Priya Krishna

Normative values for the Voice Handicap Index-10.

OBJECTIVES The objective of this study was to elucidate the normative values for the Voice Handicap Index-10 (VHI-10) questionnaire. METHODS VHI questionnaires were completed by 190 subjects without voice complaints. The results were then analyzed for mean, standard error of the mean (SEM), and standard deviation (SD) for both the original VHI and VHI-10 subset questionnaires. Outliers were defined as being more than three standard deviations above the mean. RESULTS Analysis of 156 VHI questionnaires revealed a mean of 6.86 (SEM=0.79, SD=9.88) for the normative values. One hundred fifty-eight VHI-10 questionnaires were analyzed to show a mean of 2.83 (SEM=0.31, SD=3.93) for the normative values. CONCLUSIONS This study offers normative data for the VHI-10 that has been missing in the literature. A VHI-10 score >11 should be considered abnormal.

Operating Room Versus Office‐Based Injection Laryngoplasty: A Comparative Analysis of Reimbursement

Background: Injection laryngoplasty (IL) continues to evolve as new indications, techniques, approaches, and injection materials are developed. Although historically performed under local or general anesthesia in the operating room suite, IL is now increasingly being performed in an office‐based setting. This report presents the results of a reimbursement analysis comparing office‐based versus operative IL.

Effects of Transforming Growth Factor-β1 on Human Vocal Fold Fibroblasts

Objectives: We studied the effect of transforming growth factor (TGF)–β on immortalized human vocal fold fibroblasts. Methods: Normal human vocal fold fibroblasts were subjected to sequential lentiviral transduction with genes for human telomerase (hTERT) and SV40 large T antigen in order to produce an “immortalized” cell line of normal phenotype. After confirmation of vocal fold fibroblast transfection, these cells, referred to as HVOX, were treated with various concentrations of exogenous TGF-β1 and assayed for collagen secretion, migration, and proliferation. In addition, components of the TGF-β signaling pathway were examined in this cell line. Results: TGF-β stimulated collagen secretion and migration without altering proliferation of HVOX. HVOX constitutively expressed type I and II TGF-β receptors, as well as messenger RNA for the Smad signaling proteins and for all TGF-β isoforms. Exogenous TGF-β1 induced temporally dependent alterations in Smad2 and Smad3 gene expression. TGF-β increased Smad7 expression at both 4 and 24 hours. Prolonged exposure to TGF-β decreased TGF-β1 gene expression. Conclusions: Insight into the underlying pathophysiology of vocal fold fibrosis is likely to yield improved therapeutic strategies to mitigate vocal fold scarring. Our data suggest that TGF-β signaling may be both paracrine and autocrine in this vocal fold fibroblast cell line, and we therefore propose that TGF-β may be a reasonable target for therapies to prevent and/or treat vocal fold fibrosis, given its putative role in both acute and chronic vocal fold injury, as well as its effects on vocal fold fibroblasts.

Patient tolerance of awake, in‐office laryngeal procedures: A Multi‐Institutional Perspective

An increasing number of laryngeal procedures are performed in the office. However, little is known about how well these procedures are tolerated and what factors determine success or failure.

Primed fibroblasts and exogenous decorin: Potential treatments for subacute vocal fold scar

OBJECTIVE To investigate hepatocyte growth factor (HGF) primed fibroblasts and decorin application on skin and vocal fold fibroblasts in vitro and in vivo in rabbit vocal fold scar model. STUDY DESIGN AND SETTING: Vocal fold and skin fibroblasts underwent five in vitro treatment conditions: control, epidermal growth factor, HGF, both decorin and HGF, and decorin alone. Hyaluronic acid and collagen enzyme-linked immunosorbent assays were performed. In vivo, 12 rabbits underwent unilateral vocal fold stripping. Injured vocal folds were then injected with skin fibroblasts, HGF, HGF-primed fibroblasts and decorin, or decorin. Outcomes included histologic and lamina propria height analyses. RESULTS: In vitro, HGF increased hyaluronic acid synthesis in vocal fold fibroblasts (P < 0.001). HGF and decorin treatment diminished collagen secretion (P < 0.01). In vivo, histologic findings indicated minimal difference in collagen amount between treatment groups. CONCLUSION: HGF and decorin together may decrease collagen production by skin and vocal fold fibroblasts. Fibroblast transplantation into scarred vocal folds has equivocal benefit.

Prospective investigation of nimodipine for acute vocal fold paralysis

Introduction: Nimodipine has been shown to be beneficial for recovery from acute vocal fold paralysis (AVFP) in an animal model. Methods: prospective, open‐label trial of patients with AVFP was performed using nimodipine. Consecutive patients were evaluated and offered nimodipine therapy. Results: Fifty‐three patients were considered for treatment with nimodipine. Thirteen did not qualify for inclusion, 5 were lost to follow‐up, and 7 had side effects requiring cessation of treatment. Thus 28 patients (30 paralyzed vocal folds) were analyzed. Eighteen of the paralyzed vocal folds experienced recovery of purposeful motion (60%). Historical controls and laryngeal electromyography meta‐analysis suggest no more than a 20% recovery rate from AVFP. Conclusions: This open label study using nimodipine for treatment of AVFP demonstrates tripling of the recovery rate of vocal fold motion compared with historical controls. Further study in a randomized, controlled manner is warranted. Muscle Nerve 50: 114–118, 2014

The effects of decorin and HGF-primed vocal fold fibroblasts in vitro and ex vivo in a porcine model of vocal fold scarring.

Vocal fold injury can be irreversible, leading to vocal fold scarring, with permanent functional effects and no optimal treatment. A porcine model of vocal fold scarring was used to test effects of decorin and primed vocal fold fibroblasts in vitro using a cell migration assay and immunoblotting, and by using functional measurements of porcine larynges and excised porcine vocal folds.

Assessment of Clinical and Social Characteristics That Distinguish Presbylaryngis From Pathologic Presbyphonia in Elderly Individuals

Importance An aging population experiences an increase in age-related problems, such as presbyphonia. The causes of pathologic presbyphonia are incompletely understood. Objective To determine what distinguishes pathologic presbyphonia from presbylaryngis. Design, Setting, and Participants This was a cohort study at an outpatient otolaryngology subspecialty clinic of a tertiary academic referral center. Participants were consecutive consenting adults older than 74 years without laryngeal pathologic abnormalities who visited the clinic as participants or companions. Patient questionnaires, otolaryngologic, video stroboscopic, and voice examinations were compiled. Patients were divided into groups based on whether they endorsed a voice complaint. Three blinded authors graded stroboscopic examinations for findings consistent with presbylaryngis (vocal fold bowing, vocal process prominence, glottic insufficiency). Main Outcomes and Measures Voice Handicap Index–10, Reflux Symptom Index, Cough Severity Index, Dyspnea Index, Singing Voice Handicap Index-10 , Eating Assessment Tool -10, Voice-Related Quality of Life (VRQOL), and Short-Form Health Survey; face-sheet addressing social situation, work, marital status, education, voice use, transportation; acoustic and aerodynamic measures; and a full otolaryngologic examination, including videostroboscopic imaging. Results A total of 31 participants with dysphonia (21 were female; their mean age was 83 years [range, 75-97 years]) and 26 control participants (16 were female; their mean age was 81 years [range, 75-103 years]) completed the study. Presbylaryngis was visible in 27 patients with dysphonia (87%) and 22 controls (85%). VHI-10 and VRQOL scores were worse in patients with pathologic presbyphonia (median [range] VHI-10 scores, 15 (0-40) vs 0 (0-16) and median VRQOL score, 19 [0-43] vs 10 [10-23]). All other survey results were indistinguishable, and no social differences were elucidated. Acoustic measures revealed that both groups averaged lower than normal speaking fundamental frequency (mean [SD], 150.01 [36.23] vs 150.85 [38.00]). Jitter was 3.44% (95% CI, 2.46%-4.61%) for pathologic presbyphonia and 1.74% (95% CI, 1.35%-2.14%) for controls (d = 0.75). Shimmer means (95% CI) were 7.8 2 (6.08-10.06) for the pathologic presbyphonia group and 4.84 (3.94-5.72) for controls (d = 0.69). Aerodynamic measures revealed an odds ratio of 3.03 (95% CI, 0.83-11.04) for patients with a maximum phonation time of less than 12 seconds who had complaints about dysphonia. Conclusions and Relevance Presbylaryngis is present in most ambulatory people older than 74 years. Some will endorse pathologic presbyphonia that has a negative effect on their voice and quality of life. Pathologic presbyphonia seems to be influenced by respiratory capacity and sex. Further study is required to isolate other social, physiologic, and general health characteristics that contribute to pathologic presbyphonia.

Should Antiviral Medications Be Considered Preoperatively for Microlaryngoscopy in Patients With a History of Recurrent Herpes Stomatitis

Infectious complications following phonomicrosurgery are rare. Reports of herpetic laryngitis are in the literature but none following microlaryngoscopy. We present a case of a 55-year-old female who underwent microsurgical excision of a left vocal fold (VF) lesion and KTP ablation of bilateral vascular ectasias. Postoperative stroboscopy demonstrated severe bilateral VF edema, erythema, and ulcerations of the VFs, encompassing an area greater than the original surgical field. Initial management included voice rest, antibiotics, steroids, and aggressive reflux treatment. The patient experienced prolonged VF edema and poor voice outcome, which ultimately resolved over 6 months. Clinical diagnosis of herpetic laryngitis was presumptively made after the patient revealed a history of relapsing oral herpes incited by stress with a recent episode before microlaryngoscopy. This case highlights the importance of thorough review of a patients medical history. A protocol for preoperative (prophylactic) antiviral therapy and appropriate timing of surgery is presented for patients with history of herpes infection.

Acute Glutaraldehyde Mucosal Injury of the Upper Aerodigestive Tract Due to Damage to the Working Channel of an Endoscope

Objectives Glutaraldehyde (Cidex) is a commonly used agent for cold sterilization of endoscopes despite its known irritative, allergic, and carcinogenic potential. This report details the clinical course of 2 patients who suffered acute glutaraldehyde exposure during office injection procedures. Methods Clinical records of 2 outpatients undergoing office injection procedures were reviewed. One patient underwent bilateral injections of hydroxyapatite, and 1 underwent voice gel injection. Results Both patients developed acute mucosal injury in the form of supraglottitis and laryngitis. Both patients required inpatient admission with airway monitoring (1 requiring admission to the intensive care unit) and were treated with steroids and antibiotics. The same channel endoscope was used for both procedures and was noted after careful examination to have retained glutaraldehyde inside the scope due to a perforation of the lining of the working channel. Conclusions Glutaraldehyde can cause acute mucosal injury to supraglottic and glottic structures, and diligent procedures must be maintained for flushing the channels and monitoring glutaraldehyde retention in the channels. Great care should be taken to avoid damage to the lining of working channels from instrumentation.