Vocal fold botulinum toxin injection for refractory paradoxical vocal fold motion disorder

Repetitive Transcranial Magnetic Stimulation, a Novel Therapeutic Strategy for Refractory Paradoxical Vocal Fold Motion Disorder

Paradoxical vocal fold motion disorder (PVFMD) is a condition involving the inappropriate narrowing of the larynx with symptoms of laryngeal tightness and dyspnea. A 23-year-old woman was diagnosed with PVFMD by imaging, revealing dynamically constricted, supraglottic tissue, an abnormal adduction of the vocal cords with a characteristic "posterior chink" observed. After diagnosis, laryngeal control retraining protocols and biofeedback therapy were initiated. To treat persistent symptoms, interventions such as vocal fold botulinum toxin (BoNT) injections were performed with slight improvements. Ultimately, psychiatry performed 10 repetitive transcranial magnetic stimulations (rTMS) with a right-sided, low-frequency approach to treat the patient's underlying major depressive disorder and comorbid anxious distress. Afterward, the patient's symptoms were successfully reduced with an improvement in Dyspnea Severity Index. Although most patients with PVFMD were relieved with laryngeal control therapy, some are refractory and lack the literature on the best treatment. In this case, we followed the multidisciplinary approach and individualized our novel therapeutic strategies including especially rTMS, which successfully reduced symptoms. This is the first reported case of refractory PVFMD to be treated with novel interventions, and rTMS might play a role in PVFMD mitigation.

Voice Pitch Shaping and Genderization: New Needs of Cosmetic Phonoplastic Surgery

Voices can convey content, emotion, and essential information about an individual's gender and social information. Closely related to gender identification and sexual attraction, voices also positively affect many psychological factors of individuals. Surgeries have evolved from treating congenital diseases to fulfilling an individual's aesthetic needs for voice. Voice shaping is emerging as the next cosmetic surgery hotspot after skincare and appearance and body shaping. This paper summarizes the development of voice pitch shaping and genderization procedures out of the cosmetic need. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors https://www.springer.com/00266 .

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Management of comorbidities in difficult and severe asthma

Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.

Predictors of voice therapy efficacy in vocal cord dysfunction at a tertiary care center

OBJECTIVE

Vocal cord dysfunction is inappropriate adduction of vocal cords during inspiration that causes dyspnea and is commonly mistaken for exercise-induced asthma. To improve diagnostic accuracy, this study aims to identify demographics associated with vocal cord dysfunction and to determine their impact on the efficacy of voice therapy in improving vocal cord function.

STUDY DESIGN

Retrospective chart review.

SETTING

Single tertiary care institution between January 2015 and December 2021.

METHODS

184 patients who underwent voice therapy for vocal cord dysfunction were included. The primary outcome was patient self-reported percent improvement of symptoms. The secondary outcome was number of voice therapy treatments.

RESULTS

The mean duration of symptoms was 2 ± 3 years. The mean number of voice therapy treatments was 2.2 ± 1.5. Of the 107 (58.2 %) patients with documented perceived breathing improvement percentages recorded, the mean maximal percent improvement was 72.5 ± 21.5 %. Mean maximal percent improvement of symptoms increased with each voice therapy treatment (p = 0.01). This association remained significant when controlling for comorbid conditions such as allergic rhinitis with postnasal drip, anxiety, asthma, and gastroesophageal reflux disease in multivariate analysis (p = 0.005). Patients with asthma had significantly higher maximum percent breathing improvement compared to those without asthma (p = 0.026). Similarly, patients who played sports had significantly higher maximum percent breathing improvement compared to those who did not (p = 0.022).

CONCLUSION

Patient perceived breathing improvement with voice therapy is higher among those with concomitant asthma and those who play sports. Voice therapy is a safe and effective first line treatment of vocal cord dysfunction even when controlling for comorbid conditions.

Vocal cord dysfunction/inducible laryngeal obstruction: novel diagnostics and therapeutics

INTRODUCTION

Vocal cord dysfunction/inducible laryngeal obstruction (VCD/ILO) is an important medical condition but understanding of the condition is imperfect. It occurs in healthy people but often co-exists with asthma. Models of VCD/ILO pathophysiology highlight predisposing factors rather than specific mechanisms and disease expression varies between people, which is seldom appreciated. Diagnosis is often delayed, and the treatment is not evidence based.

AREAS COVERED

A unified pathophysiological model and disease phenotypes have been proposed. Diagnosis is conventionally made by laryngoscopy during inspiration with vocal cord narrowing >50% Recently, dynamic CT larynx was shown to have high specificity (>80%) with potential as a noninvasive, swift, and quantifiable diagnostic modality. Treatment entails laryngeal retraining with speech pathology intervention and experimental therapies such as botulinum toxin injection. Multidisciplinary team (MDT) clinics are a novel innovation with demonstrated benefits including accurate diagnosis, selection of appropriate treatment, and reductions in oral corticosteroid exposure.

EXPERT OPINION

Delayed diagnosis of VCD/ILO is pervasive, often leading to detrimental treatments. Phenotypes require validation and CT larynx can reduce the necessity for laryngoscopy, thereby fast-tracking diagnosis. MDT clinics can optimize management. Randomized controlled trials are essential to validate speech pathology intervention and other treatment modalities and to establish international standards of care.

Treatment effectiveness for Vocal Cord Dysfunction in adults and adolescents: A systematic review

OBJECTIVE

To determine whether treatment effectiveness can be established for a range of vocal cord dysfunction (VCD) interventions in adolescents and adults.

DESIGN

A systematic review of the literature and risk of bias appraisal was completed using the Joanna Briggs Institute Critical Appraisal Tools. Data were qualitatively synthesized in the broad intervention groups of glottic airway and respiratory retraining, pharmacological therapies, airway device therapies and psychological therapies.

DATA SOURCES

Nine electronic databases, two clinical trial registries and the grey literature were searched from inception to September 2021 for articles on VCD interventions or equivalent terms.

ELIGIBILITY CRITERIA

Studies were included if they were randomized controlled trials, non-randomized controlled trials, quasi-experimental pre- and post-test studies and within-subject repeated measure designs, participants were 13 years or older, VCD was diagnosed using laryngoscopy or CT larynx, VCD intervention was provided and outcome measures reported on VCD symptoms.

RESULTS

The search yielded no randomized controlled trials. There were 17 quasi-experimental studies that met the eligibility criteria, and these studies reported on glottic airway and respiratory retraining, botulinum toxin injections, inspiratory muscle strength training and amitriptyline; all were associated with VCD symptom reduction. In addition, 2 within-subject repeated measure studies reported inspiratory muscle strength training and respiratory retraining to be effective in reducing symptoms in participants with exertional VCD. The included studies were reported in full-text publications (11) and conference proceedings (8). There was a high risk of bias and low quality of evidence across all intervention areas.

CONCLUSION

Glottic airway and respiratory retraining, botulinum toxin injections, low-dose amitriptyline and inspiratory muscle strength training devices have been associated with symptom reduction in adults and adolescents with vocal cord dysfunction. Limited objective data exist to support the effectiveness of these interventions, and robust controlled trials are needed in this area. Systematic Review Registration: CRD42018092274 (PROSPERO).

Visual biofeedback for paradoxical vocal fold motion (PVFM)

Objectives

Paradoxical vocal fold motion (PVFM) is a common condition where the vocal folds inappropriately adduct during inspiration. This results in dyspnea and occasionally significant distress. The condition is thought to be primarily functional, with behavioural therapy considered mainstay in the non-acute setting. However, practice variations and limited access to speech language pathology (SLP) services can pose management challenges. We aimed to examine the efficacy of surgeon performed visual biofeedback as first-line treatment for PVFM.

Study design

Prospective, non-randomized, non-comparative clinical study.

Methods

Adult patients referred for possible PVFM and congruent laryngoscopy findings over a two-year period were included. Patients were excluded if they presented in acute distress, had alternate diagnosis to explain symptomology and/or coexisting untreated lower respiratory pathology. Patients underwent immediate surgeon-performed visual biofeedback on the same visit day. The primary outcome of interest was change in Dyspnea Index (DI) scores pre- and post-intervention 3 months follow-up. The secondary outcome measured was change in asthma medication use from baseline to follow-up.

Results

Of 34 patients presenting, 25 met inclusion criteria. Of these, 72% were female with an average age of 36.9 ± 14.1. Approximately 48% of patients had a diagnosis of well-controlled asthma at presentation and co-morbid psychiatric diagnoses were common (52%). Pre- and post-intervention analysis showed significant improvement in DI scores (p < 0.001) and reduction in bronchodilator use (p = 0.003).

Conclusion

This is a prospective study that evaluates the role of visual biofeedback in PVFM patients. Our data suggests that visual biofeedback effectively reduces short-term subjective symptoms and asthma medication use.

Level of evidence

3

Graphical abstract