Daniela Ginocchio

Prevalence and Voice Characteristics of Laryngeal Pathology in an Italian Voice Therapy-seeking Population.

OBJECTIVES The aim of this study was to determine the prevalence and clinical characteristics of voice disorders in a large group of patients seeking voice therapy. STUDY DESIGN This is a prospective prevalence study. METHODS A total of 821 patients were enrolled. Each patient was evaluated following a multidimensional protocol including videolaryngostroboscopy, perception, acoustics, aerodynamics, and self-rating by the patient. Data regarding age, gender, tobacco use, gastroesophageal reflux disease (GERD), and professional voice use were collected and analyzed. RESULTS Based on videolaryngoscopic findings, the sample group was divided into patients with functional dysphonia (n = 155), patients with organic dysphonia (n = 359), and patients with dysphonia due to movement disorders (n = 307). The most frequently detected pathologies were vocal fold paralysis, muscle tension dysphonia, and vocal fold edema. Children (n = 41) and adolescents (n = 43) represented a minority of the sample group. Dysphonia was significantly more common in women. Organic dysphonia was more common in children and adolescents. GERD was suspected in 382 patients and confirmed in 83 of them; 164 patients were smokers. Professional voice users composed the large majority of the working population and were more frequently affected by organic dysphonia. Patients with dysphonia due to movement disorders presented a worse voice quality and voice-related quality of life. CONCLUSIONS In patients seeking voice therapy, there are more females than males, children and adolescents represent a minority of the sample, professional voice users more commonly present organic dysphonia, and patients with dysphonia due to movement disorders show significantly worse voice quality.

FEESST in the Rehabilitation of Dysphagia after Partial Laryngectomy

Objectives: We describe the role of the laryngeal adductor reflex (LAR) and fiberoptic endoscopic evaluation of swallowing with sensory testing (FEESST) in the rehabilitation of patients with oropharyngeal dysphagia after partial laryngectomy. Methods: Ten patients with a mean age of 64 years (range, 45 to 72 years) were included in the study. Seven patients underwent supraglottic laryngectomy, and 3 had supracricoid laryngectomy. Six patients underwent additional radiotherapy (RT), and 8 had functional neck dissection (ND). FEESST was performed on each patient in order to establish a swallowing rehabilitation program. Results: In 2 patients, not submitted to either ND or RT, the LAR was preserved; in 6 patients, who underwent both procedures, the LAR was delayed or absent. In 2 patients who underwent ND but not RT, the LAR was preserved in 1 case and delayed in the other. The patients with an absent LAR presented severe aspiration, whereas in those with a preserved LAR, no penetration was found. Moderate aspiration was found in the remaining patients. In the patients with a reduced or absent LAR, tactile and chemical sensory stimulation was added to the rehabilitation program. Conclusions: FEESST represents a useful tool in everyday clinical practice for the planning of swallowing rehabilitation after partial laryngectomy.

Cross-Cultural Adaptation and Validation of the Italian Version of the Voice Symptom Scale (I-VoiSS)

OBJECTIVES To evaluate the reliability and validity of the Italian Voice Symptom Scale (I-VoiSS). STUDY DESIGN Cross-sectional, nonrandomized, prospective study with controls. METHODS The study consisted of five phases: item generation, reliability analysis, normative data generation, validity and responsiveness analysis. A group of 113 dysphonic patients was enrolled for the internal consistency analysis. Seventy-three of them completed the I-VoiSS twice, 2 weeks apart, for test-retest reliability analysis. A group of 150 vocally healthy participants completed the I-VoiSS for normative data generation. I-VoiSS scores obtained by dysphonic and vocally healthy participants were compared for validity analysis. I-VoiSS scores were correlated with those of the Italian version of the Voice Handicap Index (I-VHI) in 49 dysphonic patients for criterion validity analysis. I-VoiSS scores obtained in a group of 37 nonsmoker dysphonic patients before and after surgical treatment for vocal fold polyps were compared for responsiveness analysis. Finally, the cutoff value of the I-VoiSS was calculated. RESULTS All the enrolled participants managed to complete the I-VoiSS autonomously. Internal consistency and test-retest were satisfactory (α = 0.92 and r = 0.91). A significant difference in the I-VoiSS scores between the dysphonic and vocally healthy participants was found (p = 0.001). Positive significant correlations were found between I-VoiSS and I-VHI scores (r = 0.85). I-VoiSS scores obtained in the pretreatment condition were significantly higher than those obtained after surgery (p = 0.001). The cutoff value of I-VoiSS was 15.5. CONCLUSION I-VoiSS is reliable, valid, responsive to changes, and recommended for clinical practice and outcome research.

Audiovestibular disorders as autoimmune reaction in patients with melanoma

Melanoma is an aggressive form of cancer derived from neuroectodermal melanocytes. Melanocytes are present in the skin and hair follicles, as well as in the eye (iris and choroids), the leptomeninges, the anal canal and the inner ear. In the inner ear melanocytes are found both in the intermediate layer of the stria vascularis of the cochlea and in the dark cells of the vestibular organs. They are believed to play an important role in the production of endolymphatic potentials and in the maintenance of normal volumes of the inner ear fluids. Recently, audiovestibular dysfunctions have been demonstrated in patients treated with immunotherapy for metastatic melanoma and have been related to an autoimmune attack on the normal melanocytes of the inner ear. Melanoma is an immunogenic tumor type frequently associated with spontaneous autoimmune manifestations which seem to be associated with better prognosis. The melanoma-associated antigens are also expressed in normal melanocytes in the skin, eye and ear. We hypothesize that inner ear melanocytes could be a target of an autoimmune process in patients affected by melanoma. The immune system could produce antibodies that cross-react with both the melanoma cells and the labyrinth melanocytes causing an altered homeostasis of endolymphatic liquids and provoking some labyrinthic disorders such as vertigo, hearing loss, aural fullness and tinnitus resembling or influencing Ménières disease. In this perspective, audiovestibular disorders could be interpreted as an attempt by the individual immune system to develop anti-tumor response. In patients affected by melanoma an autoimmune genesis has already been advocated for ocular symptoms in melanoma-associated retinopathy, where the cross-reaction happens against retinal cells. A possible role of inner ear melanocytes should be considered as a potential cause of audiovestibular disorders. Further research is needed to demonstrate a connection between melanoma and labyrinth dysfunctions such as in melanoma-associated retinopathy.

Exacerbation of audiovestibular symptoms in a patient with Ménière's disease and choroidal melanoma.

We report the case of a man affected by a unilateral Ménières disease who, after being free from vertigo spells and tinnitus for more than ten years, manifested an exacerbation of symptoms just before the diagnosis of a choroidal melanoma. Melanoma is an aggressive form of cancer derived from neuroectodermal melanocytes. Melanocytes are present in the inner ear where they contribute to the production of endolymphatic potentials and to the maintenance of normal volumes of the inner ear fluids. A possible autoimmune connection between the exacerbation of audiovestibular symptoms and melanoma is discussed.

Benign paroxysmal positional vertigo and tinnitus.

INTRODUCTION In our clinical experience, some of the patients affected by benign paroxysmal positional vertigo (BPPV) reported the onset of tinnitus shortly before or in association with the positional vertigo. OBJECTIVES The aim of this study was to describe the prevalence and the clinical patterns of tinnitus episodes which occurred in association with BPPV and to suggest possible interpretative hypotheses. METHODS 171 normal hearing patients affected by BPPV (50 males and 122 females; age range: 25-77 years; mean age 60.3 years ± 14.9) underwent pure tone audiometry, immittance test and a clinical vestibular evaluation before and after repositioning manoeuvers. Those suffering from tinnitus were also assessed using visual analogue scales and tinnitus handicap inventory. RESULTS 19.3% of the patients reported the appearance of tinnitus concurrently with the onset of the positional vertigo. It was mostly unilateral, localized on the same ear as the BPPV, slight in intensity and intermittent. Tinnitus disappeared or decreased in all patients except two, either spontaneously, before performing the therapeutic manoeuvers, or shortly after. CONCLUSIONS A possible vestibular origin of tinnitus determined by the detachment of macular debris into the ductus reuniens and cochlear duct is discussed.

Cross-cultural Adaptation and Validation of the Italian Version of the Vocal Tract Discomfort Scale (I-VTD)

OBJECTIVE To evaluate the reliability and validity of the Italian version of the VTD scale (I-VTD scale). STUDY DESIGN Cross-sectional, nonrandomized, prospective study with controls. METHODS For the item generation, a cross-cultural adaptation and translation process was performed following the back translation process (phase 1). For reproducibility analysis (phase 2), 102 patients with dysphonia were recruited (internal consistency analysis); 57 of them completed the I-VTD scale twice (test-retest reliability analysis). Seventy-three vocally healthy participants completed the I-VTD scale for normative data generation (phase 3). For validity analysis (phase 4), the scores obtained by patients with dysphonia and by vocally healthy participants were compared (construct validity analysis); in addition, 45 patients with dysphonia completed both the I-VTD scale and the Italian version of the Voice Handicap Index for criterion validity analysis. Finally, for responsiveness analysis (phase 5), a cohort of 30 patients with muscle tension dysphonia was recruited, and scores of the I-VTD scale before and after voice therapy were compared. RESULTS Both the internal consistency and the test-retest reliability of the I-VTD scale were satisfactory. The scores obtained by patients with dysphonia and vocally healthy participants were significantly different. Moderate correlations between the Italian version of the Voice Handicap Index and the I-VTD scores were found. Finally, the scores of the I-VTD scale obtained in pretreatment conditions appeared to be significantly higher than those obtained after successful voice therapy. CONCLUSION The I-VTD scale appears a reliable and valid instrument for the assessment of vocal tract discomfort in Italian-speaking patients.

Neuromuscular Electrical Stimulation for Treatment-Refractory Chronic Dysphagia in Tube-Fed Patients : A Prospective Case Series

Objective: The aim of this study was to evaluate the role of neuromuscular electrical stimulation (NMES) in tube-fed patients with severe and chronic dysphagia refractory to traditional swallowing therapy (TT). Patients and Methods: A total of 11 consecutive dysphagic patients with tube-dependent nutrition and who had not responded to 6 months of TT were enrolled. Each patient received NMES for 30 min and TT for 30 min, twice a day, 5 days per week for 4 weeks. In order to evaluate the swallowing impairment, each patient underwent a fiberoptic endoscopic examination of swallowing immediately before the beginning of the treatment, after 2 weeks and after 4 weeks. Results: All enrolled patients managed to complete the swallowing treatment protocol for at least 2 weeks. After the 4-week treatment, 6 of 11 enrolled patients passed to a total oral diet with single or multiple consistencies despite specific food limitations or special preparation or compensation. Five patients, all affected by the most severe form of dysphagia, maintained tube-dependent nutrition. Conclusion: NMES as adjunctive treatment to TT may offer a new possibility for the management of tube-fed patients who are refractory to TT.