Acoustic analysis in asthmatics and the influence of inhaled corticosteroid therapy

Influence of Inhaled Corticosteroids on Voice Quality: A Systematic Review

OBJECTIVE

To investigate the incidence of dysphonia and the related voice quality assessment impairment in patients treated with inhaled corticosteroids.

METHODS

A laryngologist and librarian conducted a PubMED, Scopus, and Cochrane Library systematic review related to the voice quality features in patients treated with inhaled corticosteroids through the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statements.

RESULTS

Of the 366 identified studies, 21 publications met inclusion criteria (15 026 subjects). Dysphonia prevalence ranged from 3.0% to 34.0% according to patients and 53.3%-89.0% according to practitioners. Subjective, laryngostroboscopic, and objective voice evaluations (aerodynamic and acoustic) showed impairments influenced by IC doses, treatment duration, and particle sizes. Mean MINORS score was 5.8 ± 2.1. Substantial heterogeneity existed across studies regarding IC drugs, inclusion/exclusion criteria, and outcomes. There was no study considering a multidimensional voice quality evaluation. Most studies failed to address key confounding factors, including laryngopharyngeal reflux disease, tobacco consumption, and active allergic rhinitis.

CONCLUSION

Inhaled corticosteroids significantly impact voice quality, with substantial discrepancy between patient-reported and clinician-reported dysphonia rates. The drug features influence the occurrence of dysphonia, despite methodological limitations. Future research requires standardized multidimensional voice quality assessments and better control of confounding factors to clarify the underlying pathophysiological mechanisms.

A case of atopic cough with aphonia showed a prominent response to a histamine H1 receptor antagonist

A 33-year-old woman admitted to our hospital for further examination of severe non-productive cough lasting for about two months. Her symptom did not ameliorate by treatments including long acting β2 agonists. She had a medical history of drug allergy to non-steroidal anti-inflammatory drugs. At the initial visit, she could not speak at all and communicated with us in writing. Chest auscultation revealed no wheezes, rhonchi and other crackles. Laboratory findings showed a mild eosinophilia with normal total and specific serum immunoglobulin E. The results of an electrocardiogram, a chest X-ray and a chest CT were unremarkable. A fractional exhaled nitric oxide value was within normal limit. Based on these observations, a diagnosis of atopic cough (AC) was suspected, and we started treatment with a histamine H1 receptor antagonist (H1-RA). She had become able to speak again in association with complete disappearance of cough by eight-weeks after treatment initiation, and her symptoms did not recur even after cessation of treatment. By the confirmation of remarkable clinical improvement in response to a H1-RA, a diagnosis of AC was made. To the best of our knowledge, this is the first report of an AC patient who presented severe cough with aphonia. J. Med. Invest. 70 : 281-284, February, 2023.

The Utility of Pulmonary Function Testing in Patients Presenting With Dysphonia

OBJECTIVE

We aimed to evaluate the utility of pulmonary function testing (PFT), particularly forced expiratory flow (FEF) 25-75%, in patients presenting with dysphonia.

STUDY DESIGN

A retrospective chart review was carried out.

METHODS

Records of 199 patients who presented with dysphonia were reviewed to determine whether in-office PFTs, which we perform routinely, lead to new pulmonary diagnoses or the need for additional pulmonary medications, after assessment by a pulmonologist. Of particular interest was evaluating if FEF25-75% of predicted values less than 80% can be used as a marker for occult pulmonary disease in patients presenting with dysphonia.

RESULTS

Of the 199 patient charts reviewed, 129 were female and 70 were male. The age of patients ranged from 18 to 88 years, with a mean of 46.8 years. The body mass index ranged from 17.5 to 53.4 kg/m². One hundred five (52.8%) patients had FEF25-75% values less than 80% of predicted (poor midflow values). Of these patients, 76 (72.4%) were referred to a pulmonologist, 22 of 76 (28.9%) completed the referral, and 17 of 22 (77.3%) received a new pulmonary diagnosis or change in medications. Of the 155 patients without a history of pulmonary disease, 76 had poor midflow values, 57 (75%) of these patients were referred, and 12 of 57 (21%) completed the referral. Eight (67%) of these 12 patients were diagnosed with a previously unrecognized pulmonary disorder. Of the 44 patients with a prior history of pulmonary disease, 29 (65.9%) had poor midflow values. Nineteen (65.5%) of these patients were referred, and 9 (47%) received a new pulmonary diagnosis or a change in their medications. There were 51 classically trained singers and 148 nonclassically trained singers or nonsingers. There was no significant difference in average midflow values between the two groups (80.96 ± 24.7 and 80.73 ± 28.4, respectively) or in the percentage of classically trained singers with poor midflow values compared with nonsingers (53.5% vs. 49%, respectively).

CONCLUSION

This study suggests that patients with dysphonia may have unrecognized underlying pulmonary disease, and PFT should be considered as part of the routine initial voice evaluation for patients presenting with dysphonia.

Phonatory Symptoms and Acoustic Findings in Patients with Asthma: A Cross-Sectional Controlled Study

To investigate the prevalence of phonatory symptoms, perceptual, acoustic and aerodynamic findings in patients with asthma compared to a control group. This study is a cross-sectional study. A total of 50 subjects, 31 asthmatic and 19 control subjects matched according to age and gender were enrolled in this study. All subjects were asked about the presence or absence of dysphonia, vocal fatigue, phonatory effort, cough, dyspnea, and respiratory failure. Perceptual evaluation, acoustic analysis and aerodynamic measurements were also performed. Patient's self assessment using the Voice Handicap Index 10 was reported. The mean age of patients was 43.5 years with a female to male ratio of 2:1. There was a statistically significant difference in the prevalence of dysphonia between the two groups (32.3 vs. 5.3%, p value 0.025) with a non-significant higher prevalence of vocal fatigue and phonatory effort. The overall grade of dysphonia was significantly higher in asthmatics compared to controls (p value 0.002). Patients with asthma had also significantly higher degree of asthenia and straining (p value of 0.04 and 0.008, respectively) with borderline significant difference with respect to roughness. There was no significant difference in the means of any of the acoustic parameters between patients and controls except for Shimmer, which was higher in the asthmatic group (p value of 0.037). There was also no significant difference in the Maximum phonation time between the two groups. Dysphonia is significantly more prevalent in patients with asthma compared to controls.

Effects of inhaled corticosteroids on voice production in healthy adults

The isolated effects of inhaled corticosteroids (ICS) on voice production were examined in 30 healthy adults with no known pre-existing airway disease. All participants followed a daily ICS treatment regime of 500 μg in the morning and evening over a 6-day period. Sustained vowels and connected speech samples were audio recorded before, during, and after the ICS regime. Each participant's audio recorded samples were acoustically analysed. Results revealed that ICS has a short-term detrimental effect on various acoustic properties of voice. These effects were more evident in connected speech compared to isolated vowel productions. All acoustic parameters returned to normalcy after discontinuing the ICS. The study provides insight as to the influence of ICS on healthy voice production.

The effect of asthma on phonation: a controlled study of 34 patients

The effect of upper respiratory tract diseases on phonation has been reviewed, but little is known about the influence of lower respiratory tract diseases. In particular, the effect of asthma as a reversible obstructive small-airway disease on phonatory variables is not yet clear. We conducted a cross-sectional controlled study to evaluate the quality of phonation in a group of 34 adults with untreated mild to severe persistent asthma who were seen at the Ghaem Hospital in Mashhad, Iran. Patients with sinusitis, gastroesophageal reflux disease, or primary laryngeal disease were ineligible for study participation. For comparison purposes, we identified a group of nonasthmatic, age- and sex-matched healthy controls. We evaluated eight voice parameters: basal voice frequency at the glottic level (F0), jitter, shimmer, breathiness, harshness, hoarseness, normalized noise energy (NNE), and S/Z ratio. These parameters were measured by a voice meter with Dr. Speech statistical software. We found that values for F0, jitter, and shimmer were very similar in the two groups, but there were statistically significant differences in values for harshness, hoarseness, NNE, S/Z ratio (all p < 0.01), and breathiness (p = 0.015). Our findings suggest that lower airway diseases such as asthma can impair phonation, and we recommend future studies with larger populations to further explore this issue.

Management of Dysphonic Patients by Otolaryngologists

Objective

To investigate common treatment approaches of general otolaryngologists for adult dysphonic patients without obvious laryngeal anatomic abnormalities.

Study Design

Cross-sectional survey.

Setting

General otolaryngology community.

Subjects and Methods

One thousand randomly chosen American Academy of Otolaryngology—Head and Neck Surgery general otolaryngologists were mailed a survey.

Results

The response rate was 27.8%. Mean years in practice was 19.5. The most common treatments were proton pump inhibitor (PPI), referral to speech pathology, and stroboscopy. Muscle tension dysphonia, vocal fold nodules, and dysphonia of uncertain etiology were the most common reasons for voice therapy referral. Various forms of supraglottic compression and tender extralaryngeal muscles were identified as findings of muscle tension dysphonia. Response to once-daily PPI, laryngeal signs, and throat symptoms were the most common determinants for laryngopharyngeal reflux. When patients failed initial treatment, 58.2% refer for voice therapy, 46.9% obtain stroboscopy, and 33.3% extend or increase duration of PPI treatment.

Conclusions

Varied treatment approaches to adult dysphonic patients were identified. How practice patterns vary from best practice guidelines, affect patient outcome, and influence health care costs needs examination.

Vocal cord dysfunction and asthma

PURPOSE OF REVIEW

Vocal cord dysfunction can occur independently or can co-exist with asthma. It often mimics asthma in presentation and can be challenging to diagnose, particularly in those with known asthma. Vocal cord dysfunction remains under-recognized, which may result in unnecessary adjustments to asthma medicines and increased patient morbidity. There is a need to review current literature to explore current theories regarding disease presentation, diagnosis, and treatment.

RECENT FINDINGS

The underlying cause of vocal cord dysfunction is likely multifactorial but there has been increased interest in hyper-responsiveness of the larynx. Many intrinsic and extrinsic triggers have been identified which in part may explain asthma-like symptomatology. A variety of techniques have been reported to provoke vocal cord dysfunction during testing which may improve diagnosis. There is a significant gap in the literature regarding specific laryngeal control techniques, duration of therapy, and the effectiveness of laryngeal control as a treatment modality.

SUMMARY

Those with vocal cord dysfunction and asthma report more symptoms on standardized asthma control questionnaires, which can result in increasing amounts of medication if vocal cord dysfunction is not identified and managed appropriately. Clinicians need to maintain a high index of suspicion to identify these patients. Videolaryngostroboscopy remains the diagnostic method of choice. Evidence-based guidelines are needed for the most effective diagnostic techniques. Laryngeal control taught by speech pathologists is the most common treatment. Effectiveness is supported in case reports and clinical experience, but not in larger randomized trials which are needed.