Persistent Dysphonia in Hospitalized COVID-19 Patients

Can We Use the Maximum Phonation Time as a Screening of Pulmonary Forced Vital Capacity in Post-COVID-19 Syndrome Patients?

OBJECTIVE

To verify the accuracy of the maximum phonation time of the vowel /a/ (MPT/a/), fricative /s/ (MPT/s/), number counting (MPTC), and number reached in this count (CN) to estimate forced vital capacity (FVC) in patients with post-COVID-19 syndrome.

METHOD

Cross-sectional study involving adult patients, who were admitted to the intensive care unit and referred to the Post-COVID-19 Rehabilitation Outpatient Clinic. Voice function was assessed using a Vocal Handicap Index (VHI) self-assessment questionnaire and MPT tests. To perform the phonatory tests, the patients remained in a standing posture and were instructed to inhale as much air as possible and, during a single exhalation, at usual pitch and loudness, sustain the emission of /a/ and /s/; and in another breath, to perform the ascending numerical count, starting from the number one up to the highest number they could reach. Pulmonary function was assessed by spirometry. The receiver operating characteristic (ROC) curve was plotted, and FVC values lower than the normal limit by Z-score (fifth percentile) were classified as impaired lung function. The predictive values and likelihood ratios were calculated.

RESULTS

A total of 70 patients participated, with 20-30% having a high VHI. Approximately 24% had an FVC impairment and significantly low values of MPT/a/, MPT/s/, MPTC, and CN. The test results showed overall accuracy of 70% and the cutoff points of 9.69, 6.78, 10.60, and 13, respectively, with high sensitivity, predictive negative value and low specificity, predictive positive value, and positive likelihood ratio.

CONCLUSIONS

Our results suggest that the MPT has moderate discriminatory power for FVC impairment, indicating that it is not a reliable indicator of pulmonary function in the population studied. Therefore, in patients with an MPT of less than 10.60 seconds, or a CN lower than 13, other criteria should be added to improve the diagnostic accuracy and support the decision to perform more complex investigations.

Long-term effects on swallowing and laryngeal function after treatment for severe COVID-19 disease in intensive care

PURPOSE

This study aimed to assess swallowing and laryngeal function at long-term follow-up in patients treated for severe COVID-19 in the ICU.

METHODS

Thirty-six patients with severe COVID-19 were prospectively examined with fiberendoscopic evaluation of swallowing (FEES) about 6 and 12 months after ICU discharge. Comparison with initial FEES examinations during the time in hospital was performed in 17 patients. Analysis of swallowing function and laryngeal features was performed from video recordings. Twenty-five participants responded to Eating Assessment Tool, Voice Handicap Index, and the Hospital Anxiety and Depression Scale at follow-up.

RESULTS

Penetration to the laryngeal vestibule (PAS ≥ 3) was seen in 22% and silent aspiration (PAS = 8) in 11% of patients on at least one swallow at follow-up. Fourteen percent had obvious residue in the vallecula and/or pyriform sinuses after swallowing thick liquid or biscuits. Self-reported eating and swallowing difficulties were found in 40% of patients. Abnormal findings in the larynx were present in 53% at follow-up. Thirty-three percent had reduced or impaired vocal fold movement, of whom 22% had bilateral impaired abduction of the vocal folds. Possible anxiety and depression were found in 36% and 24% of responders, respectively.

CONCLUSION

Although a majority of patients appear to regain normal swallowing function by 1 year after treatment for severe COVID-19, our results indicate that dysphagia, abnormal laryngeal function, and anxiety/depression may remain in a substantial proportion of patients. This suggests that swallowing and laryngeal function, and emotional symptoms, should be followed up systematically over time in this patient group.

COVID-related dysphonia and persistent long-COVID voice sequelae: A systematic review and meta-analysis

PURPOSE

Dysphonia is a common symptom due to the coronavirus disease of the 2019 (COVID-19) infection. Nonetheless, it is often underestimated for its impact on human's health. We conducted this first study to investigate the global prevalence of COVID-related dysphonia as well as related clinical factors during acute COVID-19 infection, and after a mid- to long-term follow-up following the recovery.

METHODS

Five electronic databases including PubMed, Embase, ScienceDirect, the Cochrane Library, and Web of Science were systematically searched for relevant articles until Dec, 2022, and the reference of the enrolled studies were also reviewed. Dysphonia prevalence during and after COVID-19 infection, and voice-related clinical factors were analyzed; the random-effects model was adopted for meta-analysis. The one-study-removal method was used for sensitivity analysis. Publication bias was determined with funnel plots and Egger's tests.

RESULTS

Twenty-one articles comprising 13,948 patients were identified. The weighted prevalence of COVID-related dysphonia during infection was 25.1 % (95 % CI: 14.9 to 39.0 %), and male was significantly associated with lower dysphonia prevalence (coefficients: -0.116, 95 % CI: -0.196 to -0.036; P = .004) during this period. Besides, after recovery, the weighted prevalence of COVID-related dysphonia declined to 17.1 % (95 % CI: 11.0 to 25.8 %). 20.1 % (95 % CI: 8.6 to 40.2 %) of the total patients experienced long-COVID dysphonia.

CONCLUSIONS

A quarter of the COVID-19 patients, especially female, suffered from voice impairment during infection, and approximately 70 % of these dysphonic patients kept experiencing long-lasting voice sequelae, which should be noticed by global physicians.

Laryngotracheal Complications after Intubation for COVID-19: A Multicenter Study

Many of the patients with COVID-19 have suffered respiratory distress requiring prolonged endotracheal intubation (ETI) resulting in laryngotracheal complication with an impact on breathing, phonation, and swallowing. Our aim is to describe laryngeal injuries diagnosed after ETI in patients with COVID-19 in a multicentre study.

METHODS

A prospective descriptive observational study was conducted from January 2021 to December 2021, including COVID-19 patients with laryngeal complications due to ETI diagnosed in several Spanish hospitals. We analyzed the epidemiological data, previous comorbidities, mean time to ICU admission and ETI, need for tracheostomy, mean time on invasive mechanical ventilation until tracheostomy or weaning, mean time in ICU, type of residual lesions, and their treatment.

RESULTS

We obtained the collaboration of nine hospitals during the months of January 2021 to December 2021. A total of 49 patients were referred. Tracheostomy was performed in 44.9%, being late in most cases (more than 7-10 days). The mean number of days of ETI until extubation was 17.63 days, and the main post-intubation symptoms were dysphonia, dyspnea, and dysphagia, in 87.8%, 34.7%, and 42.9%, respectively. The most frequent injury was altered laryngeal mobility, present in 79.6%. Statistically, there is a greater amount of stenosis after late ETI and after delayed tracheostomy, not observing the data with the immobility alterations.

CONCLUSION

The mean number of days of ETI was long, according to the latest guidelines, with the need for several cycles of pronation. This long ETI may have had an impact on the increase of subsequent laryngeal sequelae, such as altered laryngeal mobility or stenosis.

The Health-related Quality of Life and Voice Handicap Index in Recovered COVID-19 Patients in Comparison to Healthy Subjects

INTRODUCTION

COVID-19 has various long-lasting effects on different aspects of health and life. This study aimed to evaluate the general health and voice-related quality of life (QOL) and assess their correlation in patients with COVID-19 compared to healthy people.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Sixty-eight subjects (with a mean age of 40.07 ± 5.62 years) participated in two groups including 34 recovered-COVID-19 patients and 34 healthy subjects. All participants completed the Persian version of Short Form 36 (SF-36) and Voice Handicap Index (VHI). The patients were assessed two months after recovery when they were discharged from the hospital.

RESULTS

The results showed the COVID-19 patients got significantly lower scores in all subcategories and two main components of SF-36 compared to the healthy group (P < 0.005). Also, the patients held significantly higher results in VHI and its subscales (P < 0.005). A significant correlation was observed between the physical and mental component summary (PCS and MCS) of SF-36 with a total score of VHI in the COVID-19 patients.

CONCLUSION

COVID-19 has negative consequences on various aspects of general health and voice-related QOL. Two months after recovery from COVID-19, the patients had the worst scores in all subscales of SF-36 and also, decreased physical, emotional, and functional voice-related QOL which reveals the persistent effect of COVID-19 even after recovery. The general health and voice-related QOL had a noticeable correlation in recovered COVID-19 patients that demonstrates the effect of voice quality in different aspects of life.

Long-term laryngological sequelae and patient-reported outcomes after COVID-19 infection

PURPOSE

We examine prevalence, characteristics, quality of life (QOL) assessments, and long-term effects of interventions for laryngeal dysfunction after recovery from COVID-19 infection.

MATERIALS AND METHODS

653 patients presenting to Yale's COVID clinic from April 2020 to August 2021 were identified retrospectively. Patients with PCR-positive COVID-19 who underwent evaluation by fellowship-trained laryngologists were included. Patient demographics, comorbidities, intubation/tracheostomy, strobolaryngoscopy, voice metrics, and management data were collected. Patient-reported QOL indices were Dyspnea Index (DI), Cough Severity Index (CSI), Voice Handicap Index-10 (VHI-10), Eating Assessment Tool-10 (EAT-10), and Reflux Symptom Index (RSI).

RESULTS

57 patients met inclusion criteria: 37 (64.9 %) were hospitalized for COVID-19 infection and 24 (42.1 %) required intubation. Mean duration between COVID-19 diagnosis and presentation to laryngology was significantly shorter for patients who were intubated compared to non-intubated (175 ± 98 days versus 256 ± 150 days, respectively, p = 0.025). Dysphonia was diagnosed in 40 (70.2 %) patients, dysphagia in 14 (25.0 %) patients, COVID-related laryngeal hypersensitivity in 13 (22.8 %), and laryngotracheal stenosis (LTS) in 10 (17.5 %) patients. Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms and 2 (11.8 %) patients reported resolution. VHI scores decreased for patients who reported symptom improvement. 7 (70 %) patients with LTS required >1 procedural intervention before symptom improvement. Improvement across QOL indices was seen in patients with LTS.

CONCLUSIONS

Laryngeal dysfunction commonly presents and is persistent for months after recovery from COVID-19 in non-hospitalized and non-intubated patients. Voice therapy and procedural interventions have the potential to address post-COVID laryngeal dysfunction.

Relation between Orotracheal Intubation, Inflammatory Markers, Breathing and Voice in Post-COVID-19

INTRODUCTION

COVID-19, an infectious disease with a wide spectrum of clinical manifestations and intensities in the human body, it can cause respiratory and vocal disorders, with fatigue.

OBJECTIVE

To verify the relation between biological Inflammatory markers D-dimers and C-Reactive Protein, Forced Vital Capacity, Maximum Phonation Time, vocal performance and fatigue, length of hospitalization period and gender of people affected by COVID-19 who were hospitalized, but did not use orotracheal intubation and compare with a group of post-COVID-19 patients with orotracheal intubation.

METHODS

Data on D-dimers and C-Reactive Protein, spirometry, Maximum Phonation Time, performance and vocal fatigue were collected. The study included 42 adult people affected by COVID-19 who were hospitalized, 22 (52.4%) female and 20 (47.6%) male; 23 (54.8%) critical cases composing the group with orotracheal intubation (average age 48.9 years old) and 19 (45.24%) severe cases in the group without orotracheal intubation (average age 49.9 years old).

RESULTS

hospital length of stay was significantly longer for the group with orotracheal intubation; D-dimers were significantly altered in all groups; correlations between maximum phonation times were positive and significant; correlations between maximum phonation times, vocal performance and fatigue were both negative and significant.

CONCLUSION

Patients with orotracheal intubation had longer hospital internment and increased D-dimers and were amazed that, whenever maximum phonation times decreased performance and vocal fatigue increased.

Dysphonia Severity Index and Consensus Auditory-Perceptual Evaluation of Voice Outcomes, and Their Relation in Hospitalized Patients with COVID-19

OBJECTIVES

This study aimed to compare the results of the Dysphonia Severity Index (DSI) and Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) between patients hospitalized with COVID-19 and healthy subjects, as well as to investigate the correlation between DSI and CAPE-V.

STUDY DESIGN

Cross-sectional survey.

MATERIAL AND METHODS

Eighty subjects, 40 COVID-19 patients (with a mean age of 41.2± 5.41) and 40 healthy subjects (with a mean age of 44.50± 3.50) participated in this study. Assessments included the DSI for aerodynamic-acoustic measurement and the Persian version of Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) for evaluating auditory-perceptual voice quality. Data were analyzed by means of the independent t-test and Pearson correlation at the 5% significance level.

RESULTS

The results showed COVID-19 patients got significantly lower score in DSI compared to healthy subjects (P < 0.05). Moreover, the patients with COVID-19 had higher scores in all categories of voice production (severity, roughness, loudness, pitch, strain and breathiness) than the healthy group (P < 0.05). Comparing the result of the two voice assessments in each group revealed that there was a greater negative significant correlation in the diseased group (r p: -0.68, P: 0.001) than in the healthy group (r p: -0.37,P: 0.049).

CONCLUSIONS

Hospitalized COVID-19 patients experience deviations in the voice quality and acoustic-aerodynamic features of their voice. Also, the results of this study showed the patient group had higher perceptual dysphonia and lower voice quality compared to the healthy group. Further studies are recommended to determine the relationship between objective and subjective voice evaluation in patients with COVID-19 after recovery.

Current opinion of presentation of dysphagia and dysphonia in patients with coronavirus disease 2019

PURPOSE OF REVIEW

Dysphagia and dysphonia are common presentations of both acute and long coronavirus disease 2019 (COVID-19). The majority of peer-reviewed publications in 2020 and early 2021 were expert guidance and consensus statements to support dysphagia management in multidisciplinary teams while protecting clinicians and patients from the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. This review discusses dysphagia and dysphonia primary data published in 2021-2022, focusing on patient presentations, pathophysiology, and evidence for interventions.

RECENT FINDINGS

Clinicians and researchers amassed knowledge of the cross-system presentation of dysphagia and dysphonia in patients with COVID-19, from severe disease requiring ICU stays to those with mild-to-moderate disease presenting to outpatient clinics. Pre-COVID-19 health status, hospitalization experience, presence of neurological symptoms, and impact of the virus to the upper aerodigestive and respiratory system need consideration in patient management. Long-term dysphagia and dysphonia manifested from COVID-19 require otolaryngologist and speech-language pathologist input.

SUMMARY

Changes in immunity through population vaccination and variations in COVID-19 from SARS-CoV-2 mutations means prevalence data are challenging to interpret. However, there is no doubt of the presence of long-term dysphagia and dysphonia in our clinics. Long-term dysphagia and dysphonia are complex and a multidisciplinary team with a tailored approach for each patient is required.

Isolated Severe Dysphonia as a Presentation of Post-COVID-19 Syndrome

This is the first study assessing the clinical management of severe, isolated dysphonia during post-COVID-19 syndrome. One hundred and fifty-eight subjects met the inclusion criteria for the post-COVID-19 condition as specified by the WHO. Six patients were diagnosed with isolated severe dysphonia, constituting 3.8% of the initial group. The pre- and post-examination protocol consisted of subjective voice self-assessment and routine laryngological examination, followed by an instrumental examination by means of Laryngovideostroboscopy (LVS) and High-Speed Videolaryngoscopy (HSV). The treatment included short-term systemic steroids in decreasing doses, moisturizing inhalations with hyaluronic acid, and protective agents against Laryngopharyngeal Reflux. The kinematic imaging of the glottis performed by means of HSV before treatment showed deviations in the regularity and symmetry of vocal fold vibrations, absence of mucosal wave, and incomplete glottal closure. Improvement of the structural and functional state of the larynx was observed post-treatment. Kymographic sections and Glottal Width Waveform (GWW) graphs obtained from post-treatment HSV recordings showed improvement in vocal fold vibrations. The decrease in mean Jitter and Shimmer was observed, with the following mean values of 3.16 pre-treatment and 2.97 post-treatment for Jitter and 7.16 pre-treatment and 2.77 post-treatment for Shimmer. The post-treatment self-evaluation of voice showed considerable improvement in vocal function and voice quality in all the examined patients. Severe dysphonia in patients with post-COVID-19 syndrome requires urgent ENT diagnosis using instrumental assessment with the evaluation of laryngeal phonatory function and intensive comprehensive treatment.