hypothesis: To determine the coprevalence of voice problems and hearing loss in the el... more Objectives/Hypothesis: To determine the coprevalence of voice problems and hearing loss in the elderly, to assess whether hearing loss is a risk factor for dysphonia, and to evaluate the quality-of-life impact of dysphonia and hearing loss among the elderly. Study Design: Cross-sectional study of independent living residents in two retirement communities. Methods: Main outcome measures include prevalence of dysphonia and hearing loss, Voice Related Quality of Life (VRQOL), Hearing Handicap Inventory for the Elderly–Screening Version (HHIE-S), and the Center for Epidemiologic Studies Depression (CES-D) scale. Relationships between continuous variables were analyzed with Spearman correlation, between categorical variables with chi-square, and between categorical and continuous variable with analysis of variance (ANOVA) on ranks. Results: A total of 248 residents responded with a mean age of 82.4 years. Of those, 19.8% had dyspho-nia, 50.0% had hearing loss, and 10.5% had both. Respondents with hearing loss were more likely to have dysphonia than those without hearing loss (odds ratio ¼ 2.31, 95% confidence interval, 1.19-4.47). Worse VRQOL scores were associated with more impairment on the HHIE-S (Spearman correlation ¼ À0.36, P < .001). Respondents with both dysphonia and hearing loss had greater depression scores than those with neither symptom (median CES-D score 13 vs. 8, P ¼ .03, ANOVA on ranks, Dunn's method, P < .05). Conclusions: Voice problems and hearing loss are common in the elderly, adversely impact quality of life, and require simultaneous management.
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Papers by S. Cohen