PurposeOver 4.5 million people in North America had a diagnosis of dementia in the year 2000, and more than half had advanced disease with potential aspiration risk. There is much controversy regarding the use and timing of enteral feeding support in these patients with dysphagia. The management of dysphagia is far more complex when considering quality of life, “comfort care” hand feeding, the use of percutaneous endoscopic gastrostomy tube (PEG), and associated mortality rates. This study seeks to critically review the literature that evaluates PEG placement in this population.MethodsA systematic literature review of PubMed, from 1995–2012, was conducted to identify studies relating to PEG placement in dementia patients with dysphagia. The principal outcomes and related survival rates for this population were compared.ResultsIn total, 100 articles were identified in the search. Of these, ten met the search criteria and were analyzed. There was one study with a 2b level of evidence, one with 3b, and the remainder had level 4. All studies discussed long-term survival in the PEG versus non-PEG populations. No studies showed definitive evidence to suggest long-term survival rates improved in patients who underwent PEG placement as compared to those who did not. Two studies documented median survival worse in patients over age 80 with dementia and PEG placement.ConclusionThere is presently no evidence to suggest long-term survival rates improved in patients with advanced dementia who underwent PEG placement for dysphagia. Relevance to quality of life, need for nutrition and hydration, and ethical considerations in the decision process are discussed.
Objectives/Hypothesis VT is often considered the preferred treatment for vocal feminization in transgender patients. However, Wendler glottoplasty offers a surgical option for increasing fundamental frequency and perception of vocal femininity. We aimed to determine whether the addition of glottoplasty to VT results in greater fundamental frequency elevation and improvement in quality‐of‐life measures. Study Design Retrospective case series. Methods Forty‐eight trans female patients were treated for vocal feminization. Twenty‐seven patients underwent VT, and 21 patients underwent VT with additional glottoplasty (VTWG). Pre‐ and posttreatment acoustic measures, Trans Woman Voice Questionnaire (TWVQ), and Voice Handicap Index‐10 (VHI‐10) data were compared. Results Glottoplasty in combination with VT elevated average speaking fundamental frequency (SF0) to a greater extent than VT alone (P < .0001). The VTWG group achieved a 42‐Hz increase in SF0, whereas the VT group achieved a 15‐Hz increase in SF0. In both the VT and VTWG groups, the lower bound of physiologic range increased by 18 Hz (P = .0008 and P = .016, respectively). The addition of glottoplasty also resulted in greater improvement in voice‐related quality of life. Improvement in TWVQ and VHI‐10 was significantly greater in the VTWG group than the VT group (P = .007 and P = .029, respectively). TWVQ showed statistically significant improvement in the VTWG group only. Conclusions VT results in SF0 elevation and improvement in VHI‐10. The addition of glottoplasty to VT results in further improvements in SF0 and VHI‐10 and statistically significant improvement in TWVQ. Level of Evidence 4 Laryngoscope, 131:1588–1593, 2021
Objectives Formal evaluation of health states related to dysphonia have not been rigorously evaluated in affected patients. The objective of this project was to evaluate the health states of mild, moderate, and severe dysphonia using formal health state preference evaluation, and to compare these outcomes with the degree of voice handicap. Design Prospective health state preference assessment. Methods A convenience sample of patients presenting with voice complaints were enrolled from an academic voice center. Demographic and voice handicap index (VHI‐10) data were obtained, and an assessment of preference for five health states (monocular blindness, binocular blindness, mild dysphonia, moderate dysphonia, and severe dysphonia) was performed. Utility scores were calculated on a scale from 0 (death) to 1 (perfect health). Analysis was performed with ANOVA testing with post‐hoc comparisons and correlation statistics. Results Of 209 assessments, 149 (75.6%) met quality criteria. Relative to monocular blindness (score 0.61 [CI 0.57–0.64]), moderate dysphonia (0.58 [0.54–0.62]) was rated equivalently, with severe dysphonia (0.33 [0.29–0.37]) ranking significantly worse and mild dysphonia (0.96 [0.95–0.98]) significantly better. Binocular blindness (0.18 [0.15–0.21]) was the worst‐ranked health state. There was a weak inverse correlation of VHI‐10 with dysphonia‐related preference scores; with worsening reported voice handicap, scores decreased. Conclusion This study demonstrated that dysphonia had a significant impact of quality of life, with moderate dysphonia ranking equivalently with monocular blindness. These numerical estimates may be used for ongoing research into the value and cost‐effectiveness of medical, therapeutic, and surgical interventions for voice disorders. Level of Evidence 2c (outcomes research) Laryngoscope, 130:E177–E182, 2020
Objectives Voice therapy has been the primary treatment for voice feminization in transfemale patients due to concerns that surgery worsens voice quality. We aim to determine the impact of Wendler glottoplasty on acoustic measures of voice. Study Design Retrospective case series. Methods Transgender female patients treated for vocal feminization with Wendler glottoplasty at a single tertiary care center were identified. Pre‐ and postoperative measures were taken with the Kay Elemetrics Real‐Time Pitch, Analysis of Dysphonia in Speech and Voice, and Multidimensional Voice Program. Results Twenty‐eight patients were included in this study. There were no statistically significant changes in fundamental frequency variation, peak amplitude variation, soft phonation index, noise‐to‐harmonics ratio, cepstral peak prominence, or cepstral spectral index of dysphonia at a significance level of P < .05. Average speaking fundamental frequency (SF0) increased from 143 Hz after voice therapy to 163 Hz after surgery (P = .0009). Lower range decreased in 61% and increased in 26% of patients. Upper range decreased in 52% and increased in 48% of patients. Conclusions Wendler glottoplasty does not worsen voice quality based on acoustic measures. Although most patients experience an increase in average SF0, effects on vocal range are variable with approximately half of patients experiencing a reduction and half experiencing an increase in upper pitch limit. Level of Evidence 4 Laryngoscope, 131:583–586, 2021
Objectives Although patient‐reported outcome measures (PROMs) can be useful for assessing quality of life, they can be complex and cognitively burdensome. In this study, we prospectively evaluated a simple patient‐reported voice assessment measure on a visual analog scale (VAS voice) and compared it with the Voice Handicap Index (VHI‐10). Study design Prospective survey. Methods An abbreviated voice measure was designed by a team of otolaryngologists, speech pathologists, and patients that consisted of four VAS questions related to (a) a global question of voice disturbance, (b) physical function of voice, (c) functional issues, and (d) emotional handicap. All English‐speaking patients presenting to an academic laryngology clinic for a voice complaint were included. Internal consistency and validity were assessed with comparison to the VHI‐10. Results A total of 209 patients were enrolled. Ninety‐two percent of patients reported understanding the survey. The four‐item VAS survey was highly correlated with VHI‐10 score (Pearson correlation .81, P < .0001), and the Cronbach's alpha between all four VAS questions was .94. Age, gender, and diagnosis were not associated with either the global VAS or VHI‐10 tool. Conclusion Reducing the complexity of instruments assessing voice‐related quality of life is feasible, and the VAS voice correlated with existing measures. Simplified assessments may offer advantages compared to more cumbersome PROMs. Level of Evidence 2c
ObjectivesGains in pitch from gender affirming voice training (GVT) alone in trans women have historically been shown to decline after 1 year. Currently no standard exists for length and type of GVT that yields meaningful behavioral change and patient satisfaction with voice outcomes in trans women. This study aims to determine whether GVT alone leads to sustained pitch elevation and patient satisfaction in trans women.MethodsRetrospective review from 2016 to 2020 of trans women patients who underwent GVT alone for voice change. Charts were reviewed for acoustic analysis of pitch including sustained vowel fundamental frequency, speaking fundamental frequency, and quality of life data from the Trans Woman Voice Questionnaire at pre‐therapy, immediate post‐therapy, and extended post‐therapy time intervals.ResultsA total of 157 patients presented to our Voice Center, of which 34 participated in the full course of GVT. Patients underwent an average of six sessions of GVT (range 5–7) over an average of 13.14 weeks (range 6–16). Average time between completing GVT and presenting for extended follow‐up was 11.37 months (range 6–31). Compared to initial presentation prior to therapy, at extended follow‐up after completing GVT average change in F0/a/, SF0, and TWVQ were 64.6 Hz, 31.3 Hz, and 32.45. No significant change was noted between immediate post‐therapy and extended post‐therapy acoustic measures. TWVQ demonstrated continued improvement between immediate post‐therapy and extended post‐therapy.ConclusionsIn self‐selected patients who present for extended follow‐up, GVT alone can result in sustained pitch elevation and voice‐related quality life in trans women.Level of Evidence4 Laryngoscope, 133:2340–2345, 2023
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