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Objectives/hypothesis: The Voice Handicap Index-10 (VHI-10) is commonly used to measure patients' perception of vocal handicap. Clinical consensus has previously defined clinically meaningful improvement as a decrease ≥5. This study determines the minimal clinically important difference (MCID) for VHI-10 in patients with unilateral vocal fold paralysis (UVFP) using anchor-based methodology., Study Design: Prospective cohort questionnaire analysis., Methods: Two hundred eighty-one UVFP patients completed the VHI-10 on two consecutive visits (within 3 months). At the follow-up visit, patients answered an 11-point Global Rating of Change Questionnaire (GRCQ) scored from -5 to +5. Relationship between the GRCQ and change in VHI-10 was quantified using analysis of variance, and MCID for the VHI-10 was determined using receiver operating characteristic (ROC) curve analysis., Results: Overall mean VHI-10 change was -3.71 (standard deviation [SD] = 8.89) and mean GRCQ was 1.37 (SD = 2.51). Average interval between measurements was 1.73 months (SD = 0.83). Mean changes in VHI-10 scores were -7.45, -0.53, and +4.40 for patients whose GRCQ scores indicated improvement, no change, and worsening, respectively. Differences between mean scores were statistically significant (P < .001). Area under the ROC curve was 0.80, demonstrating the classification accuracy of VHI-10 change scores. A VHI-10 change of -4 was determined to be the optimal threshold that discriminated between improvement and no improvement (sensitivity and specificity 0.62 and 0.88, respectively)., Conclusions: The MCID for improvement in VHI-10 in UVFP patients is a decrease of 4. This information improves understanding of patients' response to treatment and allows comparison between different treatments. Future research should determine MCID for VHI-10 across all voice disorders., Level of Evidence: 4. Laryngoscope, 128:1419-1424, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: At presentation, unilateral vocal fold paralysis (UVFP) patients have different treatment options, including conservative management (CM), injection laryngoplasty (IL) with a temporary agent, or permanent medialization (PM). This study evaluates long-term outcomes for UVFP patients relative to intervention., Study Design: Retrospective chart review., Methods: A retrospective chart review was performed of UVFP patients who presented to the University of California San Francisco Voice and Swallowing Center. Videolaryngostroboscopy examinations were reviewed. Maximum glottic closure was quantified with the normalized glottic gap area (NGGA). Perceptual voice analysis was performed using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) at corresponding time points., Results: Fifty-three patients met inclusion criteria. Six underwent CM only, 20 went on to require PM, 19 underwent IL only, and eight underwent IL and subsequent PM. NGGA at presentation was similar among groups; however, the CM group was noted to have more favorable CAPE-V scores for Breathiness (P = .007) and Loudness (P = .018). All groups had similar NGGA and CAPE-V scores at last follow-up. When compared to pooled data for patients who underwent PM, the IL group was noted to have similar NGGA and CAPE-V scores at presentation. Although improvements in both groups were noted following intervention, both groups appeared similar at last follow-up with the exception of Roughness, for which the IL group retained a slightly improved outcome (13.3 vs. 18.3, P = .03)., Conclusions: At presentation, UVFP patients have similar NGGA. This finding suggests that treatment recommendations cannot be made on the size of the glottic gap alone. Furthermore, in many patients, IL results in long-term benefit with glottic closure and CAPE-V scores equivalent to that obtained with PM., Level of Evidence: 4. Laryngoscope, 128:430-436, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Benign midmembranous vocal fold lesions (BMVFLs) are common voice disorders, but interpretation of outcomes following treatment is difficult due to the lack of a standardized nomenclature system for these lesions. Outcome results are increasingly important to third party payers. This study aimed to investigate the outcomes of patients with BMVFLs using a previously validated nomenclature, and to provide incidences and outcome results for each diagnosis., Methods: A retrospective chart review of BMVFL patients was performed. Treatment was individualized but typically involved implementation of nonsurgical therapy followed by phonomicrosurgery as needed. A previously reported BMVFL stratification system was used., Results: A total of 224 patients with BMVFLs were studied. Sixty-seven percent of all patients with a BMVFL underwent phonomicrosurgery. The most common BMVFL types were polyp and nonspecific vocal fold lesion. Pseudocyst represented 0.9% of the cohort. The Voice Handicap Index-10 (VHI-10) and acoustic data demonstrate a high degree of treatment success. The mean change in VHI-10 was greatest for cyst-subepithelial and polyp. Fibrous mass-ligamentous patients had the smallest mean change in VHI-10. Mean post-treatment VHI-10 scores of all the lesions except fibrous mass-ligamentous were within normal limits (<11)., Conclusions: This study represents the first outcomes-based report of BMVFLs using a strictly defined nomenclature system for stratification of lesions. Ligamentous fibrous mass lesions have a decreased response to treatment compared to all other lesions. This study demonstrates the ability to return most BMVFL patients to normal speaking voice capabilities following treatment., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: 1) Present phonatory aerodynamic data for healthy controls (HCs) in connected speech; 2) contrast these findings between HCs and patients with nontreated unilateral vocal fold paralysis (UVFP); 3) present pre- and post-vocal fold augmentation outcomes for patients with UVFP; 4) contrast data from patients with post-operative laryngeal augmentation to HCs., Study Design: Retrospective, single-blinded., Methods: For phase I, 20 HC participants were recruited. For phase II, 20 patients with UVFP were age- and gender-matched to the 20 HC participants used in phase I. For phase III, 20 patients with UVFP represented a pre- and posttreatment cohort. For phase IV, 20 of the HC participants from phase I and 20 of the postoperative UVFP patients from phase III were used for direct comparison. Aerodynamic measures captured from a sample of the Rainbow Passage included: number of breaths, mean phonatory airflow rate, total duration of passage, inspiratory airflow duration, and expiratory airflow duration. The VHI-10 was also obtained pre- and postoperative laryngeal augmentation., Results: All phonatory aerodynamic measures were significantly increased in patients with preoperative UVFP than the HC group. Patients with laryngeal augmentation took significantly less breaths, had less mean phonatory airflow rate during voicing, and had shorter inspiratory airflow duration than the preoperative UVFP group. None of the postoperative measures returned to HC values. Significant improvement in the Voice Handicap Index-10 scores postlaryngeal augmentation was also found., Conclusions: Methodology described in this study improves upon existing aerodynamic voice assessment by capturing characteristics germane to UVFP patient complaints and measuring change before and after laryngeal augmentation in connected speech., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: This study investigated financial and treatment implications of a speech-language pathologist (SLP) performing a voice evaluation at the initial laryngologic visit., Study Design: Retrospective chart review., Methods: Medical records from 75 consecutive adult voice therapy patients during a 3-month period were categorized into two groups: group 1 (n = 37) represented patients who underwent a medical speech evaluation (MSE) at the initial voice assessment with the laryngologist (+SLP), and group 2 (n = 38) represented patients who did not receive an MSE (-SLP). Data collected included age, gender, voice diagnosis, number of therapy sessions attended and cancelled, reason for discharge, and pre- and post-voice therapy Voice Handicap Index-10 (VHI-10) scores., Results: Patients in the +SLP group had fewer cancellations (P = 0.001), greater change in VHI-10 from pre- to post-therapy (P = .001), and were more likely to be discharged from therapy having met therapeutic goals (P = .007) than patients in the -SLP group. In addition, lost revenue over 3 months due to cancellations/no-shows was $2,260 in the +SLP group compared to $7,030 in the -SLP group (P < .001)., Conclusions: Concurrent voice evaluation by an SLP and laryngologist at initial diagnostic visit affects therapy attendance, voice therapy outcomes, and ultimately SLP and departmental billing revenue. Results may be due to more appropriate therapy referrals from SLP assessment of patients in conjunction with a laryngologist., Level of Evidence: 4., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To develop and validate a cough severity index (CSI) which quantifies patients' symptoms associated with upper airway chronic cough and to provide a tool for treatment outcome measures., Methods: Two hundred patients who had a complaint of chronic cough and/or dyspnea were given a 49- item questionnaire developed through a clinical consensus of the most common symptoms of chronic cough of upper airway origin. The instrument was reduced to 10 questions using statistical methodology. Fifty subsequent patients were given the CSI to measure test-retest reliability at two different moments in time. Twenty healthy controls (HC) were given the instrument to obtain validity. An additional 95 participants provided pre- and posttreatment outcomes using the CSI., Results: Principle Component Analysis (PCA) revealed a single factor with the original 49 questions. A combination of PCA, rank-ordering item-total correlation and communality, as well as clinical consensus further reduced the questionnaire to 10 items. Internal consistency of the CSI was 0.97. Test-retest reliability was r = 0.83. An r = 0.60 for divergent validity between the CSI and the Cough-Specific Quality-of-Life Questionnaire (CQLQ) demonstrated two fairly separate instruments, although both measured cough. Mann-Whitney test was significant between symptomatic patients and healthy controls (P < 0.0004). The results of 20 HC showed a mean of 0.45 (standard deviation = 1.39). Results for treatment outcomes revealed significance with the Wilcoxon test (P < 0.0001) and paired samples t test showed significantly different correlations between pre- and postmeasures., Conclusion: The CSI is a short, simple instrument that can be used in the clinical setting to quantify a patient's symptoms of chronic cough of upper airway origin. It represents a statistically reliable, valid, and clinically relevant instrument that can be used to measure treatment outcomes for chronic cough., (© 2012 The American Laryngological, Rhinological and Otological Society, Inc.)

Olfactory neuroblastomas are rare tumors whose clinical prognosis is not predictable by assessment of initial stage or grade. The pathologic diagnosis is often difficult because of the wide range of the patient's age and histologies. In this report, we document that the diagnosis of olfactory neuroblastoma can be clarified by immunohistochemical demonstration of a unique antigenic profile that can be obtained in routinely processed biopsies. We describe four cases of olfactory neuroblastoma diagnosed and treated from 1979 to 1989, each confirmed by immunohistology. One of our patients was misdiagnosed twice at an outside institution, first as having nasopharyngeal carcinoma and then as having small-cell, undifferentiated "oat cell" carcinoma. Despite accurate tumor diagnosis and appropriate therapy, we found that there was no apparent correlation of clinical outcome with Kadish clinical stage or histologic grade of tumor.