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Objective: Exposure to chlorine gas can cause many problems for people who work in chlorine chemical production factories. The present study was conducted to investigate the prevalence of laryngeal and voice symptoms and related factors among workers in a chlorine chemical production factory., Design: A case-control study., Patients and Methods: A total number of 208 workers, including 138 workers (13 females, 125 males) who work in a chlorine chemical production factory and 70 (three females, 67 males) workers of a non-chlorine producing factory (producing metal materials), participated in the study. All participants completed self-reported questionnaires to investigate laryngeal or voice problems. These questionnaires investigated workplace vocal health, presence of voice or laryngeal problems, voice symptoms and laryngeal discomforts, and complications of voice problems., Results: The prevalence of laryngeal or voice problems in the workers of the chlorine factory group (18.8%) was higher than in the control group (7%) and this difference was statistically significant (P = 0.018). For all of the voice and laryngeal symptoms, workers in the chlorine factory had more symptoms than workers in the control group. Results of a Chi-Square test showed that workers in the chlorine factory had more significant vocal fatigue and dry throat symptoms than the control group (P < 0.05). Regression logistic analyses showed that age (P = 0.008; OR = 1.09; CI = 1.02-1.17), inadequate humidity (P = 0.015; OR = 2.78; CI = 1.21-6.38), and unavailability of water (P = 0.021; OR = 3.80; CI = 1.22-11.76) raised the chances of increasing the laryngeal and voice symptoms among workers. The most common side effects of laryngeal symptoms and voice problems for workers were: difficulty speaking in crowded environments, low self-esteem while talking, need for repetition to understand speech, and anxiety when speaking., Conclusion: Laryngeal and voice problems were more prevalent in the chlorine factory workers group than in the control group. The factors of age, inadequate humidity, and unavailability of water increased the probability for laryngeal or voice symptoms among chlorine factory workers. These findings indicate the need for further research with this population., Competing Interests: CONFLICT OF INTEREST The authors declare that they have no conflict of interests., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Voice disorders are common among teachers and, in particular, anatomy teachers are exposed to a potential enemy for dysphonia, irritating chemicals, that is, formaldehyde. We seek to verify the association between: (1) teaching time, (2) type of cadaveric conservation to which the teacher is exposed and (3) hours of exposure to cadaveric preservative related to the different categories of voice disorders screening (ITDV). The sample consisted of 111 teachers who answered to 02 data collection instruments: I - Sociodemographic Data; II - ITDV. Among participating teachers there were 71 male and 40 female, with an average age of 43 years and 11 months and an average teaching time of 16 years and 5 months. Association tests between teaching time and ITDV demonstrate a significant result in the relationship between voice failure and teaching time (p<0.05). All 111 teachers use their voices in laboratory classes and use cadaveric material. From those, 107 teachers are exposed to formaldehyde as cadaveric parts' conservative solution. There was a significant association (p<0.05) between voice failure and the type of cadaveric conservative solution but non-significant relationship (p>0.05) between ITDV and the time of exposure to formaldehyde preservative. Teachers' ITDV showed vocal signs and symptoms. In particular, voice loss due to time of teaching in anatomy, and voice failure, due to exposure to formaldehyde and combinations used in anatomical parts and cadavers, were significant., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objectives/hypothesis: Performing while on steroids is widely considered to increase risk of vocal injury. This study aims to determine incidence and type of injury, and changes in performers' voices after treatment of vocal fold edema (VFE) with glucocorticoids., Study Design: Prospective Cohort., Methods: Fifty-five performers (34 female; 21 male) treated for acute VFE with short-course oral glucocorticoids were prospectively evaluated pre- and post-treatment. Subjects underwent videostroboscopy, acoustic/aerodynamic assessment, and functional assessment with the Singing Voice Handicap Index-10 (SVHI-10) and Evaluation of the Ability to Sing Easily (EASE). Blinded reviewers rated videostroboscopic examinations and performed audio-perceptual assessment. Chi-square tests and Wilcoxon signed rank tests were applied for analyses of treatment changes., Results: Following glucocorticoid treatment, two instances of vocal fold hemorrhage (3.6%) and three instances of glottic thrush (5.5%) were observed. These resolved without consequence. Mucosal wave dynamics and edema improved. Nearly all subjects completed scheduled performances, and significant improvement was noted on the EASE, reflecting improved function after treatment. These were further supported by statistically significant improvements in CAPE-V and some acoustic and aerodynamic outcomes (semitone pitch range for females, airflow measures for males)., Conclusions: Oral glucocorticoids appear to be generally safe for performers presenting with acute VFE. The incidence of adverse effects, specifically hemorrhage and thrush, was low and the effects transient. Vocal fold examination should be considered obligatory before prescribing glucorticoids to working performers. A treatment strategy for acute VF edema incorporating glucocorticoids when appropriate appears to result in significant improvements in measures of glottal function including videostroboscopic appearance, subject perception, and auditory perception., Level of Evidence: 4 Laryngoscope, 131:2298-2304, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Vocal tremor is a neurologic disorder with myriad etiologies (eg, Parkinson disease, medications, or essential tremor). Vocal tremor can limit intelligibility and social interaction and can result in isolation in nonprofessional voice users. In a professional singer whose entire career is based on voice quality, onset of a vocal tremor is devastating. We report a case of sudden-onset vocal tremor that impeded a young professional singer's ability to perform and record her album. The etiology was determined to be a medication side effect of lamotrigine; a reaction that has not been previously reported. Diagnosis was based on perceptual assessment of the vocal tremor, laryngeal examination, and the singer's proximate history of lamotrigine dose adjustment. Two months after decreasing her dose, all symptoms resolved and the singer returned to her tour and performance schedule. To our knowledge, this is the first report of isolated vocal tremor as a side effect of lamotrigine and demonstrates that the voice may be more sensitive to this class of medication than previously described. It is incumbent on the vocal professional to inquire about and understand that new medication or dose changes may impact their voice., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: A large number of people around the world struggle daily to become free of their addiction to illegal psychoactive substances. In order to create an atmosphere of improved supervision, established communication and improved quality of life for drug addicts, centers have been set up to provide methadone as a substitute., Objective: The aim of the research was to assess the vocal features of drug addicts on methadone therapy via subjective and objective parameters, to ascertain if vocal damage has occurred and to determine whether subjective and objective acoustic vocal parameters are related, and how., Methods: The research included 34 adults of both genders who were undergoing methadone treatment. A subjective vocal evaluation assessed voice pitch and clarity, while the subjective acoustic analysis utilized the Roughness-Breathiness-Hoarseness scale of roughness-breathiness-hoarseness. Objective acoustic analysis was conducted after recording and analyzing an uninterrupted vocal /a/ of at least three seconds duration, using the "GllotisController" software., Results: The subjective acoustic analysis using the Roughness-Breathiness-Hoarseness scale showed pathological values in 52.9% male and 47% female participants. The average values of the roughness-breathiness-hoarseness for the entire sample were 0.91, 0.38 and 0.50, respectively. Lower roughness was associated with a higher fundamental frequency (f 0 ) and lower jitter and shimmer values (p<0.05). There was a statistically significant correlation between breathiness, jitter (p<0.01) and shimmer (p<0.05), and between hoarseness and jitter (p<0.01)., Conclusion: A statistically significant correlation was found between the two subjective vocal assessments, voice clarity and pitch, and Roughness-Breathiness-Hoarseness scale, and the parameters of the objective acoustic vocal assessment., (Copyright © 2017 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.)

Objectives: Women of reproductive age commonly use hormonal contraceptives, the vocal effects of which have been studied. Otolaryngologists should be aware of this relationship to make recommendations on hormonal contraception as it relates to each patient's voice requirements., Methods/design: A comprehensive literature review of PubMed was completed. The terms "contraception," "vocal folds," "vocal cords," and "voice" were searched in various combinations. Articles from 1971 to 2015 that addressed the effects of contraception on the vocal folds were included., Results: In total, 24 articles were available for review. Historically, contraception was believed to affect the voice negatively. However, more recent studies using low-dose oral contraceptive pills (OCPs) show that they stabilize the voice. However, stabilization generally occurs only during sustained vowel production; connected speech appears unaffected. Therefore, singers may be the only population that experiences clinically increased vocal stability as a result of taking hormonal contraceptives. Only combined OCPs have been studied; other forms of hormonal contraception have not been evaluated for effects on the voice. Significant variability exists between studies in the physical attributes of patients and parameters tested., Conclusions: Hormonal contraception likely has no clinically perceptible effects on the speaking voice. Singers may experience increased vocal stability with low-dose, combined OCP use. Other available forms of contraception have not been studied. Greater consistency in methodology is needed in future research, and other forms of hormonal contraception require study., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the effect of in vitro fertilization (IVF) treatment on acoustic properties of women's voice., Study Design: Prospective case series., Methods: Ten women undergoing IVF treatment participated in the study. All participants were recorded repeatedly in three successive sessions, before and during treatment, in addition to collecting hormonal assays, endometrial thickness measurements, and follicular growth data. Recordings were performed while sustaining an isolated vowel repeatedly and during a reading task. Acoustic analyses included a limited set of fundamental frequency (F0) measures, as well as frequency- and amplitude perturbation measures. Repeated-measure analyses of variance were performed to test for the treatment effect, and the correlations between the acoustic measures and the hormonal as well as endometrial thickness data were examined., Results: A significant reduction in the two F0 measures and in the amplitude perturbation measure was found throughout the treatment (P<0.05). Before treatment, a negative correlation was found between F0 and estrogen levels. After treatment, however, a negative correlation was found between F0 and endometrial thickness., Conclusion: An association was found between IVF treatment and specific voice properties. In addition, the possibility of a ceiling effect for the influence of estrogens on female vocal folds was introduced., (Copyright © 2014 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objective: To compare the prevalence of vocal symptoms and parameters in patients with prostate cancer treated with androgen deprivation therapy (ADT)., Materials and Methods: Thirty-two male patients aged 60-83 years were recruited for this study. The subjects were divided into two groups: one group consisted of 18 patients with prostate cancer treated with ADT using gonadotropin-releasing hormone agonists and the other group consisted of 14 controls matched according to age. Demographic data included age, history of smoking, reflux, and duration of therapy. The reported phonatory symptoms were hoarseness, inability to project the voice, and vocal fatigue. Patients also underwent acoustic analysis, and the following acoustic variables were measured: fundamental frequency, relative average perturbation, shimmer, noise-to-harmonic ratio, and voice turbulence index., Results: Compared with the control group, there was no statistical difference in any of the phonatory symptoms. The habitual pitch was significantly higher in the prostate cancer group compared with the controls (131.76 vs 114.11 Hz), with a P value of 0.021. There was also a significant increase in all the perturbation parameters, namely, relative average perturbation and shimmer, with a significant difference with respect to the latter (P value=0.014). There was also a significant increase in the noise-to-harmonic ratio (P value=0.014)., Conclusion: The administration of ADT for patients with prostate cancer can affect the habitual pitch. However, there are no noticeable vocal changes reported by the patients., (Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objectives: Perceptual judgments and patients' perception of voice and speech after concurrent chemoradiotherapy (CCRT) for advanced head and neck cancer., Study Design: Prospective clinical trial., Methods: A standard Dutch text and a diadochokinetic task were recorded. Expert listeners rated voice and speech quality (based on Grade, Roughness, Breathiness, Asthenia, and Strain), articulation (overall, [p], [t], [k]), and comparative mean opinion scores of voice and speech at three assessment points calculated. A structured study-specific questionnaire evaluated patients' perception pretreatment (N=55), at 10-week (N=49) and 1-year posttreatment (N=37)., Results: At 10 weeks, perceptual voice quality is significantly affected. The parameters overall voice quality (mean, -0.24; P=0.008), strain (mean, -0.12; P=0.012), nasality (mean, -0.08; P=0.009), roughness (mean, -0.22; P=0.001), and pitch (mean, -0.03; P=0.041) improved over time but not beyond baseline levels, except for asthenia at 1-year posttreatment (voice is less asthenic than at baseline; mean, +0.20; P=0.03). Perceptual analyses of articulation showed no significant differences. Patients judge their voice quality as good (score, 18/20) at all assessment points, but at 1-year posttreatment, most of them (70%) judge their "voice not as it used to be." In the 1-year versus 10-week posttreatment comparison, the larynx-hypopharynx tumor group was more strained, whereas nonlarynx tumor voices were judged less strained (mean, -0.33 and +0.07, respectively; P=0.031). Patients' perceived changes in voice and speech quality at 10-week post- versus pretreatment correlate weakly with expert judgments., Conclusion: Overall, perceptual CCRT effects on voice and speech seem to peak at 10-week posttreatment but level off at 1-year posttreatment. However, at that assessment point, most patients still perceive their voice as different from baseline., (Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objectives: Laryngeal botulinum toxin (BoNT) injection is a well-established symptomatic treatment for adductor spasmodic dysphonia (AdSD). Injections may be followed by a period of muscle weakness characterized by breathiness, voice weakness, and dysphagia for liquids. A recent study described some detriment and limited functional improvement with "good voice" for only one-third of the period between successive injections. Our objective was to examine the longitudinal effect of BoNT treatment for AdSD upon functional outcomes and quality of life when using a patient-specific dosing regimen., Study Design: Prospective cohort study., Methods: Patients presenting for BoNT treatment of AdSD were asked to complete evaluation of voice function after each injection using the percentage of normal function (PNF) scale (daily for two weeks, then weekly). Other parameters measured included voice handicap index (VHI), duration of effect, and complications., Results: A total of 133 patients treated continuously between January 2006 and January 2009 with an individuated regime (dose, pattern, and schedule) were included. Of 1,457 treatments, 50.9% experienced some breathiness. Mean VHI improvement was 9.6%. Mean PNF improvement was 30.3%. There was correlation between the two scales. Dysphagia to liquids was reported after 14.2% of treatments. We describe two distinct types of functional outcome curve. A total of 28.5% of treatments were followed by initial functional decline. Mean time below baseline function was 5.7%. Mean proportion of time in plateau phase was 42.5%., Conclusions: It is important to consider longitudinal functional outcomes in BoNT treatment of AdSD. An individuated dosing regimen helps minimize side effects and maximize functional and quality-of-life outcomes., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Aasthma is one of the most common chronic diseases with a prevalence of 5% in Germany. Nearly half of the patients complain about permanent voice disorders. Mucosal changes due to the obstructive respiratory disease as well as mucus abnormalities and regularly accompanying chronic rhinosinusitis may explain these symptoms. The additional influence of laryngopharyngeal reflux is discussed controversially. Additionally, dysphonia may as well occur due to side effects of the therapy with inhaled corticosteroids: the ingredients as well as physical effects may be responsible for the development of chronic laryngitis. The concomitant therapy by an ENT specialist is important in asthma-related voice disorders to identify the basic cause of dysphonia systematically and to intervene at an early stage., (Georg Thieme Verlag KG Stuttgart * New York.)

Purpose: Voice problems are reported as a frequent side effect of inhaled combination (IC) treatments. The purpose of this experimental study was to investigate whether IC treatments are detrimental to phonation. We hypothesized that IC treatment would significantly increase phonation threshold pressure (PTP) and perceived phonatory effort (PPE), whereas sham treatment would not., Method: Fourteen healthy adults participated in a repeated-measures design in which they received IC and sham treatments in counterbalanced order. PTP and PPE were measured prior to treatments, immediately following treatments, and at 1 and 2 hr following treatments., Results: IC treatment increased PTP, but sham treatment did not. The increase in PTP was maintained for a 2 hr period following administration. PPE ratings were not significantly correlated with PTP., Conclusions: IC treatments can have acute, adverse effects on phonation. Detrimental phonatory effects were elicited in participants with no self-reported voice problems. IC treatments are being increasingly prescribed across the lifespan. The current data increase our understanding of the nature of phonatory deterioration associated with IC treatment and lay the groundwork for increased research effort to develop IC treatments that effectively control respiratory disease while minimizing an adverse effect on phonation.

Tardive laryngeal dystonia, a rare form of dystonic syndrome, was only reported to be induced by typical antipsychotics. Here, we report one case of ziprasidone-induced tardive laryngeal dystonia in a schizophrenic female patient, who showed dysphonia, hoarseness and dyspnea after taking ziprasidone 120 mg/day for 8 months. These symptoms were significantly improved after discontinuing ziprasidone and increasing the dose of trihexyphenidyl for 1 week. Although atypical antipsychotics are associated with a lower risk of extrapyramidal symptoms, caution should be taken for any tardive dystonic movement when using these medications.

A 39 year male pharmaceutical worker employed in a clean-room developed in 2003 acute dysphonia after environmental disinfection with glutaric aldehyde and isopropyl alcohol. Laryngoscopic examination showed glottis edema; the syndrome healed after a cycle of cortisone. In subsequent years, withdrawal from exposure to irritating chemicals was observed. The worker, however, complained for recurrent episodes of dysphonia, in the absence of abnormalities of the larynx, and gradually developed intolerance for perfume, solvents, and other smelling substances. He came to our observation in 2007, showing strong conviction that occupational exposure had a causative effect in his complaints. He was working in an office open to public, and fragrance exposure appeared to be the main cause of dysphonic episodes. We rejected the hypothesis of association between complaint and job exposure, and advised him to work in a well defined working situation, such as in a clean room, where chemical contamination may be effectively controlled over time.

Background: Oropharyngeal adverse events associated with inhaled corticosteroid (ICS) use can affect adherence; however, these effects have been studied less extensively than those that occur systemically., Objective: To calculate the risk of ICS-induced oral candidiasis, dysphonia, and pharyngitis among currently available therapies and to determine related effects of dose and device., Methods: A computerized search in MEDLINE (January 1966 to June 2004) and EMBASE (January 1974 to June 2004) was conducted using indexed MedDRA terms for oropharyngeal adverse events. Odds ratios (ORs) were used to determine the rate of ICS-induced adverse events based on dose and device., Results: A total of 23 studies (59 drug arms) were evaluated. Incidence of oral candidiasis (P < or = .001), dysphonia (P < or = .001), and pharyngitis (P < or = .023) increased significantly with dose vs placebo at all dose levels and combined, regardless of device. Overall, the ICS metered-dose inhaler (MDI) device (hydrofluoroalkane formulation, 4 arms; chlorofluorocarbon formulation, 26 arms) was associated with a 5-fold greater risk of oral candidiasis vs MDI placebo (OR, 5.40). In contrast, the ICS dry-powder inhaler (DPI) device had a 3-fold greater risk for oral candidiasis vs DPI placebo (OR, 3.24). A similar trend was observed with regard to dysphonia (ICS MDI: OR, 5.68; ICS DPI: OR, 3.74; both vs. placebo). Both ICS MDI and DPI were associated with an approximately 2-fold greater risk of pharyngitis compared with placebo., Conclusions: Currently available inhaled corticosteroids canbe associated with oropharyngeal adverse events. Such events may be reduced by postdose mouth rinsing or use of a spacer.

We report the case of a woman complaining of dysphonia while she was treated by acitretin. Her symptoms totally regressed after drug withdrawal and reappeared when acitretin was reintroduced. To our knowledge, this is the first case of acitretin-induced dysphonia. This effect may be related to the pharmacological effect of this drug on mucous membranes.

At present, thrombolysis remains the principal reperfusion strategy for ST-elevation acute coronary syndromes in most countries, due to the limited availability of primary angioplasty. Haemorrhagic complications, which are among the most frequent side effects, are usually not very important. As a matter of fact, 70% of the bleeding takes place at venepuncture sites and does not require special treatment. We report an unusual case of vocal cord haematoma after thrombolysis with tenecteplase in a patient with acute myocardial infarction. As far as we know, this type of side effect has only been described once in the literature, namely, after thrombolysis with tissue plasminogen activator in deep vein thrombosis.

Chlorine gas inhalation, similar to other toxic gas exposures, can impart a variety of effects to the entire airway ranging from mucous membrane irritation to acute respiratory distress syndrome. The extent and location of damage is determined by numerous situational factors such as the duration of exposure, quantity of gas released, environmental factors, and instituted chemical defense measures. Reactive airways dysfunction and nonspecific bronchial hyperresponsiveness are commonly reported as sequelae to chlorine exposure. This article constitutes the first case of a single antecedent chlorine exposure inducing progressive vocal cord dysfunction.

The widespread use of inhaled corticosteroids (ICS) for the treatment of persistent asthma, although highly effective, may be associated with both systemic and local side effects. Systemic side effects of ICS have been extensively studied. In contrast, relatively few studies have been performed to specifically evaluate local side effects of ICS. These local side effects--including oropharyngeal candidiasis, dysphonia, pharyngitis, and cough--are generally viewed as minor complications of therapy. However, they can be clinically significant, affect patient quality of life, hinder compliance with therapy, and mask symptoms of more serious disease. Local side effects result from deposition of an active ICS in the oropharynx during administration of the drug. Numerous factors can influence the proportion of an inhaled dose that is deposited in the oropharyngeal cavity, including the ICS formulation, type of delivery system, and patient compliance with administration instructions. Therefore, the incidence of local side effects can vary widely. The goal in developing a new ICS is to include key pharmacologic characteristics that reduce oropharyngeal exposure to active drug while maintaining efficacy comparable with currently available ICS.

Objective: To report on the incidence of dysphonia and/or associated throat symptoms after steroid injections in the axial skeleton., Design: A prospective cohort study., Setting: Academic spine center., Participants: Patients (N = 100) undergoing a diagnostic injection followed by a therapeutic injection in the axial skeleton., Interventions: Not applicable., Main Outcome Measure: Presence or absence of dysphonia and/or associated throat symptoms, as determined by completion of a predetermined 10-item questionnaire. This questionnaire was administered before participation in the study and at specific intervals after a diagnostic injection and, again, after a therapeutic spinal injection., Results: There was a 12% incidence of transient dysphonia and/or associated throat symptoms in this study population after a therapeutic injection., Conclusions: Throat symptoms are a potential, albeit transient side effect, after an epidural space corticosteroid injection. The mechanism through which dysphonia or other throat symptoms develop is unknown but appears to be mediated by a systemic steroid effect.

Glucocorticosteroid injections into the shoulder are commonly used in the treatment of rotator cuff tendinitis. These injections rarely result in any serious complications and are generally considered a safe therapeutic intervention. Despite the extensive application of this treatment, there have been no reports of dysphonia occurring after corticosteroid injection into the subacromial space. We report the case of a 66-yr-old man with dysphonia after undergoing subacromial glucocorticosteroid injection for treatment of rotator cuff tendinitis.

Oxaliplatin is a new, third-generation platinum complex. It has a good safety profile characterized by low hematological-gastrointestinal toxicity. No significant nephro-ototoxicity has been observed. Acute peripheral neuropathy is a common event affecting, as grade 1 or 2, 85-95% of patients. Recently, data on dysphonia toxicity, after the administration of oxaliplatin, has been reported in literature. This toxicity with acute onset can be misunderstood if not carefully looked for. However, it is self-limiting and a non-permanent (grade 1-2) neurotoxic phenomenon, which impairs transiently the quality of life of a percentage of oxaliplatin-treated patients. We report our experience in consecutive patients affected by advanced colorectal cancer treated with oxaliplatin-based chemotherapy. Overall, we observed 13 (16%) cases of dysphonia out of 81 consecutive patients treated with oxaliplatin-based chemotherapy. This toxic effect was self-limiting and all patients recovered rapidly. Nonetheless, a deeper understanding of this phenomenon is essential to give correct information to the patients.

Unlabelled: Injection laryngoplasty is one of the most frequently performed procedures in patients with voice complaints. Various biomaterials have been used to medialize vocal folds or to treat symptoms of vocal fold scar. The ideal biomaterial would be easily injected through a fine-gauge needle, well tolerated, and long lasting. Injectable collagen preparations fulfill at least two of these criteria, and collagen has been used widely for vocal fold injections., Materials and Methods: We present a retrospective review of two unusual complications of collagen injection and a review of the relevant literature on the complications of medical use of collagen compounds., Results: Two patients in whom collagen was injected formed firm submucosal deposits that interrupted the normal mucosal wave and produced significant dysphonia. Surgical removal of these deposits restored the mucosal wave and improved voice quality. Management of this unusual complication of human collagen injection in the vocal fold has not been reported previously. Other complications of collagen injection include hypersensitivity reactions to bovine collagen, local abscess formation at injection sites, and possibly induction of collagen vascular disease in some patients., Conclusions: Although collagen injections of the vocal fold rarely result in complications, physicians using collagen must be familiar with the types of complications that can occur. Proper diagnosis and prompt management of complications can result in good outcomes.

Voice disturbances in asthma patients may be caused by inhaled corticosteroids. In order to study the prevalence of such voice disturbances, a questionnaire was delivered to asthma patients at three asthma and allergy departments in Stockholm. The questionnaire consisted of 25 questions concerning the asthma disease symptoms, medication, voice function, and voice disturbances. A total of 350 questionnaires were delivered. Response frequency was 80%. There was a significant positive correlation between inhalation of cortison and voice disturbances. Most of the patients complained about hoarseness, followed by throat clearing, a lump in the throat, loss of voice, and less frequently, throat pain. There were no significantly differences between men and women. Elderly had more voice problems than young persons. Patients with voice-demanding professions had more problems than patients who used their voice to a lesser extent during the working day. There was a significant positive correlation between high cortison doses and voice problems as well as between voice problems and acid regurgitation.

Educational Objective: At the conclusion of this article, the readers should be able to 1) describe the laryngeal findings in patients who use combination therapy for asthma, 2) discuss the mechanism of laryngeal irritation from the use of inhalers, and 3) describe possible mechanisms for reducing laryngeal irritation and secondary dysphonia from the use of inhalers., Objectives: To describe voice changes and laryngeal findings in patients who are started on combination corticosteroid and bronchodilator therapy in the form of a dry powder inhaler (DPI)., Study Design: Retrospective, single-subject design., Methods: Retrospective review of 10 consecutive patients meeting inclusion criteria, who presented at the voice center with more than 4 weeks of dysphonia after being started on a combination form of asthma medication for control and maintenance therapy. All patients were nonsmokers and without history of previous identification or excision of vocal pathology. All patients were treated previously with a proton pump inhibitor for gastroesophageal reflux. Laryngeal videostroboscopic evaluations were performed on all patients. Patients were asked to complete a questionnaire regarding their perceived voice change and history of medical maintenance therapy for asthma., Results: Dysphonia was present in the patients selected for greater than 4 weeks. Patients had been switched to combination therapy after previously using traditional two-drug asthma regimens. In eight of nine patients, the vocal folds demonstrated areas of hyperemia, with plaque-like changes on the surface mucosa. Reduced amplitude of vibration and a reduction in mucosal wave propagation were present on videostroboscopy. Questionnaires revealed that all patients were initiated on combination DPI treatment within the last 6 months., Conclusions: Dysphonia caused by a change in the surface mucosa is a side effect from the use of DPI therapy for asthma. The high-impact force during inhalation of the medication and carrier leads to deposition of particles in the upper airway. We believe the extent of mucosal irritation can be minimized by patient education in the proper delivery of DPI. In some cases, however, return of the two medications delivered separately was necessary. The irritation of the laryngeal mucosa and return of normal vibratory parameters occurred in all patients.

Purpose: Positive pressure ventilation using a laryngeal mask airway (LMA) has gained increased popularity. This study examined the influence of neuromuscular blockade on the incidence and severity of pharyngolaryngeal discomfort after positive pressure ventilation using a LMA., Methods: 130 patients were included in this prospective, double-blind, randomized two-centre study. Anesthesia was induced with remifentanil and propofol and maintained using remifentanil and sevoflurane in 30% oxygen and 70% air. Patients were mechanically ventilated at 15 breaths.min(-1) with tidal volumes to maintain Petco(2) 30-40 mmHg. Patients were randomly assigned to receive no neuromuscular blocking agent (NOBLOCK group) or cisatracurium prior to LMA insertion (BLOCK group). Prior to the end of surgery, morphine 3 to 5 mg iv were injected. The ease of insertion of the LMA, cuff pressure, and inspiratory pressure were recorded. Patients were asked immediately after two hours, and 24 hr after surgery to rate sore throat, dysphonia, or dysphagia as absent, minimal, moderate or severe. Continuous and categorical data were compared using t test and Chi-squared test, respectively., Results: 68 and 62 patients were randomized to the NOBLOCK and BLOCK groups, respectively. Successful insertion on first attempt were 89% and 92% in the NOBLOCK and BLOCK groups, respectively. Mean intracuff and inspiratory pressures were 85 +/- 35 mmHg and 13 +/- 3 mmHg for the NOBLOCK group, and 96 +/- 34 mmHg and 15 +/- 2 mmHg for the BLOCK group. The immediate, two and 24 hr postoperative incidences and severity of sore throat, dysphonia, and dysphagia did not differ significantly between the two groups., Conclusion: Neuromuscular blockade does not influence the ease or rate of success of LMA insertion nor the incidence and severity of pharyngolaryngeal discomfort after positive pressure ventilation using a LMA.

The frequent use of inhaled corticosteroids (ICSs), especially at higher doses, has been accompanied by concern about both systemic and local side effects. The systemic complications of ICSs have been extensively studied and are well-documented in the literature. There are comparatively few studies reporting on the local complications of ICSs. Compared with systemic side effects, the local side effects of ICSs are considered to constitute infrequent and minor problems. However, while not usually serious, these local side effects are of clinical importance. They may hamper compliance with therapy and the symptoms produced may mimic more sinister pathology. This review considers the prevalence of local side effects, their clinical features, the potential causes, the role of inhaler devices, and current measures that have been suggested to avoid the problem.

Distinguishing between vocal changes that occur with normal aging and those that are associated with disease is an important goal of research in voice. Several acoustic measures have been used in an attempt to illuminate the integrity of the vocal mechanism, including harmonics-to-noise ratio (HNR), jitter, and fundamental frequency (F0). HNR is a measure that quantifies the amount of additive noise in the voice signal; jitter reflects the periodicity of vocal fold vibration. In this study, measures of HNR, jitter and F0 were used to compare vocal function in three groups of normally speaking women: young adults, middle-aged adults, and elderly adults. Significant differences in HNR emerged between the elderly women and the other two groups. F0 differences were also apparent between the elderly group and the two younger groups; there were no significant differences in jitter between the three groups. HNRwas found to be a more sensitive index of vocal function than jitter. The significant lowering of HNR evident in t he elderly speakers may be attributable in part to medications taken by the majority of these elderly subjects.

(1) In patients with cystic fibrosis, chronic bronchial infection with Pseudomonas aeruginosa is a major factor in the development of chronic respiratory failure and premature death. (2) Over the last two decades, such patients have commonly received long-term treatment with antibiotic aerosols (mainly tobramycin or colistin, in off-licence uses). (3) Tobramycin solution for nebulisation is the first antibiotic preparation to be licensed in the EU for this indication. (4) Comparative evaluation of antibiotic aerosol therapy for chronic bronchial infections due to P. aeruginosa includes two large trials of nebulised tobramycin. (5) A combined analysis of these two placebo-controlled trials, both lasting 20 weeks, showed that tobramycin aerosol delayed the deterioration of respiratory function and reduced the number of hospitalisations. However, an increase in P. aeruginosa resistance to tobramycin was reported. (6) The file on tobramycin includes no precise criteria for stopping treatment, and no data on the long-term impact of the observed increase in bacterial resistance. (7) The main adverse effects of tobramycin aerosol are tinnitus and voice changes. Deafness has also been reported. (8) The available assessment file does not show whether the risk-benefit ratio of tobramycin aerosol differs from that of other nebulised antibiotics used (off-licence) in this setting. However, tobramycin is the best-assessed nebulised antibiotic for this indication. (9) In practice, tobramycin solution for nebulisation may be considered the reference long-term treatment for chronic pulmonary infections due to P. aeruginosa in patients with cystic fibrosis. Assessment should continue, however, especially regarding the possible impact on mortality and the selection of resistant strains.

A 46-year-old patient with left-side low back pain developed symptoms of dysphonia and throat irritation 24 hours after receiving a fluoroscopically guided steroid injection into the epidural space. A direct laryngoscopy performed before a second injection detected no abnormalities. When dysphonia reappeared 48 hours after that injection, laryngoscopy revealed edema in the anterior vocal cord with thick surrounding mucous. Full clinical resolution of the dysphonia was apparent by laryngoscopy 15 days after the second injection. The mechanism of dysphonia after epidural steroid injection is unknown, but it may result from a systemic steroid effect.

Objective: To describe a condition that is referred to as steroid inhaler laryngitis, a clinical entity that is caused by the use of inhaled fluticasone propionate and manifested by dysphonia, throat clearing, and fullness., Design: Case series., Setting: An outpatient clinic of an academic referral center., Patients: The study population consisted of 20 patients with reactive airway disease and dysphonia who were receiving inhaled fluticasone therapy and who were diagnosed as having steroid inhaler laryngitis during the period from January 1998 to June 2000., Intervention: Cessation of inhaled fluticasone therapy when possible, as well as treatment of other underlying causes of dysphonia, such as laryngopharyngeal reflux and infectious processes., Main Outcome Measure: The resolution of dysphonia with cessation of inhaled fluticasone therapy., Results: Patients with steroid inhaler laryngitis were found to have laryngeal findings ranging from mucosal edema, erythema, and thickening to leukoplakia, granulation, and candidiasis. Patients with more severe mucosal findings were more likely to have laryngopharyngeal reflux as well. Resolution of dysphonia occurred only after discontinuation of the inhaled fluticasone therapy., Conclusions: Steroid inhaler laryngitis is a form of chemical laryngopharyngitis induced by topical steroid administration. Symptoms and physical findings mimic laryngopharyngeal reflux, but only respond completely to discontinuation of the inhaled steroid therapy. The otolaryngologist should be familiar with this cause of dysphonia.

The medical literature contains relatively few examples of reports of voice disorders that could be attributed to chemical exposure at work. General medical conditions such as gastro-oesophageal reflux and the use of medication such as inhaled steroids are well-recognized causes of laryngitis, but the occupational causes are less well documented. This paper describes the results of a literature review looking at the reporting of cases of occupationally acquired voice disorders due to exposure to irritants in the workplace.

The use of inhaled steroids in the treatment of asthma is not without its complications. In some studies up to 50% of such patients complain of oropharyngeal and voice problems. We present the findings in 22 patients complaining of dysphonia who underwent videostrobolaryngoscopy (VSL) and computerized speech analysis. A number of abnormalities were identified. On VSL, these included mucosal changes (noted in 58%), apposition abnormalities (noted in 43%), and supraglottic hyperfunction (noted in 40%). On speech analysis, cycle-to-cycle irregularity was frequently noted (mean of 39%). Maximum phonation time was reduced in 73%. Our findings did not confirm the widely held views that steroid dysphonia is due primarily to a fungal infection or a steroid-induced adductor myasthenia of the larynx. A larger-scale prospective study is indicated.

Background: Dysphonia is a known local adverse effect of inhaled corticosteroids. This symptom was investigated by laryngoscopy and assessment in a voice laboratory. The effects of changing the treatment of patients with dysphonia, reported whilst using the pMDI, to pMDI plus Nebuhaler or Tubuhaler was also assessed., Methods: Seventy-two patients reporting dysphonia and taking inhaled steroids from a pMDI entered a 12-week, open, parallel group study. Fifty-one completed the study per protocol; 26 in the Nebuhaler group [21 female, mean age 57 years (22-77)] and 25 in the Turbuhaler group [18 female, mean age 58 years (21-81)]. A dysphonia diary card was completed weekly. Voice laboratory assessments and laryngoscopy were performed on entry and at 12 weeks., Results: There were no differences in voice laboratory data, laryngoscopic evidence of disordered glottic closure and diary data between the two groups at 12 weeks. At study entry laryngoscopic appearances were normal in almost half the patients. Vocal cord bowing was rarely seen. Glottic closure changed in nine patients during the study period, but there was no correlation with voice symptoms. The trend of symptomatic improvement of voice status in the Turbuhaler group did not correlate with voice laboratory assessments and laryngoscopic evidence of disordered glottic closure. After 4 weeks, 40% of patients using Turbuhaler and 8% in the Nebuhaler group scored their voice status as better (P < 0.02) but there was no significant difference between the two groups at 12 weeks (Turbuhaler 52%, Nebuhaler 23%, P=0.08)., Conclusion: This study does not support the view that dysphonia in asthmatics inhaling corticosteroids is usually caused by myopathic bowing of the vocal cord muscles.

Four women aged between 27 and 58 years sought otolaryngological examination due to significant alterations to their voices, the primary concerns being hoarseness in vocal quality, lowering of habitual pitch, difficulty projecting their speaking voices, and loss of control over their singing voices. Otolaryngological examination with a mirror or flexible laryngoscope revealed no apparent abnormality of vocal fold structure or function, and the women were referred for speech pathology with diagnoses of functional dysphonia. Objective acoustic measures using the Kay Visipitch indicated significant lowering of the mean fundamental frequency for each woman, and perceptual analysis of the patients' voices during quiet speaking, projected voice use, and comprehensive singing activities revealed a constellation of features typically noted in the pubescent male. The original diagnoses of a functional dysphonia were queried, prompting further exploration of each woman's medical history, revealing in each case onset of vocal symptoms shortly after commencing treatment for conditions with medications containing virilizing agents (eg, Danocrine (danazol), Deca-Durabolin (nandrolene decanoate), and testosterone). Although some of the vocal symptoms decreased in severity with the influences from 6 months voice therapy and after withdrawal from the drugs, a number of symptoms remained permanent, suggesting each subject had suffered significant alterations in vocal physiology, including muscle tissue changes, muscle coordination dysfunction, and propioceptive dysfunction. This retrospective study is presented in order to illustrate that it was both the projected speaking voice and the singing voice that proved so highly sensitive to the virilization effects. The implications for future prospective research studies and responsible clinical practice are discussed.

In order to clarify the later sequelae of sarin poisoning that occurred in Matsumoto City, Japan, on June 27, 1994, a cohort study was conducted on all persons (2052 Japanese people) inhabiting an area 1050 meters from north to south and 850 meters from east to west with the sarin release site in the center. Respondents numbered 1237 and 836 people when surveys were conducted at one and three years after the sarin incident, respectively. Numbers of persons with symptoms of sarin toxicity were compared between sarin victims and non-victims. Of the respondents, 58 and 46 people had symptoms associated with sarin such as fatigue, asthenia, shoulder stiffness, asthenopia and blurred vision at both points of the survey, respectively. The prevalences were low; some complained of insomnia, had bad dreams, difficulty in smoking, husky voice, slight fever and palpitation. The victims who had symptoms one year after the incident had a lower erythrocyte cholinesterase activity than did those who did not have symptoms at the early stage; such persons lived in an area with a 500 meter long axis north east from the sarin release site. The three-year cohort study clearly showed that the odds ratios of almost all of the symptoms were high in the sarin-exposed group, suggesting a positive relationship between symptoms and grades of exposure to sarin. These results suggest that symptoms reported by many victims of the sarin incident are thought to be sequelae related to sarin exposure.