Effectiveness of voice therapy after recovery from COVID-19 infection: A Rare Case Report

doi:10.21203/rs.3.rs-2499932/v1

Download PDF

Research Article

Effectiveness of voice therapy after recovery from COVID-19 infection: A Rare Case Report

https://doi.org/10.21203/rs.3.rs-2499932/v1

This work is licensed under a CC BY 4.0 License

Version 1

posted

You are reading this latest preprint version

Introduction: COVID-19 induces ear, nose, and throat (ENT) difficulties in nearly 57.4 percent of patients. In patients with COVID-19, voice disorder and dysphonia can be created by shortness of breath, upper airway congestion, and changes in the larynx.

Case Presentation: We aimed to study the effect of voice therapy (VT) on a woman who suffered from long-term post-COVID-19 dysphonia and recurrent coughs that interrupted the connected speech. This study is a single case report. The patient was a 33-year-old woman referred by a laryngologist to the VT clinic with the diagnosis of muscle tension dysphonia (MTD). All voice assessments were conducted during two sessions before and after 10 sessions of VT. The evaluations included laryngostroboscopy, perceptual voice assessment, and acoustic-aerodynamic voice measurement. After that, ten sessions of Eclectic VT were done by a voice therapist. Following VT, the results showed better findings in all aspects of voice assessments.

Conclusions: The results of this study showed improvement of different aspects of voice after Eclectic VT and also, and the effectiveness of VT for decreasing dysphonia post-COVID-19. Although significant improvement was achieved, there was some degree of dysphonia and recurrent coughs after VT. These findings indicated that some side-effects of COVID_19 are persistent even after VT. This case report can highlight the sensory-motor deficit hypothesis or damage in ACE2 receptor in the larynx after COVID_19, but it still needs more investigations.

COVID_19

larynx

voice disorder

dysphonia

voice therapy

recurrent cough

case report

The world confronted a new coronavirus strain in 2019 known as Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-COV-2^{^[1]}) (Chan et al., 2020; Singhal, 2020; Wu & McGoogan, 2020) called COVID-19 (Elibol, 2021). Cough, anosmia, and sore throat were the most often reported otolaryngological symptoms (Elibol, 2021). Recent research reports that otolaryngological complications in COVID-19 include dysphonia, sore throat, nasal obstruction, and rhinorrhea (Lechien et al., 2021). Additionally, the most commonly reported vocal complaints during COVID-19 treatment are dry throat and voice fatigue, particularly in individuals with persistent cough (A. P. Dassie-Leite et al., 2021). Coughing is one of the prevalent symptoms of COVID-19, occurring in 76 % of patients, and can result in edema, vocal fold irritation, and even phonotrauma (Halpin et al., 2021). Based on the previous studies, there is a strong correlation between voice problems and respiratory disturbances in different voice disorders in patients with COVID-19. On the other hands, adequate respiratory support is necessary for proper subglottic airflow and phonation, which is widely affected by COVID-19 due to respiratory conflicts (Azzam, Samy, Sefein, & ElRouby, 2021; Coelho, Siqueira, Fadel, Rosa, & Dassie-Leite, 2018; Ana Paula Dassie-Leite et al., 2021).

As mentioned previously, dysphonia can be a sign of COVID-19 and persistent even after recovery (Cantarella et al., 2021). The prevalence of dysphonia as an apparent sign of COVI D-19 infection was estimated at up to 79% (Watson et al., 2021). Another study across Europe found that 26.8% of individuals with mild to severe COVID-19 had varying degrees of dysphonia, and 3.7% had aphonia (Lechien et al., 2020). Also, studies showed that three months after recovery from COVID-19, dysphonia persisted in 25% of COVID patients admitted to the ICU[2] and 10.3% of COVID patients admitted to the ward (Leis-Cofiño et al., 2021). Another study concluded that dysphonia persisted one month after recovery in 15% of COVID-19-infected patients who were not hospitalized (Cantarella et al., 2021). Moreover, numerous studies on the measurement of voice quality in patients with COVID-19 demonstrated that it could alter various components of voice quality, including acoustic and auditory-perceptual parameters (Tohidast, Mansuri, Memarian, Ghobakhloo, & Scherer, 2021). For instance, it can result in a series of abnormal changes in the acoustic voice parameters of infected patients, such as insufficient airflow, signal perturbation, increased aperiodicity, and an increased noise to harmonics level, as a result of its effect on the respiration and larynx (Saki et al., 2021).

A recent study suggested that airway inflammation could involve the larynx and cause dysphonia in COVID-19 (7). There are three primary explanations for the development of dysphonia in COVID-19, including intubation damage in the intensive care unit, post-viral neuropathy, and sensory neuropathy (Helding et al., 2020; Watson et al., 2021). Dysphonia in ICU patients can be explained by the increased incidence of vocal fold injury following orotracheal intubation (Leis-Cofiño et al., 2021). For post-viral neuropathy, dysphonia might be induced by inflammation of the vocal folds. Studies have demonstrated that the SARS-COV-2 receptor ACE2[3] is present in the larynx, vocal folds, and other organs, including the lungs, and can cause direct virus entry and tissue inflammation (Descamps et al., 2020; Hu, Huang, & Yin, 2021; Sato et al., 2021). The third probable cause is sensory neuropathy and nerve injury; in severe cases, SARS-COV-2 can disrupt nerve cell activity in the vague and glossopharyngeal nerves (Paliwal, Garg, Gupta, & Tejan, 2020).

In some cases, dysphonia and hoarseness remain stable for several months after recovery from the virus and require voice therapy (VT[4]) intervention to restore better voice quality. As far as we searched, there is no study examining the effect of VT on persistent dysphonia in patients who had recovered from coronavirus. Regarding the lack of documents about the effectiveness of VT after recovery from SARS-COV2, the present study aimed to report the effect of VT on a 33-year-old female who had persistent dysphonia and frequent coughs nine months after recovering from a COVID-19 infection that the severity of these coughs was so severe that it prevented continuous speech production.

[1] Severe acute respiratory syndrome coronavirus 2

[2] Intensive Care Unit

[3] Angiotensin-converting enzyme 2

[4] Voice therapy

A 33-year-old female patient with recurrent coughs and voice complaints attended the VT clinic, head and neck clinic, Amir-Alaam hospital, Tehran, Iran. A laryngologist referred her to voice therapist with the diagnosis of muscle tension dysphonia (MTD[5]) for evaluation and treatment of the voice. Firstly, demographic data, voice history, and medical history were gathered through interviews. After that, the voice and larynx assessments were done. The interview and voice assessments were conducted by a speech and language pathologist (SLP[6]) who had approximately 14 years of experience in the assessing and treating voice disorders. The medical history revealed that she was detected positive for COVID-19 by PCR test approximately nine months ago. There was no history of any disease except for allergy in the medical history. After recovery from C0VID-19, she experienced dysphonia and recurrent coughs, which improved utterly after one month. The patient reported frequent coughs and severe dysphonia returned three months after recovery. To be more exact, frequent coughs and severe dysphonia returned two days after receiving the first SARS-COV-2 vaccine injection, Sputnik V COVID-19 vaccine. In the first session and during the interview, we noticed recurrent coughs interrupting the consistency of speech.

[5] Muscle Tension Dysphonia

[6] speech and language pathologist

All assessments included laryngo-video-stroboscopic, auditory-perceptual, acoustic-aerodynamic were performed during one session before the VT initiation. After the tenth session of VT all voice assessment was done by one experienced voice therapists, except the laryngo-video-stroboscopic assessment that done by an experienced laryngologist. The Eclectic VT was performed individually throughout ten sessions twice a week by an experienced voice therapist. Each VT session lasted 45 minutes.

Laryngeal imaging was performed by the Karl Storz Pulsar II LED video stroboscopy system and a 70-degree endoscope (KAY model 9106). The larynx was examined at both rest and phonation (/i/ vowel at habitual pitch and loudness) by a laryngologist with more than 20 years of experience in laryngology. To determine the severity of dysphonia perceptually, we used the Persian version of consensus auditory-perceptual evaluation of voice (called ATSHA) (Dabirmoghaddam, Khoramshahi, Dehqan, Scherer, & Ansari, 2020; Khoramshahi, Khatoonabadi, Khoddami, Dabirmoghaddam, & Ansari, 2018; Majd, Khoddami, Drinnan, Kamali, & Amiri, 2014). Two SLPs with five years of clinical experience who were not included the VT did the auditory-perceptual assessment. The voice samples were gathered by Zoom 5 microphone including sustained /a/ and /i/ vowels for 5 seconds, six standard sentences, and a conversational speech an acoustic room. We asked the raters to score the overall severity, roughness, breathiness, strain, loudness, and pitch in the range of 0 to 100 during vowels sustain, reading sentences, and conversation. For the acoustic-aerodynamic measurement, the dysphonia severity index (DSI[7]) was calculated (F. L. Wuyts et al., 2000) that has 4 components. The DSI was calculated using the following formula: DSI =0.13 MPT + (0.0053 F0 High) (0.26 I Low ) (1.18 Jitter%) + 12.4. The patient was asked to produce sustained /a/ comfortably for 5 seconds at a comfortable pitch and loudness as soft as possible for extract jitter and I-Low. For calculating F0-High, the patient was instructed to produce vowel /a/ at a comfortable pitch going up to the highest frequency as possible and for each formula variable; the best result between 3 attempts of the patient was considered. We used Praat software to extract the acoustic and aerodynamic data (version 6.0.39). For calculating MPT, we asked the patient to produce sustained vowel /a/ as long as possible after a maximum inhalation in three trials and the most prolonged duration in three trials was selected.

Table 1 is here.

After all assessment,a combination of indirect and direct VT was designed and presented according to the patient's complaints and evaluations during ten approximately 45 min sessions twice a week. Indirect VT included vocal hygiene. The patient received vocal hygiene during the first two VT sessions, and in continues, vocal misuse and abuse behaviors and other aspects of vocal hygiene were rechecked in the first minutes of the remaining sessions. According to the patients' complaints, Eclectic VT was presented along with vocal hygiene in other sessions. In the following table, we describe the treatment plan for each session of the VT:

As we see in Table 1, a combination of indirect and direct VT was presented. In the indirect VT section, vocal hygiene was utilized on reducing or optimally eliminating vocal abuses. For the direct VT, a combination of symptomatic and physiologic techniques was provided. A set of vocal facilitating techniques (VFTs[8]) including glottal fry, chewing, open-mouth, yawn-sigh, focus, and respiration training, were employed for the symptomatic VT. In the physiologic VT, manual circumlaryngeal therapy (MCT[9]) was used.

In continue, the results of the assessments before and after ten sessions of VT are presented. In laryngo-video-stroboscopic, muscle tension during phonation, inter arytenoid inflammation, and mild pachydermia on the mucous membrane of the posterior commissure were evident before the VT. The mucosal wave was reduced; the glottal closure presented a bowing pattern, the edge of the vocal folds was smooth, the vibration amplitude was moderately decreased, and the phase symmetry of the vocal folds' vibration was sometimes irregular. Evidence of GERD[10] was noticeable in the different spots of the larynx (Figure 1). After the VT, the results of laryngo-video-stroboscopic based on the reports of laryngologist revealed a decrease in the degree of muscle tension and inter arytenoid inflammation. Also, a reduction in the signs, increased mucosal wave, and complete glottal closure pattern were reported. The vocal folds edge remained smooth, the phase symmetry of the vocal folds' vibration became regular, and the vibration amplitude was slightly decreased. Improvement in the results amplitude of vibration after VT was seen (Figure 2).

The results of auditory-perceptual voice evaluation with the ATSHA (Majd et al., 2014) before and after the VT were presented in Table 2.

Table 2 is here.

As seen in the above Table, the first rater scored the overall severity from 85 to 25 and the second rater graded 75 to 40 (pre to post of the VT, respectively). According to the scores of two raters, decreased scores were obtained in all perceptual parameters of the ATSHA after the VT.

Table 3 is here.

For determining the DSI score pre and post-treatment, MPT, the highest frequency, lowest intensity, and jitter were placed in the DSI formula (F. L. Wuyts et al., 2000). There are more detailed data in Table 3.

As we see in Table 3, the DSI score was -2.57 before the VT in while it was increased to + 1.48 after the VT. Moreover, the Jitter and Lowest intensity scores decreased, and the highest frequency and MPT increased after the VT.

[7] Dysphonia Severity Index

[8] Vocal facilitating techniques

[9] manual circumlaryngeal therapy

[10] Gastroesophageal reflux disease

This study aimed to investigate the effect of VT on post-COVID-19 dysphonia with recurrent coughs in a female patient. As we noted in the former parts, a laryngologist referred her as an MTD patient after recovering from a COVID-19 infection. We performed various assessments before and after ten sessions of the VT to clarify the diverse aspects of voice as far as possible and determine the effect of VT more precisely. Eclectic VT was employed, so we combined different therapy techniques based on the patient's complaints and characteristics of her voice. The results revealed that VT effectively modified her COVID-19 dysphonia-related complaints and decreased recurrent coughs. We observed improvement in all voice assessments and the degree to which VT was effective will be discussed in the following. Since there was not much data on the outcome of VT after COVID-19, we compare the results of this study with the results of VT in MTD patients.

Laryngo-video-stroboscopic results after the VT showed more appropriate vocalization behavior and reduced tension during rest and phonation, inflammation, and GERD signs. Also, increased mucosal wave and vibration amplitude, the corrected glottal closure pattern, and increased phase symmetry were reported after the VT. It seems that the progress in stroboscopy findings after the VT is due to several factors. The relaxation of the internal and external muscles of the larynx based on direct and indirect VT leads to a reduction of laryngeal tension (Gartner-Schmidt, Roth, Zullo, & Rosen, 2013). Also, applying VFT techniques reduces musculoskeletal tension and contraction in the internal and external muscles of the larynx and surrounding areas (Samira Aghadoost, Shohreh Jalaie, Ahmad Reza Khatoonabadi, Peyman Dabirmoghaddam, & Seyyedeh Maryam Khoddami, 2020). However, the frequent coughs after COVID-19 in this case caused some tension to remain in the larynx. It is also supposed that decreased GERD and inflammation, improvements in the vocal folds' closure, mucosal wave, vibration amplitude, and symmetry can be due to VFTs and vocal hygiene. Vocal hygiene (including change of lifestyle, increasing hydration, counseling about abuses during phonation and rest, etc.) eliminates or reduces vocal abuses and misuses such as glottal attacks (Daniel R Boone, McFarlane, Von Berg, & Zraick, 2005); therefore, improvements in true vocal folds' vibration characteristics and reduction in the larynx tension are predictable (N. Roy et al., 2002). Moreover, in previous studies were noted that after direct VT in MTD patients, significant changes were seen in the results of laryngo-video-stroboscopic that was parallel with our findings (Rodríguez-Parra, Adrián, & Casado, 2011).

In auditory-perceptual assessment, all of the six parameters of the ATSHA (Majd et al., 2014) improved after the VT. This improvement represents the positive effect of VT on the auditory-perceptual aspect of voice, although there was still some degree of dysphonia in her voice. It is assumed that this remaining dysphonia probably is due to laryngeal tissue inflammation after the entrance of COVID-19 into the larynx and lungs and the effect of recurrent coughs on the function of vocal folds during vocalization. As we noted above, vocal hygiene counseling improves information about proper vocalization and laryngeal health (Boominathan, Chandrasekhar, Nagarajan, Zainab, & Sundarrajan, 2008; Pasa, Oates, & Dacakis, 2007). These instructions typically require the affected person to dispose of those vocalization behaviors that are potentially unsafe and replace them with extra vocally hygienic substitutes (N. Roy et al., 2002) and lead to reduce the symptoms and complaints resulting from phono-traumatic behaviors (Bolbol, Zalat, Hammam, & Elnakeb, 2017; Pasa et al., 2007). Moreover, with performing VFTs, the voice quality improved with changing voice production characteristics (Samira Aghadoost et al., 2020). For instance, the focus technique changes the focus of the voice during vocalization (Daniel R Boone, McFarlane, Von Berg, & Zraick, 2009). In this patient, we observed more intense and more frequent bursts of coughs while she was trying to increase her voice loudness. We assume that this happens due to more required airflow and air pressure that can agitate the larynx, which has become more sensitive due to inflammation and nerve damage caused by COVID-19. It is acceptable that using MCT and VFT has caused the reduction and balancing of the musculoskeletal tension in MTD patients, better control of airflow, and reduced effortful vocalization, and eventually improving voice quality (da Cunha Pereira, de Oliveira Lemos, Dalbosco Gadenz, & Cassol, 2018; N. Roy, Bless, Heisey, & Ford, 1997; N. Roy, Nissen, Dromey, & Sapir, 2009; Van Houtte, Van Lierde, & Claeys, 2011). Former studies about the effects of VT on the perceptual voice quality in MTD patients confirm our findings (de Oliveira Lemos, da Cunha Pereira, Druck SantAnna, & Cassol, 2017; Dehqan & Scherer, 2019; MacKenzie, Millar, Wilson, Sellars, & Deary, 2001; Mansuri et al., 2019).

In the acoustic and aerodynamic assessment, improvements were observed in all of the four components of the DSI formula and consequently the DSI score after the VT. Increasing the voice quality after the VT can create a better DSI score (Samira Aghadoost et al., 2020; M. Hakkesteegt, 2009; Floris L Wuyts et al., 2000). Before the VT, the degree of jitter and intensity low were greater, and a shorter duration of MPT and lower value of f0-high were observed. Post-COVID-19 recurrent coughs probably can cause inflammation and degeneration of vocal folds' tissue, and finally, uneven weighing of them, leading to jitter variations (Asiaee, Vahedian-Azimi, Atashi, Keramatfar, & Nourbakhsh, 2020). This infection also influences the MPT duration; shorter MPT is probably due to the effects of the virus on the lung volume and inadequate closure of the inflamed larynx. The MPT enhancement is probably due to improvement in the patient's control over respiratory support and gaining balance between myloelastic and aerodynamic forces leading to more efficient coordination between respiratory and phonatory systems and, finally, better voice production (Van Den Berg, 1958; Zhang, 2016). This more coordinated vocalization pattern is probably due to respiratory exercises, which enhance breath support (Desjardins & Bonilha, 2020) and also MCT by balancing phonatory muscles and relaxing vocalization muscles. Despite MPT improvement, it seems that COVID-19 has a more persistent influence on the lungs, larynx, and coordination between them. As we mentioned, the decline in jitter point indicates better voice quality achieved through better sensory-motor control of the phonatory subsystems and more regular vibration of the vocal folds after VT (Rad et al., 2018). F0-high improvement like jitter is probably due to increased skills in better airflow control and phonation and decreased mechanical pressure on vibration (S. Aghadoost, S. Jalaie, A. R. Khatoonabadi, P. Dabirmoghaddam, & S. M. Khoddami, 2020). After direct and indirect therapies, a soft, effortless speaking style decreased I-low by reducing tension and increasing control in the respiratory, phonatory, and articulatory subsystems (S. Aghadoost et al., 2020). More balance between phonatory subsystems mentioned above can result from a better adjustment of extra laryngeal muscles leading to better function of intrinsic ones after MCT (Rad et al., 2018). VFTs produce more relaxed vocalization and better acoustic results can be predicted after the use of this technique(Daniel R. Boone & McFarlane, 1993). Our results were aligned with former studies after VT (M. M. Hakkesteegt, Brocaar, & Wieringa, 2010; Mathieson et al., 2009; Ribeiro, Pedrosa, Silverio, & Behlau, 2018; N. Roy et al., 1997; Nelson Roy & Leeper, 1993; Van Lierde, De Bodt, Dhaeseleer, Wuyts, & Claeys, 2010; Van Lierde, De Ley, Clement, De Bodt, & Van Cauwenberge, 2004). Finally, it seems using of Eclectic VT reduced laryngeal muscle tension, reduced struggle and tension during voice production. Moreover, reducing vocal abuse and misuses and creating a new comfortable phonation pattern after vocal hygiene influences the acoustic features, as a result create better condition on DSI score (Behrman, Rutledge, Hembree, & Sheridan, 2008).

The patient declared that her quality of life related to her voice improved highly, as her coughs interrupted her communication less frequently. Also, as she said, she could talk louder and with better voice quality without running out of breath. Overall, the patient was satisfied with the outcomes after 10 sessions of VT.

The results of this study showed that Eclectic VT approach including combination of direct and indirect VT is effective for treatment of patient with residual dysphonia after recovery of COVID-19 according to the results of different voice assessments including video-laryngo-stroboscopy, auditory-perceptual, and acoustic-aerodynamic measures. The findings of this study emphasized that although voice quality improved after ten sessions of the VT, more time is needed to improve the patient's voice quality and making coordination between the larynx and respiration function. We guess that the persistence of symptoms is due to inflammation of the vocal folds after direct entry and tissue inflammation caused by SARS-COV-2 attaching the ACE2 receptor and need more time. Also, it is better that VT is planned based on the patient complaints and evaluation of voice therapist in the patients with COVID-19.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Conflicts of interest

The authors declare no conflict of interests.

Ethics approval:

Not applicable

Consent to participate

The patient completed consent form before starting the study.

Written Consent for publication

Consent to publish was obtained from the participant of the study.
Availability of data and material

Not applicable

Code availability

Not applicable

Authors' contributions

The authors have made a substantial contribution to the concept, and design of the article, acquisition, analysis, interpretation of data, and also drafting or revising the article.

Aghadoost, S., Jalaie, S., Khatoonabadi, A. R., Dabirmoghaddam, P., & Khoddami, S. M. (2020). A study of vocal facilitating techniques compared to manual circumlaryngeal therapy in teachers with muscle tension dysphonia. Journal of Voice, 34(6), 963. e911-963. e921.
Aghadoost, S., Jalaie, S., Khatoonabadi, A. R., Dabirmoghaddam, P., & Khoddami, S. M. (2020). A Study of Vocal Facilitating Techniques Compared to Manual Circumlaryngeal Therapy in Teachers With Muscle Tension Dysphonia. J Voice, 34(6), 963.e911-963.e921. doi:10.1016/j.jvoice.2019.06.002
Asiaee, M., Vahedian-Azimi, A., Atashi, S. S., Keramatfar, A., & Nourbakhsh, M. (2020). Voice Quality Evaluation in Patients With COVID-19: An Acoustic Analysis. J Voice. doi:10.1016/j.jvoice.2020.09.024
Azzam, A. A. A., Samy, A., Sefein, I., & ElRouby, I. (2021). Vocal Disorders in Patients with COVID 19 in Egypt. Indian J Otolaryngol Head Neck Surg, 1-7. doi:10.1007/s12070-021-02663-0
Behrman, A., Rutledge, J., Hembree, A., & Sheridan, S. (2008). Vocal Hygiene Education, Voice Production Therapy, and the Role of Patient Adherence: A Treatment Effectiveness Study in Women With Phonotrauma. Journal of speech, language, and hearing research, 51(2), 350-366. doi:doi:10.1044/1092-4388(2008/026)
Bolbol, S. A., Zalat, M. M., Hammam, R. A., & Elnakeb, N. L. (2017). Risk Factors of Voice Disorders and Impact of Vocal Hygiene Awareness Program Among Teachers in Public Schools in Egypt. J Voice, 31(2), 251.e259-251.e216. doi:10.1016/j.jvoice.2016.07.010
Boominathan, P., Chandrasekhar, D., Nagarajan, R., Zainab, M., & Sundarrajan, A. (2008). Vocal Hygiene Awareness Program for Professional Voice Users (Teachers): An Evaluative Study from Chennai. Asia Pacific Journal of Speech Language and Hearing., 11, 39-45. doi:10.1179/136132808805297377
Boone, D. R., McFarlane, S., Von Berg, S., & Zraick, R. (2009). The voice andvoice therapy. Englewood Cliffa, NJ.
Boone, D. R., & McFarlane, S. C. (1993). A critical view of the yawn-sigh as a voice therapy technique. Journal of Voice, 7(1), 75-80. doi:https://doi.org/10.1016/S0892-1997(05)80114-6
Boone, D. R., McFarlane, S. C., Von Berg, S. L., & Zraick, R. I. (2005). The voice and voice therapy.
Cantarella, G., Aldè, M., Consonni, D., Zuccotti, G., Berardino, F. D., Barozzi, S., . . . Pignataro, L. (2021). Prevalence of Dysphonia in Non hospitalized Patients with COVID-19 in Lombardy, the Italian Epicenter of the Pandemic. Journal of voice : official journal of the Voice Foundation, S0892-1997(0821)00108-00109. doi:10.1016/j.jvoice.2021.03.009
Chan, J. F., Yuan, S., Kok, K. H., To, K. K., Chu, H., Yang, J., . . . Yuen, K. Y. (2020). A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission: a study of a family cluster. Lancet, 395(10223), 514-523. doi:10.1016/s0140-6736(20)30154-9
Coelho, A., Siqueira, L., Fadel, C., Rosa, M., & Dassie-Leite, A. (2018). Influence of the speech-language pathologist’s orientation on maximum phonation times. Revista CEFAC, 20, 201-208. doi:10.1590/1982-021620182028717
da Cunha Pereira, G., de Oliveira Lemos, I., Dalbosco Gadenz, C., & Cassol, M. (2018). Effects of Voice Therapy on Muscle Tension Dysphonia: A Systematic Literature Review. J Voice, 32(5), 546-552. doi:10.1016/j.jvoice.2017.06.015
Dabirmoghaddam, P., Khoramshahi, H., Dehqan, A., Scherer, R. C., & Ansari, N. N. (2020). Construct and Discriminant Validity of the Persian Version of the Consensus Auditory Perceptual Evaluation of Voice (CAPE-V). J Voice. doi:10.1016/j.jvoice.2020.09.023
Dassie-Leite, A. P., Gueths, T. P., Ribeiro, V. V., Pereira, E. C., Martins, P. D. N., & Daniel, C. R. (2021). Vocal Signs and Symptoms Related to COVID-19 and Risk Factors for their Persistence. J Voice. doi:10.1016/j.jvoice.2021.07.013
Dassie-Leite, A. P., Gueths, T. P., Ribeiro, V. V., Pereira, E. C., Martins, P. d. N., & Daniel, C. R. (2021). Vocal Signs and Symptoms Related to COVID-19 and Risk Factors for their Persistence. Journal of Voice. doi:https://doi.org/10.1016/j.jvoice.2021.07.013
de Oliveira Lemos, I., da Cunha Pereira, G., Druck SantAnna, G., & Cassol, M. (2017). Effects of a Voice Therapy Program for Patients with Muscle Tension Dysphonia. Folia Phoniatr Logop, 69(5-6), 239-245. doi:10.1159/000487942
Dehqan, A., & Scherer, R. C. (2019). Positive Effects of Manual Circumlaryngeal Therapy in the Treatment of Muscle Tension Dysphonia (MTD): Long Term Treatment Outcomes. J Voice, 33(6), 866-871. doi:10.1016/j.jvoice.2018.07.010
Descamps, G., Verset, L., Trelcat, A., Hopkins, C., Lechien, J. R., Journe, F., & Saussez, S. (2020). ACE2 Protein Landscape in the Head and Neck Region: The Conundrum of SARS-CoV-2 Infection. Biology (Basel), 9(8). doi:10.3390/biology9080235
Desjardins, M., & Bonilha, H. S. (2020). The Impact of Respiratory Exercises on Voice Outcomes: A Systematic Review of the Literature. J Voice, 34(4), 648.e641-648.e639. doi:10.1016/j.jvoice.2019.01.011
Elibol, E. (2021). Otolaryngological symptoms in COVID-19. Eur Arch Otorhinolaryngol, 278(4), 1233-1236. doi:10.1007/s00405-020-06319-7
Gartner-Schmidt, J. L., Roth, D. F., Zullo, T. G., & Rosen, C. A. (2013). Quantifying component parts of indirect and direct voice therapy related to different voice disorders. J Voice, 27(2), 210-216. doi:10.1016/j.jvoice.2012.11.007
Hakkesteegt, M. (2009). Evaluation of Voice Disorders: Dysphonia Severity Index and Voice Handicap Index.
Hakkesteegt, M. M., Brocaar, M. P., & Wieringa, M. H. (2010). The applicability of the dysphonia severity index and the voice handicap index in evaluating effects of voice therapy and phonosurgery. Journal of Voice, 24(2), 199-205.
Halpin, S. J., McIvor, C., Whyatt, G., Adams, A., Harvey, O., McLean, L., . . . Sivan, M. (2021). Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A cross-sectional evaluation. J Med Virol, 93(2), 1013-1022. doi:10.1002/jmv.26368
Helding, L., Carroll, T. L., Nix, J., Johns, M. M., LeBorgne, W. D., & Meyer, D. (2020). COVID-19 After Effects: Concerns for Singers. J Voice. doi:10.1016/j.jvoice.2020.07.032
Hu, B., Huang, S., & Yin, L. (2021). The cytokine storm and COVID-19. J Med Virol, 93(1), 250-256. doi:10.1002/jmv.26232
Khoramshahi, H., Khatoonabadi, A. R., Khoddami, S. M., Dabirmoghaddam, P., & Ansari, N. N. (2018). Responsiveness of Persian Version of Consensus Auditory Perceptual Evaluation of Voice (CAPE-V), Persian Version of Voice Handicap Index (VHI), and Praat in Vocal Mass Lesions with Muscle Tension Dysphonia. J Voice, 32(6), 770.e721-770.e730. doi:10.1016/j.jvoice.2017.08.008
Lechien, J. R., Chiesa-Estomba, C. M., Cabaraux, P., Mat, Q., Huet, K., Harmegnies, B., . . . Saussez, S. (2020). Features of Mild-to-Moderate COVID-19 Patients With Dysphonia. J Voice. doi:10.1016/j.jvoice.2020.05.012
Lechien, J. R., Chiesa-Estomba, C. M., Vaira, L. A., De Riu, G., Cammaroto, G., Chekkoury-Idrissi, Y., . . . Saussez, S. (2021). Epidemiological, otolaryngological, olfactory and gustatory outcomes according to the severity of COVID-19: a study of 2579 patients. Eur Arch Otorhinolaryngol, 278(8), 2851-2859. doi:10.1007/s00405-020-06548-w
Leis-Cofiño, C., Arriero-Sánchez, P., González-Herranz, R., Arenas-Brítez, Ó., Hernández-García, E., & Plaza, G. (2021). Persistent Dysphonia in Hospitalized COVID-19 Patients. J Voice. doi:10.1016/j.jvoice.2021.07.001
MacKenzie, K., Millar, A., Wilson, J. A., Sellars, C., & Deary, I. J. (2001). Is voice therapy an effective treatment for dysphonia? A randomised controlled trial. Bmj, 323(7314), 658-661. doi:10.1136/bmj.323.7314.658
Majd, N., Khoddami, S., Drinnan, M., Kamali, M., & Amiri, Y. (2014). Validity and rater reliability of Persian version of consensus auditory perceptual evaluation of voice (CAPE-V). Audiology, 23, 65-74.
Mansuri, B., Torabinezhad, F., Jamshidi, A. A., Dabirmoghadam, P., Vasaghi-Gharamaleki, B., & Ghelichi, L. (2019). Effects of Voice Therapy on Vocal Tract Discomfort in Muscle Tension Dysphonia. Iran J Otorhinolaryngol, 31(106), 297-304.
Mathieson, L., Hirani, S., Epstein, R., Baken, R., Wood, G., & Rubin, J. (2009). Laryngeal manual therapy: a preliminary study to examine its treatment effects in the management of muscle tension dysphonia. Journal of Voice, 23(3), 353-366.
Paliwal, V. K., Garg, R. K., Gupta, A., & Tejan, N. (2020). Neuromuscular presentations in patients with COVID-19. Neurol Sci, 41(11), 3039-3056. doi:10.1007/s10072-020-04708-8
Pasa, G., Oates, J., & Dacakis, G. (2007). The relative effectiveness of vocal hygiene training and vocal function exercises in preventing voice disorders in primary school teachers. Logopedics Phoniatrics Vocology, 32(3), 128-140. doi:10.1080/14015430701207774
Rad, A., Moradi, N., Yazdi, M., Soltani, M., Mehravar, M., & Latifi, S. (2018). Efficacy of Manual Circumlaryngeal Therapy in Patients with Muscle Tension Dysphonia. Shiraz E-Medical Journal, In Press. doi:10.5812/semj.64478
Ribeiro, V. V., Pedrosa, V., Silverio, K. C. A., & Behlau, M. (2018). Laryngeal manual therapies for behavioral dysphonia: a systematic review and meta-analysis. Journal of Voice, 32(5), 553-563.
Rodríguez-Parra, M. J., Adrián, J. A., & Casado, J. C. (2011). Comparing voice-therapy and vocal-hygiene treatments in dysphonia using a limited multidimensional evaluation protocol. J Commun Disord, 44(6), 615-630. doi:10.1016/j.jcomdis.2011.07.003
Roy, N., Bless, D. M., Heisey, D., & Ford, C. N. (1997). Manual circumlaryngeal therapy for functional dysphonia: an evaluation of short- and long-term treatment outcomes. J Voice, 11(3), 321-331. doi:10.1016/s0892-1997(97)80011-2
Roy, N., & Leeper, H. A. (1993). Effects of the manual laryngeal musculoskeletal tension reduction technique as a treatment for functional voice disorders: perceptual and acoustic measures. Journal of Voice, 7(3), 242-249.
Roy, N., Nissen, S. L., Dromey, C., & Sapir, S. (2009). Articulatory changes in muscle tension dysphonia: evidence of vowel space expansion following manual circumlaryngeal therapy. J Commun Disord, 42(2), 124-135. doi:10.1016/j.jcomdis.2008.10.001
Roy, N., Weinrich, B., Gray, S. D., Tanner, K., Toledo, S. W., Dove, H., . . . Stemple, J. C. (2002). Voice amplification versus vocal hygiene instruction for teachers with voice disorders: a treatment outcomes study. J Speech Lang Hear Res, 45(4), 625-638. doi:10.1044/1092-4388(2002/050)
Saki, N., Zamani, P., Bayat, A., Nikakhlagh, S., Moghateli, N., & Salmanzadeh, S. (2021). Auditory-Perceptual Evaluation of Vocal Characteristics in Patients with the New Coronavirus Disease 2019. Folia Phoniatr Logop, 1-8. doi:10.1159/000518341
Sato, T., Ueha, R., Goto, T., Yamauchi, A., Kondo, K., & Yamasoba, T. (2021). Expression of ACE2 and TMPRSS2 Proteins in the Upper and Lower Aerodigestive Tracts of Rats: Implications on COVID 19 Infections. Laryngoscope, 131(3), E932-E939. doi:10.1002/lary.29132
Singhal, T. (2020). A Review of Coronavirus Disease-2019 (COVID-19). Indian J Pediatr, 87(4), 281-286. doi:10.1007/s12098-020-03263-6
Tohidast, S. A., Mansuri, B., Memarian, M., Ghobakhloo, A. H., & Scherer, R. C. (2021). Voice Quality and Vocal Tract Discomfort Symptoms in Patients With COVID-19. J Voice. doi:10.1016/j.jvoice.2021.09.039
Van Den Berg, J. (1958). Myoelastic-aerodynamic theory of voice production. J Speech Hear Res, 1(3), 227-244. doi:10.1044/jshr.0103.227
Van Houtte, E., Van Lierde, K., & Claeys, S. (2011). Pathophysiology and treatment of muscle tension dysphonia: a review of the current knowledge. J Voice, 25(2), 202-207. doi:10.1016/j.jvoice.2009.10.009
Van Lierde, K. M., De Bodt, M., Dhaeseleer, E., Wuyts, F., & Claeys, S. (2010). The treatment of muscle tension dysphonia: a comparison of two treatment techniques by means of an objective multiparameter approach. Journal of Voice, 24(3), 294-301.
Van Lierde, K. M., De Ley, S., Clement, G., De Bodt, M., & Van Cauwenberge, P. (2004). Outcome of laryngeal manual therapy in four Dutch adults with persistent moderate-to-severe vocal hyperfunction: a pilot study. Journal of Voice, 18(4), 467-474.
Watson, N. A., Karagama, Y., Burnay, V., Boztepe, S., Warner, S., & Chevretton, E. B. (2021). Effects of coronavirus disease-2019 on voice: our experience of laryngeal complications following mechanical ventilation in severe coronavirus disease-2019 pneumonitis and review of current literature. Curr Opin Otolaryngol Head Neck Surg, 29(6), 437-444. doi:10.1097/moo.0000000000000768
Wu, Z., & McGoogan, J. M. (2020). Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention. Jama, 323(13), 1239-1242. doi:10.1001/jama.2020.2648
Wuyts, F. L., Bodt, M. S. D., Molenberghs, G., Remacle, M., Heylen, L., Millet, B., . . . Heyning, P. H. V. d. (2000). The dysphonia severity index: an objective measure of vocal quality based on a multiparameter approach. Journal of speech, language, and hearing research, 43(3), 796-809.
Wuyts, F. L., De Bodt, M. S., Molenberghs, G., Remacle, M., Heylen, L., Millet, B., . . . Van de Heyning, P. H. (2000). The dysphonia severity index: an objective measure of vocal quality based on a multiparameter approach. J Speech Lang Hear Res, 43(3), 796-809. doi:10.1044/jslhr.4303.796
Zhang, Z. (2016). Mechanics of human voice production and control. J Acoust Soc Am, 140(4), 2614. doi:10.1121/1.4964509

Table1. Voice therapy plan for a female with recurrent cough and dysphonia after recovery from COVID-19 infection
Treatment	The first two sessions	The second two sessions	The third two sessions	The fourth two sessions	The fifth two sessions
Eclectic VT	vocal hygiene (30 minutes) + Chewing (10 minutes) + Glottal fry (5 minutes) + Breathing exercises (5 minutes + Manual circumlaryngeal therapy (15 minutes)	Vocal hygiene (10 minutes) + Chewing (10 minutes) + yawn-sigh (5 minutes) + Respiration training (5 minutes) + Manual circumlaryngeal therapy (15 minutes)	Chewing (10 minutes) + yawn-sigh (5 minutes) + glottal fry (5 minutes) + Respiration training (10 minutes) + Manual circumlaryngeal therapy (15 minutes)	Chewing (5 minutes) + yawn sigh (5 minutes) + glottal fry (5 minutes) + focus shifting (10 minutes) + Respiration training (10 minutes) + Manual circumlaryngeal therapy (15 minutes)	Chewing (5 minutes) + yawn-sigh (5 minutes) + glottal fry (5 minutes) + focus shifting (10 minutes) + Respiration training (10 minutes) + Manual circumlaryngeal therapy (15 minutes)
* Voice therapy

Table 2. the results of auditory-perceptual voice evaluation according to the opinions of two raters pre and post VT in the case
Time of assessment		Roughness	Strain	Pitch	Loudness	Breathiness	Severity
Rater 1	BeforeVT*¹	30	85	70	75	80	85
Rater 1	After VT	15	40	30	30	30	25
Rater 2	Before VT	40	85	80	75	80	75
Rater 2	After VT	20	35	30	30	35	40
*¹VT: Voice Therapy,

Table 3. The results of DSI and its components pre- and post-VT in the case.
Components Of DSI**	MPT (sec)	The highest frequency (Hz)	Lowest intensity (dB)	Jitter (%)	DSI
Before VT^*	5.8	308	63	0.83	-2.57
After VT	8.9	380	52	0.48	+ 1.48
MPT: maximum phonation time, ¹VT: Voice Therapy, DSI*: Dysphonia Severity Index

CAREchecklistEnglish.pdf

Download PDF

Version 1

posted

You are reading this latest preprint version

Effectiveness of voice therapy after recovery from COVID-19 infection: A Rare Case Report

Status:

Version 1

Abstract

Figures

Introduction

Case Report

Materials And Methods

Discussion

Conclusion

Declarations

References

Tables

Supplementary Files

Status:

Version 1