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This cross-sectional study evaluates the association of sociodemographic characteristics and care utilization with improved voice function among a large sample of older US adults.

Literature review of patient-reported outcome (PRO) measures after surgical intervention for unilateral vocal fold paralysis (UVFP). The majority of studies focus on resolution of dysphonia, dyspnea, and dysphagia, while few studies focus on psychosocial dimensions. Overall, voice-related PRO measures improve after all interventions; however, they do not normalize to pre-UVFP levels, as issues remain with singing, loud speech, and high-vocal-demand activities. All voice-related PRO measures have comparable improvement across all interventions. Dyspnea symptoms are common after UVFP; however, studies evaluating dyspnea-related PRO measures are not. Symptoms improve after interventions, but do not fully resolve in activities with high physical demand. All dysphagia-related PRO measures are associated with improvement after all types of interventions. Patient-reported symptoms, diet advancement, and decline in prevalence of aspiration are achieved in the majority of patients, though persistent diet modification and compensatory strategies continue to be employed by most. UVFP interventions result in meaningful patient-reported improvements in voice, breathing, and swallow aspects, though do not normalize to pre-UVFP levels. Further PRO measure studies are needed to improve patient-centered care for UVFP.

Health and medical contexts have emerged as an important area of inquiry for researchers at the intersection of user experience and technical communication. In addressing this intersection, this article advocates and extends patient experience design or PXD ( Melonçon, 2017 ) as an important framework for user experience research within health and medicine. Specifically, this article presents several PXD insights from a task-based usability study that examined an online intervention program for people with voice problems. We respond to Melonçon's call ( 2017 ) to build PXD as a framework for user experience and technical communication research by describing ways traditional usability methods can provide PXD insights and asking the following question: What insights can emerge from combining traditional usability methods and PXD research? In addressing this question, we outline two primary methodological and practical considerations we found central to conducting PXD research: (1) engaging patients as participants, and (2) leveraging multidisciplinary collaboration.

To compare patient responses to validated satisfaction surveys for in-person vs virtual otolaryngology ambulatory evaluation.National Research Corporation (NRC) Health patient survey answers between April 2020 and February 2021 were divided into in-person and virtual visit modalities. Responses were compared with two group t-tests or Wilcoxon rank sum tests. Relationships between visit modality by gender, age, race, and sub-specialty visit type and satisfaction scores were examined by testing interactions with separate ANOVA models.1242 in-person and 216 virtual patient satisfaction survey responses were highly favorable for all themes (communication, comprehension of treatment plan, and likelihood of future referral) with both visit modalities. Higher satisfaction for in-person evaluation was seen with communication ("care providers listened" 3.68 (0.67)-on a scale of 1-no to 4-yes, definitely) vs 3.57 (0.78), p = 0.0426; "courtesy/respect" 3.75 (0.62) vs 3.66 (0.69), p = 0.0265)), and comprehension of treatment plan ("enough info about treatment" 3.53 (0.79) vs 3.37 (0.92), p = 0.0120; "know what to do" 3.62 (0.76) vs 3.46 (0.88), p = 0.0023)). No differences were detected for future referral of clinic or provider. There was no association between visit modality and patient sociodemographic factors or sub-specialty visit types. Main effects were observed with respect to race, gender, and sub-specialty visit type.Patient satisfaction scores for virtual visit evaluation were high and comparable to in-person evaluation, with a slight preference for in-person. Future studies are needed to identify which patients and conditions are particularly suited for virtual vs in-person delivery of otolaryngology services.

This study examined the relationship between dysphagia and adverse outcomes across frailty conditions among surgical patients ≥50 years of age. A retrospective cohort analysis of surgical hospitalizations in the Healthcare Cost and Utilization Project's National Inpatient Sample among patients ≥50 years of age undergoing intermediate/high risk surgery not involving the larynx, pharynx, or esophagus. Of 3,298,835 weighted surgical hospitalizations, dysphagia occurred in 1.2% of all hospitalizations and was higher in frail patients ranging from 5.4% to 11.7%. Dysphagia was associated with greater length of stay, higher total costs, increased non-routine discharges, and increased medical/surgical complications among both frail and non-frail patients. Dysphagia may be an independent risk factor for poor postoperative outcomes among surgical patients ≥50 years of age across frailty conditions and is an important consideration for providers seeking to reduce risk in vulnerable surgical populations.

OBJECTIVE To compare healthcare utilization in voice patients with versus without mental health (MH) diagnoses STUDY DESIGN: Retrospective study using electronic medical records from large regional healthcare system. METHODS We examined data on sociodemographic characteristics, comorbidities, voice-related diagnoses, and patterns of healthcare utilization (including medication use, tests and procedures, and outpatient visits). The study period spanned January 2005 through June 2017. RESULTS A total of 24,672 patients had at least one voice-related diagnosis. Of these, 11,483 (47%) also had at least one MH diagnosis compared to 14% in the overall repository (P

Objectives: Voice handicap has generally been measured at a single timepoint. Little is known about its variability from hour to hour or day to day. Voice handicap has been shown to be negatively related to voice-related perceived control in cross-sectional studies, but the within-person variability in voice-related perceived control is also unknown. We aimed to use ecological momentary assessment (EMA) to (1) assess the feasibility of EMA to examine daily voice handicap and voice-related perceived control in patients with voice disorders, (2) measure within-person variability in daily voice handicap and perceived control, and (3) characterize temporal associations (eg, correlations over time) between daily voice handicap and perceived control. Methods: Adults with voice problems were recruited from a large public university medical center in the Midwest. They completed baseline measures, followed by twice-daily assessments, including selected items measuring voice handicap and perceived control, and then repeated the baseline measures at the final timepoint. Feasibility was assessed via completion rates. Within-person variability was measured using standard deviations. Temporal associations were characterized using simulation modeling analysis. Results: EMA of voice handicap and perceived control was feasible in this patient population. Momentary voice handicap varied more than perceived control, though both were variable. Multiple patterns of temporal associations between daily voice handicap and perceived control were found. Conclusions: These findings identified important variability in (1) measures of voice handicap and perceived control and (2) their associations over time. Future EMA studies in patients with voice disorders are both feasible and warranted.

OBJECTIVES: 1) To examine the association between vocal fold paresis/paralysis (VFP) and poor swallowing outcomes in a thoracic surgery cohort at the population level, and 2) to assess utilization of ENT/speech language pathology intervention in these cases. METHODS: The National Inpatient Sample (NIS) represents a 20% stratified sample of discharges from US hospitals. Using ICD-9 codes, discharges undergoing general thoracic surgical procedures between 2008 and 2013 were identified in the NIS. Sub-cohorts of discharges with VFP and those who utilized ENT/SLP services were also identified. Weighted logistic regression models were used to compare binary outcomes such as dysphagia, aspiration pneumonia, and other complications; generalized linear models with generalized estimating equations (GEE) were used to compare total hospital costs and length of stay (LOS). RESULTS: We identified a weighted estimate of 673,940 discharges following general thoracic surgery procedures. The weighted frequency of VFP was 3,738 (0.55%). Compared to those without VFP, patients who discharged with VFP had increased odds of dysphagia (6.56, CI 95% 5.07–8.47), aspiration pneumonia (2.54, CI 95% 1.74–3.70), post-operative tracheotomy (3.10, CI 95% 2.16–4.45), and gastrostomy tube requirement (2.46, CI 95% 1.66–3.64). Discharges with VFP also had a longer length of stay and total hospital costs. Of the discharges with VFP, 15.7% received ENT/SLP intervention. CONCLUSION: VFP after general thoracic procedures is associated with negative swallowing-related health outcomes and higher costs. Despite these negative impacts, most patients with VFP do not receive ENT/SLP intervention, identifying a potential opportunity for improving adverse swallowing-related outcomes.

Background Web-based health interventions are increasingly common and are promising for patients with voice disorders because web-based participation does not require voice use. To address needs such as Health Insurance Portability and Accountability Act compliance, unique user access, the ability to send automated reminders, and a limited development budget, we used the Research Electronic Data Capture (REDCap) data management platform to deliver a patient-facing psychological intervention designed for patients with voice disorders. This was a novel use of REDCap. Objective We aimed to evaluate the usability of the intervention, with this intervention serving as a use case for REDCap-based patient-facing interventions. Methods We used REDCap survey instruments to develop the web-based voice intervention modules, then conducted usability evaluations using (1) heuristic evaluations by 2 evaluators, and (2) formal usability testing with 7 participants, consisting of predetermined tasks, a think-aloud protocol, ease-of-use measurements, a product reaction card, and a debriefing interview. Results Heuristic evaluations found strengths in visibility of system status and real-world match, and weaknesses in user control and help documentation. Based on this feedback, changes to the intervention were made before usability testing. Overall, usability testing participants found the intervention useful and easy to use, although testing revealed some concerns with design, content, and terminology. Some concerns were readily addressed, and others required adaptations within REDCap. Conclusions The REDCap version of a complex web-based patient-facing intervention performed well in heuristic evaluation and formal usability testing. REDCap can effectively be used for patient-facing intervention delivery, particularly if the limitations of the platform are anticipated and mitigated.

BACKGROUND Web-based health interventions are increasingly common and are promising for patients with voice disorders because web-based participation does not require voice use. To address needs such as Health Insurance Portability and Accountability Act compliance, unique user access, the ability to send automated reminders, and a limited development budget, we used the Research Electronic Data Capture (REDCap) data management platform to deliver a patient-facing psychological intervention designed for patients with voice disorders. This was a novel use of REDCap. OBJECTIVE We aimed to evaluate the usability of the intervention, with this intervention serving as a use case for REDCap-based patient-facing interventions. METHODS We used REDCap survey instruments to develop the web-based voice intervention modules, then conducted usability evaluations using (1) heuristic evaluations by 2 evaluators, and (2) formal usability testing with 7 participants, consisting of predetermined tasks, a think-aloud protocol, ease-of-use measurements, a product reaction card, and a debriefing interview. RESULTS Heuristic evaluations found strengths in visibility of system status and real-world match, and weaknesses in user control and help documentation. Based on this feedback, changes to the intervention were made before usability testing. Overall, usability testing participants found the intervention useful and easy to use, although testing revealed some concerns with design, content, and terminology. Some concerns were readily addressed, and others required adaptations within REDCap. CONCLUSIONS The REDCap version of a complex web-based patient-facing intervention performed well in heuristic evaluation and formal usability testing. REDCap can effectively be used for patient-facing intervention delivery, particularly if the limitations of the platform are anticipated and mitigated.

INTRODUCTION: The impact of dysphagia in persons with lung cancer is unknown. The objective of this study is to measure the prevalence and survival differences associated with dysphagia in older adults with lung cancer. MATERIALS AND METHODS: Linked SEER cancer registries - Medicare data, 1991–2009 was utilized to identify 201,674 persons with lung cancer. Most were male (53%), had regional or distant disease (74%), and were aged

OBJECTIVES Voice patients with voice disorders have a high prevalence of distress and mental health (MH) comorbidities, but it is unknown to what extent distress precedes or follows voice disorder diagnoses. Objectives were to compare 1) proportions of voice patients with MH diagnoses who received MH diagnoses first versus voice-related diagnoses first, 2) voice-related diagnoses and care utilization, and 3) time to specialty evaluation in each group. METHODS Patients with voice and MH diagnoses were identified using International Classification of Diseases, Ninth and Tenth Revisions codes in a large health system data repository from January 2005 through July 2017. Sociodemographics, comorbidities, MH- and voice-related diagnoses, and voice-related care utilization were analyzed using descriptive statistics and multivariable regression modeling. RESULTS Among the 11,419 patients with both voice and MH diagnoses, 63% (n = 7,251) received MH diagnoses prior to voice diagnoses, compared with 37% with a voice diagnosis first (P

Objective The purpose of the study was to replicate and extend previous research on the relation between perceived present control and voice handicap and to further examine the psychometric properties of a present control scale adapted for patients with voice disorders (Misono, Meredith, Peterson, & Frazier, 2016). Method Sample 1 consisted of 1,129 patients recruited from a voice disorder clinic who completed measures of perceived present control, distress, and voice handicap in the clinic. Sample 2 consisted of 62 patients from the same clinic who completed measures of present control, distress, voice handicap, and general control beliefs online at baseline and measures of present control and voice handicap again 3 weeks later (n = 59). Results With regard to the psychometric properties of the voice-adapted present control scale, alpha coefficients were above .80 and the 3-week test-reliability coefficient was .69. There was mixed support for the hypothesized 1-factor structure of the scale. In Sample 1, present control was more strongly associated with lower voice handicap than was distress and accounted for significant variance in voice handicap controlling for distress. In Sample 2, present control at baseline predicted later voice handicap, controlling for general control beliefs and distress. Conclusions Present control appears to be a promising target for adjunctive interventions for patients with voice disorders. An evidence-based online present control intervention (Hintz, Frazier, & Meredith, 2015) is being adapted for this patient population. (PsycINFO Database Record

OBJECTIVES 1) To compare laryngeal diagnoses from general medical providers (GMP) to otolaryngologists following GMP-based medication trial, and 2) to evaluate associations between GMP medication trials and pharmacologic treatment by otolaryngologists. METHODS Retrospective cohort analysis using large, national administrative U.S. claims database. Patients with laryngeal/voice disorders as per the International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2010, to December 31, 2012, seen by a GMP and then an otolaryngologist between 2 weeks to 3 months after the GMP visit, were included. Patient demographics, comorbid conditions, medication use, and initial GMP and otolaryngology laryngeal diagnoses were collected. Logistic regression was performed to evaluate the association between GMP and otolaryngologist medication trials. RESULTS A total of 12,475 unique laryngeal/voice-disordered patients met inclusion criteria. At the initial GMP visit, 15.3% received an antibiotic, 14.0% a proton pump inhibitor (PPI), and 7.7% an oral steroid. After the otolaryngology visit, increased diagnoses of vocal fold paralysis/paresis, benign vocal fold/laryngeal pathology, chronic laryngitis, and multiple diagnoses occurred. The adjusted odds for an otolaryngologist prescribing an antibiotic, PPI, or oral steroid, respectively, given that a GMP prescribed an antibiotic, PPI, or oral steroid, was roughly two to three times higher that of a GMP not prescribing the given medication. CONCLUSION Patients with structural and neuromuscular laryngeal disorders were treated with medications by GMPs, and similar mediations often were repeated after otolaryngology evaluation. These findings suggest potential areas of unnecessary pharmacologic treatment of laryngeal/voice-disordered patients. LEVEL OF EVIDENCE 2b. Laryngoscope, 128:682-689, 2018.

Objective To identify factors associated with the likelihood of attending voice therapy among patients referred for it in the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure. Study Design Prospectively enrolled cross-sectional study. Setting CHEER network of community and academic sites. Methods Data were collected on patient-reported demographics, voice-related diagnoses, voice-related handicap (Voice Handicap Index-10), likelihood of attending voice therapy (VT), and opinions on factors influencing likelihood of attending VT. The relationships between patient characteristics/opinions and likelihood of attending VT were investigated. Results A total of 170 patients with various voice-related diagnoses reported receiving a recommendation for VT. Of those, 85% indicated that they were likely to attend it, regardless of voice-related handicap severity. The most common factors influencing likelihood of VT attendance were insurance/copay, relief that it was not cancer, and travel. Those who were not likely to attend VT identified, as important factors, unclear potential improvement, not understanding the purpose of therapy, and concern that it would be too hard. In multivariate analysis, factors associated with greater likelihood of attending VT included shorter travel distance, age (40-59 years), and being seen in an academic practice. Conclusions Most patients reported plans to attend VT as recommended. Patients who intended to attend VT reported different considerations in their decision making from those who did not plan to attend. These findings may inform patient counseling and efforts to increase access to voice care.

To assess perspectives of patients with voice problems and identify factors associated with the likelihood of referral to voice therapy via the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure.Prospectively enrolled cross-sectional study of CHEER patients seen for a voice problem (dysphonia).The CHEER network of community and academic sites.Patient-reported demographic information, nature and severity of voice problems, clinical diagnoses, and proposed treatment plans were collected. The relationship between patient factors and voice therapy referral was investigated.Patients (N = 249) were identified over 12 months from 10 sites comprising 30 otolaryngology physicians. The majority were women (68%) and white (82%). Most patients reported a recurrent voice problem (72%) and symptom duration4 weeks (89%). The most commonly reported voice-related diagnoses were vocal strain, reflux, and benign vocal fold lesions. Sixty-seven percent of enrolled patients reported receiving a recommendation for voice therapy. After adjusting for sociodemographic and other factors, diagnoses including vocal strain/excessive tension and vocal fold paralysis and academic practice type were associated with increased likelihood of reporting a referral for voice therapy.The CHEER network successfully enrolled a representative sample of patients with dysphonia. Common diagnoses were vocal strain, reflux, and benign vocal fold lesions; commonly reported treatment recommendations included speech/voice therapy and antireflux medication. Recommendation for speech/voice therapy was associated with academic practice type.

Although an association between psychosocial distress (depression, anxiety, somatization, and perceived stress) and voice disorders has been observed, little is known about the relationship between distress and patient-reported voice handicap. Furthermore, the psychological mechanisms underlying this relationship are poorly understood. Perceived control plays an important role in distress associated with other medical disorders. The objectives of this study were to (1) characterize the relationship between distress and patient-reported voice handicap and (2) examine the role of perceived control in this relationship.This is a cross-sectional study in a tertiary care academic voice clinic.Distress, perceived stress, voice handicap, and perceived control were measured using established assessment scales. Association was measured with Pearson correlation coefficients; moderation was assessed using multiple hierarchical regression.A total of 533 patients enrolled. Thirty-four percent of the patients met criteria for clinically significant distress (ie, depression, anxiety, and/or somatization). A weak association (r = 0.13; P = 0.003) was observed between severity of psychosocial distress and vocal handicap. Present perceived control was inversely associated with distress (r = -0.41; P 0.0001), stress (r = -0.30; P 0.0001), and voice handicap (r = -0.30; P 0.0001). The relationship between voice handicap and psychosocial distress was moderated by perceived control (b for interaction term, -0.15; P 0.001); greater vocal handicap was associated with greater distress in patients with low perceived control.Severity of distress and vocal handicap were positively related, and the relation between them was moderated by perceived control. Vocal handicap was more related to distress among those with low perceived control; targeting this potential mechanism may facilitate new approaches for improved care.

Objectives/hypothesis Prior studies have observed a high prevalence of psychosocial distress, including depression, in patients with voice problems. However, these studies have largely been performed in care-seeking patients identified in tertiary care voice clinics. The objective of this study was to examine the association between depression and voice problems in the U.S. Study design Cross-sectional analysis of National Health Interview Survey (NHIS) data. Methods We identified adult cases reporting a voice problem in the preceding 12 months in the 2012 NHIS. Self-reported demographics and data regarding healthcare visits for voice problems, diagnoses given, severity of the voice problem, and depression symptoms were analyzed. Results The total weighted sample size was 52,816,364. The presence of depressive symptoms was associated with a nearly two-fold increase (odds ratio = 1.89, 95% confidence interval = 1.21-2.96) in the likelihood of reporting a voice problem in the past year. Patients who reported feeling depressed were less likely to receive care for the voice problem and less likely to report that treatment had helped than those who did not feel depressed. Conclusion These findings indicate that the co-occurrence of voice problems and depressive symptoms is observed in the general population, not only in care-seeking patients, and that depressive symptoms may influence reported likelihood of receiving voice treatment and effectiveness. This suggests that voice care providers should take mental health symptoms into account when treating patients, and also indicates a need for further investigation. Level of evidence NA. Laryngoscope, 126:1859-1864, 2016.

Summary Objective Voice disorders are common and negatively affect various life domains such as occupational functioning and emotional well-being. Perceived present control, a factor that is amenable to change, may reduce the effect of voice disorders on these outcomes. This pilot study aimed to (1) establish the feasibility, usability, and acceptability of a web-based perceived present control intervention for individuals with voice disorders and (2) gather preliminary data on the effectiveness of the intervention. This study is the first to assess whether a web-based psychological intervention would decrease self-reported voice handicap in this population. Methods Participants (N = 20) were recruited from an otolaryngology clinic at a large, Midwest university and the surrounding urban community, and completed a 3-week web-based intervention that incorporated psychoeducation and written exercises on increasing perceived present control. Results Supporting feasibility, the intervention components had high completion rates (75%–95%). Most participants planned to continue the perceived control exercises after study completion and would recommend the intervention to others, demonstrating usability and acceptability. There was a significant decrease in self-reported voice handicap (Voice Handicap Index-10) from pretest (M = 18.38, standard deviation = 4.41) to post-test (M = 15.22, standard deviation = 4.55) with a large effect size (within-group d = −0.86, P Conclusions Focusing on perceived present control as a teachable skill may be a useful addition to voice disorder treatment armamentarium. Future studies will incorporate a comparison group and larger sample sizes to assess further the role of perceived present control interventions in voice care.

OBJECTIVES: To examine the relationship between community acquired pneumonia (CAP) and proton pump inhibitor (PPI) treatment in laryngeal/voice disordered patients. STUDY DESIGN: Retrospective cohort analysis. SETTING: Large, national administrative U.S. claims database. SUBJECTS AND METHODS: Patients ≥ 18 years of age with outpatient treatment for a laryngeal/voice disorder per ICD-9-CM codes from January 1, 2010 to December 31, 2014 with 12 months continuous enrollment prior to the index date (first laryngeal/voice disorder diagnosis), no pre-index diagnosis of CAP, and had prescription claims captured from 1 year pre-index to end of follow-up were included. Patient demographics, comorbid conditions, index laryngeal diagnosis, number of unique pre-index patient encounters, and CAP diagnoses during 3 year post-index date were collected. Two models, a time-dependent Cox regression model and a propensity score based approach with marginal structural model, were each separately performed in patients with and without pre-index date PPI prescriptions. RESULTS: 392,355 unique patients met inclusion criteria. 188,128 (47.9%) patients had a PPI prescription. The 3 year absolute risk for CAP was 4.0% and 5.3% in patients without and with pre-index PPI use, respectively. The CAP occurrence for a person who already received a PPI is 30% to 50% higher than for a person who has not yet had a PPI but may receive one later for patients without and with pre-index date PPI use, respectively. CONCLUSIONS: Patients without and with pre-index date PPI use experienced roughly 30% to 50% increased likelihood of CAP, respectively, compared to patients who had not had PPI prescriptions.

To assess the prevalence and severity of dysphonia in patients with cystic fibrosis sinusitis. We hypothesized that patients with CF sinusitis, compared with 2 control groups, would have higher self-reported prevalence of dysphonia and greater severity of dysphonia, according to patient-reported outcome measures as well as auditory-perceptual evaluation by expert listeners.Cross-sectional comparative pilot study.Academic tertiary care clinic.Analysis included 37 study participants: 17 patients with CF sinusitis, 10 healthy individuals, and 10 patients with non-CF sinusitis. All participants completed the 10-item Voice Handicap Index (VHI-10) questionnaire and provided voice samples. On all samples, 6 blinded speech-language pathologists independently performed auditory-perceptual evaluation, using Consensus Auditory-Perceptual Evaluation of Voice. To assess severity of sinonasal symptoms, we used the 20-item Sinonasal Outcome Test (SNOT-20). Standard parametric and nonparametric statistical analysis was performed.The differences between the 3 groups in prevalence of abnormal VHI-10 scores were not statistically significant. SNOT-20 scores were similar in the 2 sinusitis patient groups. VHI-10 scores were highest in patients with CF sinusitis, intermediate in patients with non-CF sinusitis, and lowest in healthy individuals (P = .005). Auditory-perceptual evaluation demonstrated greater overall severity of dysphonia in patients with CF sinusitis compared with the 2 control groups (P = .0005).Cystic fibrosis sinusitis appeared to be associated with worse vocal function as measured by patient self-report as well as auditory-perceptual evaluation of voice compared with patients with non-CF sinusitis and healthy controls. Further investigation in this area is warranted.

Importance The minimal important difference (MID) on patient-reported outcome measures can indicate how much of a change on that scale is meaningful. Objective To use an anchor-based approach to estimate MID in the Voice Handicap Index–10 (VHI-10) total score. Design, Setting, and Participants In this cohort study, a volunteer sample of adult patients visiting the voice clinic at the University of Minnesota from April 7, 2013, through July 3, 2016, completed the VHI-10 (range, 0-40, with higher scores indicating greater voice-related handicap) at baseline and 2 weeks later in conjunction with a global rating of change. An anchor-based approach was used to identify an MID. The association between the global change score and change in VHI-10 score was analyzed using Pearson rank correlation. A distribution-based method was used to corroborate the findings. Main Outcome and Measures Global rating of change on the VHI-10. Results Of the 273 participants, 183 (67.0%) were women and 90 (33.0%) were men (mean [SD] age, 54.3 [15.6] years); 259 (94.9%) were white. Participants had a variety of voice disorders, most commonly muscle tension dysphonia, irritable larynx, benign vocal fold lesions, and motion abnormalities. Among patients reporting no change on the global change score, the mean (SD) change in VHI-10 score was 1 (5). Among those reporting a small change, the mean (SD) change in VHI-10 was also 1 (5). Among those reporting a moderate change in voice symptoms, the mean (SD) change in VHI-10 score was 6 (8). Among those with a large change, the mean (SD) change in VHI-10 score was 9 (13). The correlation between the global change score and the change in VHI-10 score was 0.32 (95% CI, 0.12-0.49). Distribution-based analyses identified effect sizes comparable to those of the anchor-based categories. Conclusions and Relevance These findings suggest that a difference of 6 on the VHI-10 may represent an MID. This difference was associated with a moderate change on the global rating scale, and the small-change and no-change categories were indistinguishable. Given the lack of differentiation between small and no change and the modest correlation between the global change score and change in the VHI-10 score, additional studies are needed.

OBJECTIVES: 1) To compare laryngeal diagnoses from general medical providers (GMP) to otolaryngologists following GMP-based medication trial, and 2) to evaluate associations between GMP medication trials and pharmacologic treatment by otolaryngologists. METHODS: Retrospective cohort analysis using large, national administrative U.S. claims database. Patients with laryngeal/voice disorders as per the International Classification of Diseases, Ninth Revision, Clinical Modification codes from January 1, 2010, to December 31, 2012, seen by a GMP and then an otolaryngologist between 2 weeks to 3 months after the GMP visit, were included. Patient demographics, comorbid conditions, medication use, and initial GMP and otolaryngology laryngeal diagnoses were collected. Logistic regression was performed to evaluate the association between GMP and otolaryngologist medication trials. RESULTS: A total of 12,475 unique laryngeal/voice-disordered patients met inclusion criteria. At the initial GMP visit, 15.3% received an antibiotic, 14.0% a proton pump inhibitor (PPI), and 7.7% an oral steroid. After the otolaryngology visit, increased diagnoses of vocal fold paralysis/paresis, benign vocal fold/laryngeal pathology, chronic laryngitis, and multiple diagnoses occurred. The adjusted odds for an otolaryngologist prescribing an antibiotic, PPI, or oral steroid, respectively, given that a GMP prescribed an antibiotic, PPI, or oral steroid, was roughly two to three times higher that of a GMP not prescribing the given medication. CONCLUSION: Patients with structural and neuromuscular laryngeal disorders were treated with medications by GMPs, and similar mediations often were repeated after otolaryngology evaluation. These findings suggest potential areas of unnecessary pharmacologic treatment of laryngeal/voice-disordered patients.

Objectives To examine voice-related health care utilization of patients in the general medical community without otolaryngology evaluation and explore factors associated with prolonged voice-related health care. Study Design Retrospective cohort analysis. Setting Large, national administrative US claims database. Subjects and Methods Patients with voice disorders per International Classification of Diseases, Ninth Revision, Clinical Modification ( ICD-9-CM) codes from January 1, 2010, to December 31, 2012, seen by a general medical physician, and who did not see an otolaryngologist in the subsequent year were included. Voice-related health care utilization, patient demographics, comorbid conditions, and index laryngeal diagnosis were collected. Logistic regression with variable selection was performed to evaluate the association between predictors and ≥30 days of voice-related health care use. Results In total, 46,205 unique voice-disordered patients met inclusion criteria. Of these patients, 8.5%, 10.0%, and 12.5% had voice-related health care use of ≥90, ≥60, and ≥30 days, respectively. Of the ≥30-day subset, 80.3% and 68.5%, respectively, had ≥60 and ≥90 days of voice-related health care utilization. The ≥30-day subset had more general medicine and nonotolaryngology specialty physician visits, more prescriptions and procedures, and 4 times the voice-related health care costs compared with those in the

Objectives/Hypothesis Voice rest is frequently recommended following surgical disruption of vocal fold epithelium, but patients report variable adherence to voice rest recommendations. The objective of this study was to assess the clinical utility of an ambulatory vocal dosimeter for measuring adherence to voice rest recommendations. Study Design Outcomes research. Methods Part 1: To determine the utility of the dosimeter in nonclinical use, the relationship between self-reported voice use and dosimeter measurements was examined in normal subjects (n = 11) who prospectively logged voice use while wearing the dosimeter. Part 2: To determine clinical utility of the dosimeter, patients undergoing vocal fold surgery for which postoperative voice rest was recommended (n = 11) wore a dosimeter for 2 days prior to and 2 days after surgery. Phonation percent and sound level were compared at baseline and during voice rest. Results The dosimeter performed as hypothesized with both normal subjects and patients. A moderate correlation (r = 0.62) was noted between self-reported voice use and dosimeter measurements in normal subjects. In patients on voice rest, a statistically and clinically significant decrease was observed in measured voice use, both in phonation time (P = .002) and intensity of phonation (P = .004). Conclusions Ambulatory vocal dosimetry may have clinical utility for assessing adherence to voice rest recommendations. This information will be useful for the design of future studies on voice rest. Level of Evidence 2c Laryngoscope, 125:171–176, 2015

BACKGROUND The objectives of this study were to identify factors associated with treatment differences, characterize changes in treatment patterns over time, and compare survival across treatment types in patients who received treatment for localized laryngeal cancer. METHODS Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of patients who were treated from 1995 to 2009 for localized laryngeal cancer. Four treatment groups were defined: (1) radiation only, (2) local surgery only, (3) local surgery and radiation, and (4) open surgery with or without radiation. Variations in treatment rates between these groups were evaluated according to demographic factors, and differences in treatment rates across time were calculated. Associations between treatment and mortality were assessed using Kaplan-Meier methods. Cox proportional hazards regression models were used to adjust for potential confounding covariates. RESULTS In total, 10,429 patients with localized laryngeal cancer were identified. Most patients (57%) were treated with radiation only; 25% with local surgery and radiation, 9% with local surgery only, and 9% with open surgery with or without radiation. Race, age, and registry were associated with differences in treatment. Receipt of single-modality treatment increased and receipt of combined-modality treatment decreased over the study period. Better survival was observed with white race, younger age, and treatment with local surgery. Survival differences associated with treatment type were observed within 3 years of diagnosis and persisted beyond 5 years after diagnosis. CONCLUSIONS Although treatment patterns became more adherent to treatment guidelines over time, we identified survival differences associated with treatment type that warrant further investigation into treatment decision-making for patients with localized laryngeal cancer. Cancer 2014;120:1810–1817. © 2014 American Cancer Society.

Objective To identify factors associated with the likelihood of attending voice therapy among patients referred for it in the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure. Study Design Prospectively enrolled cross-sectional study. Setting CHEER network of community and academic sites. Methods Data were collected on patient-reported demographics, voice-related diagnoses, voice-related handicap (Voice Handicap Index-10), likelihood of attending voice therapy (VT), and opinions on factors influencing likelihood of attending VT. The relationships between patient characteristics/opinions and likelihood of attending VT were investigated. Results A total of 170 patients with various voice-related diagnoses reported receiving a recommendation for VT. Of those, 85% indicated that they were likely to attend it, regardless of voice-related handicap severity. The most common factors influencing likelihood of VT attendance were insurance/copay, relief that it was not cancer, and travel. Those who were not likely to attend VT identified, as important factors, unclear potential improvement, not understanding the purpose of therapy, and concern that it would be too hard. In multivariate analysis, factors associated with greater likelihood of attending VT included shorter travel distance, age (40-59 years), and being seen in an academic practice. Conclusions Most patients reported plans to attend VT as recommended. Patients who intended to attend VT reported different considerations in their decision making from those who did not plan to attend. These findings may inform patient counseling and efforts to increase access to voice care.

Treatment of vocal fold leukoplakia is complicated because it is associated with a high rate of recurrence after excision and it has the potential for progression to malignancy. Authors have presented different approaches to management, one of which is directed serial excisional biopsies. Ideally, a topical or systemic agent could be administered to eradicate this troublesome condition. We present the case of a patient with an 8-year history of vocal fold leukoplakia treated with directed serial biopsies who was subsequently diagnosed with non-small-cell lung cancer and treated with erlotinib. He experienced a complete resolution after 2 months of erlotinib therapy for his lung cancer. Immunohistochemistry confirmed that his lesion exhibited a much higher than normal expression of epidermal growth factor receptor (EGFR), which supports the idea that EGFR antagonism may combat EGFR-avid leukoplakia. However, we caution that the clinical observation made herein is an association and should not be misconstrued as a recommendation regarding the safety, efficacy, or economy of using erlotinib for the treatment of vocal fold leukoplakia.

Objectives/Hypothesis: To describe the presentation, stenosis characteristics, etiological differences, and outcomes of adult laryngotracheal stenosis treated with endoscopic cold incision, balloon dilation, topical mitomycin C application, and steroid injection. Study Design: Retrospective chart review. Methods: Demographic and clinical data were extracted for patients treated between March 2000 and December 2010. Prolonged intubation and idiopathic patient data were utilized for comparative analysis. Results: Eighty patients (65 females; 15 males; 220 procedures; 2.9 years mean follow-up) presented with dyspnea (81%) and/or exercise intolerance (40%). Most commonly, etiologies were idiopathic (53 of 80; 66%) or prolonged intubation (14 of 80; 18%). Mean procedures per patient and interval between procedures were 2.8 procedures and 405 days, respectively. Mean stenosis length and distance from the caudal phonating edge of the true vocal folds were 9 mm and 19 mm. Complication, tracheotomy, and open-procedure rates were 1.8%, 1.4%, and 10.0%, respectively. Patients with more than two procedures demonstrated a mean 4-mm reduction in stenosis length and a 2-mm cephalad progression of stenosis over time. More caudal stenoses required more frequent procedures. Procedures were less frequent as more procedures were performed. Stenosis characteristics, interval between procedures, and total procedures were similar between idiopathic patients with or without intubation histories, but different between idiopathic and prolonged intubation patients. Conclusions: This procedure was shown to be a viable option in adult laryngotracheal stenosis. Repeat dilation was likely, but was performed without adversely affecting stenosis characteristics. Stenoses farther from the vocal folds required procedures more frequently. Idiopathic patients with a history of brief, elective intubation had stenosis characteristics and responses to therapy similar to idiopathic patients without an intubation history. Both idiopathic groups together demonstrated stenosis characteristics and responses to therapy dissimilar to patients with a history of prolonged intubation. Laryngoscope, 2013

This article discusses the causes and symptoms, evaluation, and management of unilateral vocal fold paralysis (UVFP). Cross-sectional imaging is appropriate in the work-up of idiopathic UVFP, but the routine use of serology is not well supported. The usefulness of laryngeal electromyography has remained controversial. Predictors of poor prognosis for functionally meaningful recovery include fibrillation potentials, positive sharp waves, and absent/reduced voluntary motor unit potentials. Voice therapy may be helpful. Injection and laryngeal framework surgery (medialization thyroplasty) improve vocal quality. The vocal impact of laryngeal reinnervation is comparable with that of medialization. Some patients may benefit from multiple procedures.

To determine how standard residency training and educational background affect otolaryngology resident auditory-perceptual judgments compared with inexperienced listeners. A secondary aim was to assess the impact of a brief training session on the reliability of judgments among otolaryngology residents.Mixed cross-sectional and cohort study.Twenty adult dysphonic and four normal speaker samples were selected from a database. Fifteen listeners at various stages of residency in otolaryngology judged all samples for breathiness and roughness using visual analog scales. Fifteen inexperienced listeners judged the same samples. Subsequently, 12 otolaryngology residents underwent a brief training session. During training, listeners were provided definitions of rating dimensions and accuracy feedback while rating 20 novel (training) stimuli. The feedback included averaged responses from experienced clinicians who had previously evaluated the same speech samples. The residents then completed posttraining evaluations.As a group, otolaryngology resident listeners had significantly better interrater agreement for judgments of roughness compared with inexperienced listeners (P0.05) and trended toward better interrater agreement for judgments of breathiness (P=0.058). Posttraining, no significant improvement in interrater agreement for judgments of roughness was observed; however, a significant improvement was found in interrater agreement of judgments of breathiness (P0.05).Compared with inexperienced (untrained) listeners, otolaryngology resident listeners had better interrater agreement overall for judgments of dysphonia. A short training module was associated with improved reliability in resident evaluation of breathiness. Results have implications for improving and standardizing resident evaluation of dysphonia.

Prior studies have observed a high prevalence of psychosocial distress, including depression, in patients with voice problems. However, these studies have largely been performed in care-seeking patients identified in tertiary care voice clinics. The objective of this study was to examine the association between depression and voice problems in the U.S.Cross-sectional analysis of National Health Interview Survey (NHIS) data.We identified adult cases reporting a voice problem in the preceding 12 months in the 2012 NHIS. Self-reported demographics and data regarding healthcare visits for voice problems, diagnoses given, severity of the voice problem, and depression symptoms were analyzed.The total weighted sample size was 52,816,364. The presence of depressive symptoms was associated with a nearly two-fold increase (odds ratio = 1.89, 95% confidence interval = 1.21-2.96) in the likelihood of reporting a voice problem in the past year. Patients who reported feeling depressed were less likely to receive care for the voice problem and less likely to report that treatment had helped than those who did not feel depressed.These findings indicate that the co-occurrence of voice problems and depressive symptoms is observed in the general population, not only in care-seeking patients, and that depressive symptoms may influence reported likelihood of receiving voice treatment and effectiveness. This suggests that voice care providers should take mental health symptoms into account when treating patients, and also indicates a need for further investigation.NA. Laryngoscope, 126:1859-1864, 2016.

Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using transoral laser microsurgery or radiation therapy.PubMed, Web of Science, and Scopus (1997-2013).These data sources were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed only with studies that included both treatment modalities, to reduce heterogeneity and maximize rigor; random effects modeling was used to pool results.Eighteen publications were identified that reported VHI data following surgery and radiotherapy for T1 glottic carcinoma. No studies were randomized. When studies that reported multiple T-stages or systematic treatment selection bias were excluded, 8 retrospective cohort studies describing 362 patients were suitable for meta-analysis. Follow-up time (mean, 47 months; range, 1-298 mo) and extent of surgical excision varied across studies. Six studies showed no VHI difference between treatment arms; 2 favored radiotherapy over surgery (1 of which reported transmuscular cordectomy for all surgical patients); and none favored surgery. Meta-analysis showed no significant difference in posttreatment VHI between radiotherapy and surgery (mean difference, -5.52; 95% confidence interval, -11.40, 0.36; heterogeneity I (2) = 61%, P = .01).VHI scores were comparable following transoral laser microsurgery and radiation therapy for T1 glottic carcinoma in the current literature, suggesting no clinically significant difference in functional voice outcomes between treatment types.

Objectives:Prior work identified differences in survival by treatment type for localized laryngeal squamous cell carcinoma (LSCC) in the Surveillance Epidemiology and End Results (SEER) registries. We sought to determine whether these differences were attributable to sociodemographic, clinical, and treatment facility characteristics in the elderly.Methods:The SEER-Medicare linked files (1991-2009) identified patients (ages 66+ years) with T1 LSCC. Logistic regression models were constructed to identify sociodemographic characteristics associated with treatment type. Kaplan-Meier methods were used to examine the association of treatment type and survival. Cox proportional hazards modeling was used to assess the impact of potentially important factors such as sociodemographic, clinical, or facility characteristics.Results:We identified 1369 patients with T1 LSSC. Radiation alone was the most common treatment. Treatment with local surgery ± radiation was associated with slightly better survival than treatmen...

Objectives:Because cystic fibrosis transmembrane conductance regulator (CFTR) chloride channels are found in human vocal fold epithelium, we aimed to (1) assess the prevalence and severity of dysphonia in patients with cystic fibrosis (CF) and (2) compare these with control patient populations.Methods:Voice samples and the Voice Handicap Index-10 (VHI-10) were collected from patients with cystic fibrosis and control patients with and without chronic sinusitis. Voice samples underwent consensus auditory-perceptual evaluation of voice (CAPE-V) assessment by blinded speech-language pathologists. Sinus-related symptoms were assessed using the SinoNasal Outcome Test (SNOT-20). Statistical analysis was performed using unpaired t-tests and one-way analysis of variance (ANOVA).Results:Thirty-seven patients participated, including 17 with CF, 10 with chronic sinusitis, and 10 healthy controls. Prevalence of dysphonia by VHI-10 criteria was 41% in CF, 20% in chronic sinusitis, and 0% in healthy controls. CF patient...

Objectives:Systematic review of literature on patient-reported voice handicap following T1 glottic squamous cell carcinoma treatment using endoscopic surgery or radiation therapy.Methods:PubMed, Web of Science, and Scopus (1988-2013) were searched for papers reporting Voice Handicap Index (VHI) after treatment of early glottic carcinoma. Review and reference cross-checking were performed using a priori selection criteria. Study data were abstracted and publication quality categorized independently by 2 authors. Corresponding authors were contacted to maximize data for analysis. Meta-analysis was performed using a random-effects model.Results:Twenty-three studies with VHI data following surgery (n = 7), radiation (n = 4), or both (n = 12) were reviewed. Meta-analysis was then pursued with studies that included both modalities. Excluding studies reporting multiple T-stages or systematic treatment selection bias, 5 retrospective cohort studies describing 238 patients in total were suitable for meta-analysis....

Summary Objectives To assess the prevalence of psychosocial distress (depression, anxiety, somatization, and perceived stress) in a consecutive sample of patients presenting with voice concerns and to qualitatively analyze patient comments on challenges associated with voice problems. Study Design Cross-sectional study. Methods New patients presenting to a multidisciplinary voice clinic with voice concerns were invited to participate. Respondents (n = 197) completed the Brief Symptom Inventory 18-item scale, the 4-item Perceived Stress Scale, and the Voice Handicap Index 10-item scale. Qualitative analysis was performed of responses to an open-ended question about challenges associated with a voice problem. Results Approximately one-third (32%) of the patients met the strict case criteria for depression, anxiety, and/or somatic concerns based on the Brief Symptom Inventory 18-item scale. Most patients had no prior diagnosis of depression or anxiety, and the degree of distress was not predicted by the type of voice-related diagnosis. Perceived stress was higher among female patients ( P = 0.02). As expected, scores on the Voice Handicap Index 10-item scale were indicative of concurrent voice-related handicap (mean, 19.5; standard deviation, 9.4). In qualitative analysis of responses regarding challenges associated with a voice problem, 19 themes were identified (eg, threat to occupational functioning). Conclusions These findings identify a high prevalence of multiple types of distress among patients with voice disorders, presenting an opportunity to provide more comprehensive care to this patient population.

To evaluate outcomes following endoscopic management of Zenker's diverticula using a carbon dioxide laser (CO2) or stapler-assisted technique, a systematic review and meta-analysis were conducted. Seven retrospective, uncontrolled case series including 391 procedures met selection criteria. No higher quality studies were identified. Outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status (2 studies), length of hospitalization (LOH, 2 studies), and fewer postoperative fevers and abnormal chest x-rays (1 study). Outcomes favoring the CO2 technique included greater improvement in postoperative dysphagia and regurgitation scores (2 studies) and a lower revision rate (1 study). Meta-analysis demonstrated increased nondental complications in the CO2 group (odds ratio 3.81; 95% confidence interval, 1.37-10.59; P = .01) but no difference in duration of NPO (P = .06), LOH (P = .07), overall complications (P = .08), dental complications (P = .57), major complications (P = .38), or revision surgery (P = .82). Implications are limited by the quality of studies identified.

The objectives of this study were to identify factors associated with treatment differences, characterize changes in treatment patterns over time, and compare survival across treatment types in patients who received treatment for localized laryngeal cancer.Using the Surveillance, Epidemiology, and End Results database, we conducted a retrospective cohort analysis of patients who were treated from 1995 to 2009 for localized laryngeal cancer. Four treatment groups were defined: (1) radiation only, (2) local surgery only, (3) local surgery and radiation, and (4) open surgery with or without radiation. Variations in treatment rates between these groups were evaluated according to demographic factors, and differences in treatment rates across time were calculated. Associations between treatment and mortality were assessed using Kaplan-Meier methods. Cox proportional hazards regression models were used to adjust for potential confounding covariates.In total, 10,429 patients with localized laryngeal cancer were identified. Most patients (57%) were treated with radiation only; 25% with local surgery and radiation, 9% with local surgery only, and 9% with open surgery with or without radiation. Race, age, and registry were associated with differences in treatment. Receipt of single-modality treatment increased and receipt of combined-modality treatment decreased over the study period. Better survival was observed with white race, younger age, and treatment with local surgery. Survival differences associated with treatment type were observed within 3 years of diagnosis and persisted beyond 5 years after diagnosis.Although treatment patterns became more adherent to treatment guidelines over time, we identified survival differences associated with treatment type that warrant further investigation into treatment decision-making for patients with localized laryngeal cancer.

Objectives:To evaluate outcomes following endoscopic Zenker’s diverticulotomy using a carbon dioxide (CO2) laser or stapler-assisted technique.Methods:Systematic review and meta-analysis of retrospective studies comparing CO2 laser and stapler-assisted endoscopic Zenker’s diverticulotomy were performed. PubMed, Scopus (Embase), and United States and United Kingdom clinical trial registries were searched. References were cross-checked.Results:No randomized controlled trials were identified. Six studies were included: 2 retrospective reviews of consecutive patients, 3 retrospective reviews with unknown consecutive status, and 1 case series totaling 379 procedures (219 laser, 160 stapler). Individual study outcomes favoring the stapler technique included a shorter duration of nil per os (NPO) status and hospital stay (4 studies), as well as fewer postoperative fevers and abnormal chest x-rays (1 study). Individual study outcomes favoring the laser technique included greater improvement in postoperative dysph...