key: cord-0782175-fjrol294 authors: Fantini, Marco; Succo, Giovanni; Tascone, Martina; Borrelli, Gabriella; Pisanu, Giuliana; Crosetti, Erika title: SPONTANEOUS VOCAL FOLD POLYPS REMISSION AFTER LOCKDOWN FOR COVID-19 PANDEMIC: DOES VOCAL LOAD MATTER? date: 2021-03-15 journal: J Voice DOI: 10.1016/j.jvoice.2021.03.006 sha: 2791de5cd59ee96ced931817683d3304d86c368d doc_id: 782175 cord_uid: fjrol294 OBJECTIVE: During the Italian lockdown for Covid-19 emergency, due to stay-at-home orders, many people experienced an unusual period of voice rest. The present case series aims at reporting the spontaneous regression of some vocal fold polyps during the Italian lockdown for SARS-CoV2 pandemic. METHODS: 5 patients with voice complaints presenting to a tertiary referral center and diagnosed with vocal fold polyps before the lockdown were included. Because of the lockdown restrictive measures, planned elective surgical procedures were suspended. The patients were re-assessed immediately after lockdown. Multidimensional voice assessments were conducted before and after the lockdown period through laryngostroboscopies, perceptual voice evaluations, electroacoustic analysis and self assessments. RESULTS: The patients included in the present case series experienced a complete or nearly complete remission of symptoms. Videolaryngostroboscopies documented a complete or nearly complete regression of the polyps. Voices considerably improved both perceptually and electroacoustically. Self assessments showed a reduction of voice-related complaints. CONCLUSIONS: The present study suggests that daily vocal load reduction may play a critical role in the conservative management of vocal fold polyps. During the lockdown, the Italian healthcare system was forced to an unprecedented pressure which threatened its sustainability. As a consequence, all the elective and non oncologic planned surgical procedures were suspended, in order not to overload the healthcare personnel. The majority of people experienced work stops or remote working solutions during phase I and II, with reduced social interactions. Such condition determined a dramatic reduction of the daily vocal load in several cases. As a consequence, professional voice users experienced an unusual period of forced voice rest, which might be a protective factor for some phonotraumatic vocal lesions 4 . Some of the most frequent vocal pathologies caused by hyperfunctional voice use are vocal folds polyps (VFPs). They represent common laryngeal benign lesions with a phonotraumatic etiology and can determine significant voice impairment. Concerning VFPs treatment, albeit phonosurgical exeresis by direct microlaryngoscopy (DML) is classically considered the preferred option by many authors 5 , in the last years other conservative therapeutic options have been described 6 . Surgical conservative approaches include office-based fiber-endoscopic phonosurgery (FEPS) under local anesthesia with the use of microscissors and microforceps 7, 8 , the use of endoscopic lasers such as the Potassium Titanyl Phosphate (KTP) [9] [10] [11] and transnasal endoscopic steroids injections (TESI) procedures 12, 13 . Non surgical conservative therapeutic options described for VFPs include medical treatments, voice therapy and vocal hygiene programs as suggested by several authors [14] [15] [16] [17] [18] [19] . In the present study, a case series of 5 patients affected by VFPs is presented. The patients were diagnosed with VFPs before the lockdown and scheduled for surgery, but the elective surgical procedure was suspended because of the epidemiological emergency. After the lockdown, the patients were all reassessed. The present case series study was carried out according to the Declaration of Helsinki. All subjects enrolled in the study gave their informed consent; experimental data were collected prospectively. Five female patients presenting to a tertiary referral center complaining vocal symptoms of moderate severity were diagnosed with vocal folds polyps between February 4 th and March 9 th 2020. They were all scheduled for phonosurgical exeresis. The patients were 33, 36, 39, 52 and 53 years old. None of the patients was a smoker, no other medical issues were declared in their medical histories. All the patients reported a professional voice use, as two of them worked as corporate employees, one of them as business manager, one as educator and one as medical doctor. Mean duration of vocal symptoms was 58  24 days. The reported symptoms were hoarseness, vocal fatigue, breathy voice quality and lack of vocal power. The patients of the present study received diagnosis right before the beginning of the lockdown but the scheduled elective surgical procedure was suspended because of the restrictive measures due to the pandemic of Covid-19. None of the patients neither received pharmacological therapy nor underwent speech therapy after diagnosis. During the lockdown, all the patients experienced a significant decrease of daily vocal load since they all had a dramatic reduction of working and social activities. The patients reported a mean daily professional vocal load of 6 hours. During lockdown, vocal load reduction was self-reported by the patients and quantified as a decrease of at least 70% of the daily use of voice. After lockdown phase I, the patients were re-assessed. Mean time between diagnosis and re-assessment was 101  16 days. The patients included in the present study were diagnosed with 2 gelatinous sessile polyps; 1 hemorrhagic sessile polyp; 1 hemorrhagic sessile polyp with contralateral nodular lesion and 1 pedunculated gelatinous polyp with contralateral hemorrhagic lesion, as shown in figure 1. Each patient underwent a multidimensional voice assessment before and after lockdown. The patients were asked to perform a sustained vowel /a/ at comfortable pitch and intensity and to In the present study, a series of spontaneously healed VFPs was presented. None of the patients underwent speech therapy, pharmacological or surgical treatments. After lockdown for Covid-19 epidemiological emergency, a complete or nearly complete remission was observed, with a considerable improvement of the voices both acoustically and perceptually, as well as for the voice-related handicap perceived by the patients. The elective therapeutic choice for VFPs is phonosurgical exeresis performed by DML, allowing for a fast recovery and a good voice quality restoration. Nevertheless, some authors highlighted that VFPs can sometimes resolve without surgery thanks to conservative treatments. Some studies suggest that voice rest, programs of voice hygiene and voice therapy can be effective in treating some vocal folds polyps 18, 19 . The patients of the present study did not receive any pharmacological treatment or voice therapy, since they were all already scheduled for surgery. The common features of the patients were that they were all females, non smokers and with small-sized VFPs. They all experienced a 2 months long period of forced vocal load reduction because of the lockdown. All the patients revealed considerable improvements at videolaryngostroboscopy (3 complete remissions and 2 nearly complete remissions), perceptual and electroacoustic voice quality improvements as well as better VHI scores. Concerning self assessments, the only exception was a patient affected by gelatinous VFP, who had unvaried VHI scores. This is not surprising though, as the polyp didn't affect severely the voice of the patient because of its features and size. Overall, all the patients came back to a satisfactory voice after lockdown: complete remission was observed for the 2 gelatinous sessile polyps and for the haemorrhagic polyp with contralateral nodular lesion, while nearly complete remission was observed for the haemorrhagic sessile polyp and the gelatinous pedunculated polyp with contralateral nodular lesion. The patients with nearly complete remission were the ones with the most severe lesions: the haemorrhagic sessile polyp was associated with a recent subepithelial diffuse right vocal fold haemorrhage, while the pedunculated gelatinous polyp was associated with an haemorrhagic contralateral lesion (figure 1). The results of the present case series confirm the findings of Nakawa 14 , Jeong 19 and Lee 28 , as all the patients involved in the study were females, with small sized VFPs and a short duration of symptoms. These aspects should be taken into account in clinical practice, in order to consider conservative approaches for VFPs that are more likely to regress spontaneously or with conservative approaches. The main limitations of the present study are the small number of recruited patients and the lack of a comparison group (e.g. patients who underwent surgery or a voice therapy program in the same period). Even if it's difficult to imagine a conservative treatment for VFPs exclusively based on a drastic and long-lasting vocal load reduction in our society, the present findings suggest that voice rest may have a critical role in favoring VFPs spontaneous remission. These aspects are worthy of future research, in order to define the best indications and the best strategy for a conservative management of VFPs. The present study outlines the importance of daily vocal load on the clinical course of selected vocal fold polyps. Given that forced voice rest during the Covid-19 emergency was an extreme condition, the unusually high occurrence of VFPs spontaneous remissions immediately after lockdown suggests that reduction of daily vocal load may play a substantial role in the conservative management of vocal fold polyps. 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