Shifts in Relative Prevalence of Laryngeal Pathology in a Treatment-Seeking Population

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1 Journal of Voice Vol. 15, No. 3, pp The Voice Foundation Shifts in Relative Prevalence of Laryngeal Pathology in a Treatment-Seeking Population *Suzanne M. Coyle, Barbara D. Weinrich, and Joseph C. Stemple *National Rehabilitation Hospital, Washington, DC; Miami University, Department of Speech Pathology and Audiology, Oxford, Ohio; Blaine Block Institute for Voice Analysis and Rehabilitation, Dayton, Ohio Summary: The prevalence of laryngeal pathology in a treatment-seeking population of southwestern Ohio underwent a 15-year reexamination. Relationships between pathology and demographic variables of age, gender, and occupation were investigated. Data were collected from 1,158 new patients seen by participating otolaryngologists between 1996 and The most frequent pathologies were reflux laryngitis, functional (including diagnoses of laryngeal myasthenia and hoarseness), vocal fold paralysis, nodules, and laryngitis. Pathologies were found to occur more often in females, with some pathologies more common to one gender. Pathologies occurred more often in the older age categories. The most common occupations found in the sample were retired persons, executives/managers, and homemakers. Comparisons were made to an earlier investigation of laryngeal pathology in the same otolaryngology practices. Differences from the previous study were noted in the prevalence of pathology and the distribution of demographic variables. Relationships between pathology and demographic variables reported by the two studies were examined for consistency. Key Words: Prevalence Laryngeal pathology Voice disorders Voice disturbances Demographic variables. INTRODUCTION Disorders of voice exist when quality, pitch, or loudness differ significantly from others of the same age, gender, cultural background, and geographic location, thereby drawing attention to the speaker. Voice disorders may result from changes in the structure and/or function of the laryngeal mechanism that Accepted for publication February 12, Research presented at the American Speech-Language- Hearing Association Convention in San Francisco, CA, November 21, Send correspondence and reprint requests to Barbara D. Weinrich, PhD, Department of Speech Pathology and Audiology, Miami University, Oxford, Ohio weinribd@muohio.edu do not allow the mechanism to meet the functional voicing needs of the speaker. Consequently, voice disorders may result from laryngeal pathologies that (1) alter the structural, physical, or neurological functioning of the vocal folds and larynx; (2) alter the respiratory and resonatory systems; or (3) cause the mechanism to function in an inappropriate manner. 1 General population studies of the prevalence of laryngeal pathology help to focus research efforts, health education, and clinical practices for voice professionals. However, such reports are relatively scarce, outdated, and provide conflicting information Herrington-Hall et al 13 investigated the incidence of laryngeal pathologies in patients seeking treatment by otolaryngologists and described the incidence of laryngeal pathologies based on the demo- 424

2 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 425 graphic variables of age, gender, and occupation. Data were gathered by examining medical records of individuals seeking treatment for voice disturbances during a three-year period ( ) from two otolaryngology practices in Dayton and Cincinnati, Ohio, including rural areas. In both participating otolaryngology practices, the type of laryngeal pathology was determined by the treating physician through the use of indirect laryngoscopy (mirror examination). Herrington-Hall et al 13 evaluated a total of 1,262 patient records. Within this population, 22 laryngeal pathologies were reported. Of those pathologies occurring in more than 5% of the total population, the investigators found that the most frequently reported pathologies were nodules, edema, polyps, laryngeal cancer, and vocal fold paralysis. Comparisons were made between the type of pathology and the demographic variables of age, gender, and occupation. While Herrington-Hall et al 13 aided in the identification of demographic variables associated with particular laryngeal pathologies found in a treatmentseeking population, these findings were limited to the specific time period and population sampled. An update of like data may lead to further identification of individuals at risk for developing laryngeal pathologies, information to enhance public education about voice disorders, and an understanding of risk factors associated with various demographic variables. The purpose of the present study was to examine the current prevalence of laryngeal pathology in a treatment-seeking population within the same otolaryngology practices used in the Herrington-Hall et al 13 study. To be consistent with Herrington-Hall et al, 13 similar methods and procedures were followed for data collection and analyses. Minor differences are described within the body of this paper. Relationships between the type of pathology and the demographic variables of age, gender, and occupation were investigated. Comparisons were made to the findings of Herrington-Hall et al 13 and discussed for relevance regarding current diagnostic procedures and treatments within participating practices. METHODS Subjects Subjects were selected using existing medical records at two otolaryngologic practices, one in Dayton, Ohio (Practice A), and one in Cincinnati, Ohio (Practice B). All new patients seeking treatment for laryngeal pathologies between January 1, 1996 and December 31, 1998 were included in the original subject selection. A total of 8,460 patient records were selected using ICD-9 diagnostic codes specifically related to voice disorders (Table 1). From the 8,460 subjects, 1,158 were randomly selected to match the sample size used by Herrington- Hall et al. 13 This included 578 subjects from Practice A and 580 from Practice B. New patients seeking treatment between the inclusion dates were numbered 1 to 7,302 in Practice A and 1 to 1,158 in Practice B. From this information, 700 patients from each practice were selected using a random number generation on Minitab for Windows, version Within this selection, the first 578 patients in Practice A and the first 580 in Practice B to meet all eligibility criteria were included. Subjects were included based on the following criteria: (1) patient s first visit to a participating otolaryngologist occurred between the inclusion dates of January 1, 1996 and December 31, 1998; (2) patient sought treatment for a laryngeal pathology and/or chief complaint concerned laryngeal function; and (3) patient was diagnosed with at least one of the TABLE 1. ICD-9 Codes Utilized for Selection of Subjects Records ICD-9 Code Diagnosis Voice disturbance unspecified Voice disturbance hoarseness Vocal cord paralysis Vocal cord polyp Neoplasm, benign larynx Neoplasm, malignant hypolarynx Neoplasm, malignant larynx, glottis Neoplasm, malignant larynx, supraglottis Laryngitis, acute Throat pain Gastroesophageal reflux Cough Dysphagia Other head and neck symptoms Laryngeal myasthenia True vocal fold bowing

3 426 SUZANNE M. COYLE ET AL ICD-9 diagnoses listed in Table 1 during the inclusion dates. Patients were excluded who visited a participating otolaryngologist during the inclusion dates for conditions other than those specified in Table 1, but were diagnosed with one of the included ICD-9 diagnoses upon evaluation. For example, patients seeking treatment for sinusitis who were found to be hoarse upon examination were not included. In addition, patients seeking treatment for gastroesophageal reflux disease (GERD) who did not present with any laryngeal complaints (hoarseness, vocal fatigue, etc.) were not included. These patients were not seeking treatment specifically for voice disorders. Procedures Medical records from participating otolaryngologic practices in Dayton and Cincinnati, Ohio, were used to obtain patient data. Data were recorded in a Microsoft Excel 15 spreadsheet and analyzed using Statistical Analysis System (SAS). 16 For each patient seeking treatment during the inclusion dates, information was obtained including type of laryngeal pathology (specific diagnosis), age, gender, and occupation. Type of laryngeal pathology was diagnosed by the participating otolaryngologist through mirror examination, flexible endoscopy, videostroboscopy, and/or histologic analysis. When patients presented with more than one diagnosis, the primary diagnosis was included in the data set. For example, if a patient presented with edema, erythema, and probable GERD, reflux laryngitis was determined to be the primary pathology in most situations. Occupation, age, and gender were reported as they appeared in the medical record. Data analysis Data were analyzed for significance between laryngeal pathology and all demographic variables. To be consistent with previous research, data were analyzed as a total sample and by geographic area. 13 Frequency of occurrence for each laryngeal pathology was determined, as well as the percentage within the total sample. A categorical data analysis, the chi-square ( 2 ) test for association, was used to determine relationships between pathology and demographic variables found within the current study. Log-linear models were utilized to determine patterns of associations and comparisons between the current study and the findings of Herrington-Hall et al. 13 RESULTS Description of pathology data For the total sample (N=1,158), 43 laryngeal pathologies were identified. Results revealed that the most common diagnoses (those occurring in more than 5% of the sample) were reflux laryngitis (18.4%), vocal fold paralysis (12.0%), nodules (10.2%), laryngitis (8.5%), polyps (7.7%), laryngeal myasthenia (7.1%), bowed vocal folds (5.2%), and hoarseness (5.1%). Table 2 contains the frequency of occurrence for each laryngeal pathology for the total sample and for each practice. To be consistent with previous research, the classification normal on exam was used when the otolaryngologist found the patient to have a normal larynx and did not state that the vocal condition was psychogenic. 13 This classification accounted for 3.6% of the total sample. A total of 15 patients were found to have psychogenic pathologies. This included 2 individuals with functional falsetto and 13 individuals with conversion aphonia or dysphonia. Fifty-nine patients presented with hoarseness, but descriptions of laryngeal examinations or possible etiologies were not found in the patient records. These patients were classified as having hoarseness. To be consistent with Herrington-Hall et al, 13 patients presenting with dysphonia in the presence of a normal larynx were classified as functional. This included individuals diagnosed with laryngeal myasthenia and hoarseness. When the latter two diagnoses were combined, functional became the second most common diagnosis in the total sample, representing 12.2% of the sample. Description of gender data Pathologies were significantly more common in females than males, with females representing 60.97% of the total sample [ 2 (1, N = 1,158) = 29.76, p < ]. Table 3 contains the distribution of laryngeal pathologies among males and females, and the percentage for each gender. Relationships between laryngeal pathology and gender were analyzed using the chi-square ( 2 ) test

4 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 427 TABLE 2. Frequency and Percentage of Occurrence of Laryngeal Pathologies Total N Dayton (Practice A) Cincinnati (Practice B) (1,158) n % (578) n % (580) n % Reflux laryngitis Functional Paralysis Nodules Laryngitis Polyps Laryngeal myasthenia Bowed vocal folds Hoarseness Normal on exam Laryngeal cancer Polypoid degeneration Cyst Edema Leukoplakia Granuloma Psychogenic Reinke s edema Cough Papilloma Erythema Laryngeal dehydration Contact ulcer Varix Tremor Laryngospasm Pharyngeal cancer Hematoma Paradoxical vocal fold movement Spasmodic dysphonia Unspecified voice disturbance Laryngocele Laryngomalacia Respiratory insufficiency Hemangioma Intubation ulceration Laryngeal stenosis Reflux laryngitis Functional Paralysis Nodules Polyps Laryngeal myasthenia Laryngeal cancer Bowed vocal folds Hoarseness Normal on exam Cyst Laryngitis Polypoid degeneration Granuloma Reinke s edema Leukoplakia Psychogenic Cough Papilloma Pharyngeal cancer Edema Varix Contact ulcer Erythema Unspecified voice disturbance Laryngomalacia Respiratory insufficiency Tremor Hemangioma Laryngeal dehydration Laryngocele Paradoxical vocal fold movement Parkinson s dysphonia Subglottic lesion Thyroid cancer Tracheal stenosis Vocal fold dysplasia Reflux laryngitis Laryngitis Paralysis Functional Nodules Laryngeal myasthenia Polyps Bowed vocal folds Hoarseness Normal on exam Polypoid degeneration Edema Leukoplakia Laryngeal cancer Laryngeal dehydration Psychogenic Cyst Erythema Laryngospasm Papilloma Contact ulcer Cough Granuloma Hematoma Reinke s edema Spasmodic dysphonia Tremor Varix Paradoxical vocal fold movement Intubation ulceration Laryngocele Laryngeal stenosis Soft tissue trauma Superior laryngeal nerve palsy (continues)

5 428 SUZANNE M. COYLE ET AL TABLE 2. continued Total N Dayton (Practice A) Cincinnati (Practice B) (1,158) n % (578) n % (580) n % Parkinson s dysphonia Soft tissue trauma Subglottic lesion Superior laryngeal nerve palsy Thyroid cancer Tracheal stenosis Vocal fold dysplasia Note: Diagnoses classified as functional are listed individually as laryngeal myasthenia and hoarseness, and combined as functional in the above table. For this reason, columns may equal more than the total number of subjects and total percentages may be greater than 100. for association. The pathology found to occur significantly more often in females than males was nodules [ 2 (1, N = 1,158) = 10.23, p = ]. Pathologies occurring significantly more often in males than females were laryngeal cancer [ 2 (1, N = 1,158) = 22.95, p = ], papilloma [ 2 (1, N = 1,158) = 8.54, p = 0.003], and granuloma [ 2 (1, N = 1,158) = 7.51, p = 0.006]. Pathologies not significantly related to gender (p > 0.01) were reflux laryngitis, functional, paralysis, laryngitis, polyps, bowed vocal folds, normal on exam, polypoid degeneration, cyst, edema, leukoplakia, psychogenic, Reinke s edema, and cough. The remaining pathologies occurred too infrequently to support the chi-square analysis. Description of age data To be consistent with previous research, ages were divided into the following categories: 0 14, 15 24, 25 44, 45 64, and over 64 years.13 Table 4 contains the distribution of laryngeal pathologies across age categories as a total sample and by gender. Within the total sample, individuals between the ages of 0 14 years (3.5% of subjects) and years (4.1% of subjects) were least frequently seen. Pathologies were most frequent in the years age category (38.9% of subjects). Patients over the age of 64 years represented 26.8% of subjects, and 26.4% of subjects were between the ages of years. A dramatic increase in the occurrence of reflux laryngitis was seen between the years and years categories. The occurrence continued to increase when compared to those in the years category. However, a decrease was noted in individuals over the age of 64 years. Functional disorders occurred more frequently in females than males in all age categories. Functional disorders were rarely diagnosed in the younger age groups (0 14, years), and were most common between the ages of 45 and 64 years. The prevalence of vocal fold paralysis increased with age. It occurred only 3 times in the years category and 19 times in the years category. The prevalence increased to 52 in the years category, and occurred 65 times in individuals over the age of 64 years. This trend remained constant when examining the occurrence of paralysis both in actual numbers of patients seen and the percentage of individuals with paralysis found in each age group. The prevalence patterns were similar for both males and females in the younger age groups (15 24 and years), but paralysis occurred slightly more often in females than males in the older age groups (45 64 and over 64 years). Nodules was the most frequent diagnosis in the 0 14 years age category, representing 74.3% of pathologies found in that group. Earlier analysis of gender data, as shown in Table 3, revealed nodules to occur significantly more often in females than males. It should be noted, however, that nodules occurred more often in males than females in the 0 14 years category, as the male-to-female ratio for nodules was 2.25:1. Nodules occurred most frequently, however, between the ages of years.

6 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 429 TABLE 3. Frequency and Percentage of Occurrence of Laryngeal Pathology Across Gender Frequency Percentage Female Male Female Male Pathologies significantly more common to females Nodules Pathologies significantly more common to males Laryngeal cancer Granuloma Papilloma Pathologies not significantly related to gender Reflux laryngitis Functional Paralysis Laryngitis Polyps Bowed vocal folds Normal on exam Polypoid degeneration Cyst Edema Leukoplakia Psychogenic Reinke s edema Cough Pathologies with small n Erythema Contact ulcer Laryngeal dehydration Varix Laryngospasm Tremor Pharyngeal cancer Hematoma Paradoxical vocal fold movement Spasmodic dysphonia Unspecified voice disturbance Laryngocele Laryngomalacia Respiratory insufficiency Hemangioma Intubation ulceration Laryngeal stenosis Soft tissue trauma Subglottic lesion Superior laryngeal nerve palsy Thyroid cancer Tracheal stenosis Vocal fold dysplasia

7 430 SUZANNE M. COYLE ET AL TABLE 4. Occurrence of Laryngeal Pathology by Age Group 0 14 years years years years Over 64 years T M F T M F T M F T M F T M F Reflux laryngitis Functional Paralysis Nodules Laryngitis Polyps Bowed vocal folds Normal on exam Laryngeal cancer Polypoid degeneration Cyst Edema Leukoplakia Granuloma Reinke s edema Papilloma Cough Erythema Varix Laryngeal dehydration Contact ulcer Tremor Laryngospasm Pharyngeal cancer Hematoma Paradoxical vocal fold movement Psychogenic Spasmodic dysphonia 3 3 Unspecified voice disturbance Laryngocele Laryngomalacia 2 2 Respiratory insufficiency Hemangioma 1 1 Intubation ulceration 1 1 Laryngeal stenosis 1 1 Parkinson s dysphonia 1 1 Soft tissue trauma 1 1 Subglottic lesion 1 1 Superior laryngeal nerve palsy 1 1 Thyroid cancer 1 1 Tracheal stenosis 1 1 Vocal fold dysplasia 1 1 Totals Abbreviations: T = total; M = male; F = female.

8 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 431 Laryngitis was found to be rare in individuals under the age of 25 years, and most common in individuals and years. The prevalence patterns were similar for both males and females, with the exception of the years category (in which all five cases were found in females). Polyps were found to occur relatively infrequently in younger age groups (0 14, years), and were most commonly diagnosed in the and years age categories. With the exception of 0 14 years (in which only two cases occurred), polyps were found to be more frequent in females than males in all age groups. For both genders, diagnosis of laryngeal cancer was found to occur primarily after the age of 45 years. The prevalence was found to be similar for the and over 64 years age categories. Laryngeal cancer was found to be rare in younger age groups. As seen in Table 3, laryngeal cancer occurred significantly more often in males than females. This was found to be true in all age categories. Leukoplakia, commonly classified as a precancerous lesion, 1 was initially diagnosed in the years age category and did not occur in younger age groups. The frequency of occurrence was found to be similar for both males and females in the 25 44, 45 64, and over 64 years age categories. Reinke s edema and polypoid degeneration, pathologies also associated with smoking, showed prevalence trends similar to leukoplakia. The prevalence of polypoid degeneration, however, showed slightly more variability between genders. It was found to occur more frequently in females than males between the ages of years, and did not occur in females over the age of 64 years. As expected, bowed vocal folds showed the highest prevalence in the older age groups, with onset for males and females beginning between years. The frequency of occurrence increased in the over 64 years group, with similar trends for both males and females. Description of occupation data Sixty-five occupations were identified in the total sample. The occupations occurring in more than 1% of the total population were retired (24.6%), executive/manager (7.8%), homemaker (7.3%), unemployed (6.9%), student (5.6%), teacher (5.2%), clerical (4.6%), factory (4.4%), sales (2.3%), nurse (2.2%), retail (2.2%), construction (1.6%), engineer (1.6%), singer (1.5%), and truck/bus driver (1.2%). The former occupations of the unemployed and retired were unknown. Occupations were unavailable for 9.2% of the total sample. Table 5 presents the frequency of occurrence for each occupation as a total sample and by the otolaryngology practice locations. Table 6 displays the pathologies that occurred in at least 5% of the total sample and the most frequent associated occupations (N > 4). This revealed that: Reflux laryngitis, functional dysphonia, paralysis, polyps, and bowed vocal folds were most common in retired persons. Students and teachers had the greatest prevalence of nodules. Laryngitis was most frequent in executives/ managers. Table 7 presents the 10 most frequent occupations and the most commonly associated pathologies (N > 4). This revealed that: Paralysis was the most frequent diagnosis among retired persons and homemakers. Reflux laryngitis was the most frequent diagnosis found in executives/managers, unemployed, clerical professions, factory workers, and sales. Nodules was the most frequent diagnosis in both students and teachers. Among nurses, no pathology was found to occur more than four times. However, polyps and laryngitis each occurred four times. Description of demographic comparison data A chi-square analysis was used to compare the demographic variables (age, gender, and occupation) of the current study to the findings of Herrington-Hall et al. 13 Pathology comparison Analysis of pathology data revealed a significant shift in frequency of pathologies reported by the two studies [ 2 (5, N = 1,287) = , p = 0.001]. For the purpose of this analysis, pathologies found to occur in more than 5% of the population of Herrington- Hall et al 13 were used for a basis of comparison. This

9 432 SUZANNE M. COYLE ET AL TABLE 5. Frequency Occupations Reported by Individuals Seeking Treatment Total Sample Dayton (Practice A) Cincinnati (Practice B) Occupation N Occupation N Occupation N Retired 285 Retired 168 Retired 117 Executive/manager 90 Homemaker 55 Executive/manager 67 Homemaker 84 Unemployed 47 Unemployed 33 Unemployed 80 Factory 39 Teacher 31 Student 65 Student 37 Homemaker 29 Teacher 60 Teacher 29 Student 28 Clerical 53 Clerical 25 Clerical 28 Factory 51 Executive/manager 23 Sales 17 Sales 27 Nurse 14 Retail 13 Nurse 26 Retail 12 Singer 13 Retail 25 Construction 11 Factory 12 Construction 19 Sales 10 Nurse 12 Engineer 18 Engineer 9 Engineer 9 Singer 17 Computer specialist 7 Attorney 8 Driver 14 Driver 7 Construction 8 Attorney 10 Self-employed 6 Driver 7 Computer specialist 10 Auto mechanic 4 Physician 5 Clergy 8 Clergy 4 Clergy 4 Physician 8 Singer 4 Janitor 4 Self-employed 8 Unknown 27 Unknown 80 Janitor 6 Miscellaneous 40 Miscellaneous 55 Auto mechanic 5 (< 4 each) (< 4 each) Counselor 5 Realtor 5 Restaurant 5 Medical technician 4 Police officer 4 Unknown 107 Miscellaneous 59 (< 4 each) included nodules, edema, polyps, cancer, paralysis, and normal on exam. The comparative distribution of pathology can be seen in Table 8. The greatest shifts in frequency of pathology were seen in the relative prevalence of edema and paralysis. Herrington-Hall et al 13 found edema to represent 20.05% of the pathologies investigated in this analysis, compared to only 4.05% in the current study. Paralysis was found to occur more often in the current study (31.31%) as compared to Herrington-Hall et al 13 (11.86%). A decrease in the relative prevalence of laryngeal cancer was also seen, with 14.12% reported by Herrington-Hall et al 13 and 8.56% reported in the current study.

10 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 433 TABLE 6. Frequently Occurring Pathologies and Associated Occupations Pathology Total N Pathology Total N Reflux laryngitis Retired 28 Clergy 18 Executive/manager 18 Factory 16 Housewife 16 Unemployed 13 Teacher 11 Sales 7 Construction 5 Driver 5 Unknown 13 Functional Retired 35 Executive/manager 14 Teacher 11 Homemaker 9 Unemployed 9 Student 8 Clerical 5 Computer specialist 5 Retail 5 Unknown 12 Paralysis Retired 54 Homemaker 19 Unemployed 11 Clerical 5 Executive/manager 5 Teacher 5 Unknown 15 Nodules Student 33 Teacher 15 Unemployed 8 Executive/manager 7 Retired 7 Clerical 5 Unknown 9 Laryngitis Executive/manager 15 Retired 13 Unknown 14 Polyps Retired 17 Homemaker 11 Teacher 7 Executive/manager 6 Factory 6 Unemployed 5 Bowed vocal folds Retired 38 Unknown 5 Note: Pathologies presented occurred in at least 5% of the total sample. N > 4 for occupations listed. Age comparison Analysis of age data revealed a significant shift in patient age [ 2 (4, N = 2,420) = 36.33, p = 0.001]. The subjects used in the current study were found to be older than those in Herrington-Hall et al. 13 The comparative distribution of patient age can be seen in Table 9. Gender comparison No significant difference was found in the distribution of male and female subjects [ 2 (4, N = 2,420) = 3.688, p > 0.05] The distribution of male and female subjects in each study is shown in Table 10. Occupation comparison The 10 most frequently occurring occupations found by Herrington-Hall et al 13 in Dayton and Cincinnati were used as a basis for comparison to the distribution of patient occupation in the current study. Significant differences between the occupations reported by Herrington-Hall et al 13 and the current study were found [ 2 (9, N = 1,347) = , p

11 434 SUZANNE M. COYLE ET AL TABLE 7. Ten Most Frequent Occupations and Most Common Associated Pathologies Total N Retired Paralysis 54 Bowed vocal folds 38 Reflux laryngitis 38 Functional 35 Nodules 7 Leukoplakia 6 Edema 5 Executive/manager Reflux laryngitis 18 Laryngitis 15 Functional 14 Nodules 7 Polyps 6 Paralysis 5 Homemaker Paralysis 19 Reflux laryngitis 16 Polyps 11 Functional 9 Polypoid degeneration 5 Unemployed Reflux laryngitis 13 Paralysis 11 Functional 9 Nodules 8 Polyps 5 Total N Student Nodules 33 Functional 8 Teacher Nodules 15 Functional 11 Reflux laryngitis 11 Polyps 7 Paralysis 5 Clerical Reflux laryngitis 18 Functional 5 Nodules 5 Paralysis 5 Factory Reflux laryngitis 16 Polyps 6 Sales Reflux laryngitis 7 Nurse No pathology N > 4 Note: N > 4 for pathologies listed. TABLE 8. Distribution of Pathology in Herrington-Hall et al 13 and Current Study Percentage of Total Sample TABLE 9. Distribution of Age in Herrington-Hall et al 13 and Current Study Percentage of Total Sample Herrington-Hall Current study Herrington-Hall Current study Nodules Edema Polyps Cancer Paralysis Normal on exam years years years years Over 64 years

12 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 435 TABLE 10. Distribution of Patient Gender in Herrington-Hall et al 13 and Current Study Percentage of Total Sample TABLE 11. Distribution of occupation in Herrington- Hall et al 13 and current study Percentage of Total Sample Herrington-Hall Current study Herrington-Hall Current study Male Female = 0.001]. Homemaker was reported significantly less often in the current study as compared to Herrington- Hall et al. 13 Executive/manager, secretary/clerical, student, and unemployed were reported slightly more often in the current study. Table 11 presents the comparative distribution of occupations reported by Herrington-Hall et al 13 and the current study. Description of comparative interaction data Log-linear models were utilized to investigate comparisons of the interactions between laryngeal pathology and the demographic variables of age and gender reported by Herrington-Hall et al 13 and the current study. Interactions between pathology and age, and pathology and gender were compared across the two studies. In each comparison the test of interest was the likelihood ratio, which utilized a chisquare test to determine consistency between Herrington-Hall et al 13 and the current study with respect to the interaction being analyzed (i.e., pathology and age, etc.). A series of chi-square analyses were utilized to compare the consistency of interactions between pathology and occupation reported by the two studies. Pathologies found to occur in more than 5% of the Herrington-Hall et al 13 population were used as a basis of comparison. These included nodules, edema, polyps, cancer, paralysis, and normal on exam. The likelihood ratio for this investigation found no significant difference in either the interaction patterns of pathology and gender or pathology and age, as reported by the two studies. These findings were consistent for all pathologies investigated. Tables 12 and 13 present the statistical support for these comparisons. Table 14 presents the shifts that have occurred in the relationships between pathology and occupation as reported by the two studies. Due to the reduced prevalence of edema reported in the current study (see Table 10), shifts in the relationship to occupation Executive/manager Homemaker Nurse Retired Secretary/clerical Self-employed Singer Student Teacher Unemployed Note: Occupations represent the 10 most frequently occurring occupations found by Herrington-Hall et al 13 in Dayton and Cincinnati locations. TABLE 12. Results of Log-Linear Analysis for Consistency of Interactions Between Pathology and Gender Reported by Herrington-Hall et al 13 and the Current Study χ 2 value p value Nodules Edema Paralysis Cancer Polyps Normal on exam Note: Total frequency (N) = 2,420; degrees of freedom (df) = 1. could not be examined. The frequency of occurrence in the current study was too small to support the chisquare analysis for all occupations. DISCUSSION Laryngeal pathology and relationships between demographic variables, including age, gender, and occupation, were compared for the same geographic re-

13 436 SUZANNE M. COYLE ET AL TABLE 13. Results of Log-Linear Analysis for Consistency of Interactions Between Pathology and Age Reported by Herrington- Hall et al 13 and the Current Study df χ 2 value p value Nodules Edema Paralysis Cancer Polyps Normal on exam Note: df = degrees of freedom. gion with a 15-year time span. Differences in these relationships were found to have occurred. Sampling the treatment-seeking population Data for the Herrington-Hall et al 13 study were extracted from medical records of patients seeking treatment between 1981 and In the current study, records of patients seeking treatment between 1996 and 1998, 15 years after the original study, were evaluated. It is expected that the society in which the patients live, and therefore the demographic composition of the patients, would have changed during the 15-year time span. One such change that occurred during the 15 years between the two studies was the dramatic increase in the number of patients seeking treatment at the two participating practices. This increase was the direct result of an increase in the number of otolaryngologists providing services to patients. In the Dayton, Ohio, practice alone, during the three-year inclusion period, 7,302 new patients sought treatment for voice concerns (a difference of 6,724 patients). The practical aspect of reviewing this number of patient charts necessitated a random selection of patients to match the subject size of Herrington-Hall et al 13 in the Cincinnati and Dayton locations. Despite the difference in sample selection, several meaningful findings emerged in the comparisons of the two studies. Distribution of pathologies Reflux laryngitis One of the most substantial differences between the pathology data reported by Herrington-Hall et al 13 and the current study was the prevalence of reflux laryngitis. In the current study, reflux laryngitis was the primary diagnosis (18.4%) of the total population, and was the most frequent pathology reported in both the Dayton and Cincinnati practices. However, it was not included in the data presented by Herrington-Hall et al. 13 This is not to suggest that gastroesophageal reflux disease (GERD) did not occur at the time of the original study, but the effects on the voice and larynx may not have been realized at that time. Gastroesophageal reflux occurs when acidic stomach contents are brought up from the stomach and spill into the posterior larynx. The laryngeal manifestations of this disorder have more recently been described as laryngopharyngeal reflux (LPR), though no ICD-9 code exists for this categorization. Patients with GERD/LPR may present with hoarseness, vocal fatigue, throat clearing, throat pain, and/or feelings of fullness or choking. It appears that these symptoms result from acid burns on the posterior larynx and consequent edema, erythema, ulcerations, and granulation of the laryngeal mucosa. If untreated, it has been suggested that it may lead to hyperkeratosis and even laryngeal carcinoma. 17 It is possible that significant numbers of patients included in the Herrington-Hall et al 13 study might have presented with symptoms of GERD/LPR. Due to the wide range of symptoms and pathologies associated with reflux laryngitis, it is possible that these subjects were diagnosed with the related pathologies rather than reflux laryngitis. This difference could explain the high occurrence of edema (14.1%) reported by Herrington-Hall et al 13 and the relatively low percentage (1.6%) reported in the current study. Functional and psychogenic disorders Herrington-Hall et al 13 classified pathologies as functional if the otolaryngologist listed some possible causes of dysphonia (i.e. overuse, abuse, muscle imbalance) but did not record whether there was actual vocal fold change (p. 58). However, current definitions of functional disorders include those thought to have psychogenic components, as in the case of functional falsetto and conversion a/dysphonia. Dysphonia that results from muscle imbalance is commonly diagnosed as laryngeal myasthenia. 1 This

14 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 437 TABLE 14. Significant Shifts in the Relationships Between Pathology and Occupation as Reported by Herrington-Hall et al 13 and the Current Study Percentage of Subjects with Pathology and Stated Occupation χ 2 value Herrington-Hall Current study Nodules Significant Shifts (p < 0.05) Factory Homemaker Secretary/Clerical Singer Constant Relationships (p > 0.05) Nurse Retired Student Teacher Polyps Significant Shift (p < 0.05) Retired Constant Relationships (p > 0.05) Factory Homemaker Unemployed Laryngeal Cancer Significant Shifts (p < 0.05) Retired Unemployed Paralysis Significant Shift (p < 0.05) Homemaker Constant Relationship (p > 0.05) Retired Normal on Exam Significant Shifts (p < 0.05) Homemaker Teacher Constant Relationship (p > 0.05) Factory Retired Note: Degrees of freedom (df) = 1. Pathologies occurred in at least 5% of the sample examined by Herrington-Hall et al. 13 Occupations analyzed are those that most frequently occurred within each pathology, as reported by Herrington-Hall et al. 13 change in nomenclature may result in confusion or misinterpretation of results when comparing the findings of Herrington-Hall et al 13 to the current study. It is possible that the change in nomenclature from functional to more specific terms, such as laryngeal myasthenia, may be a result of the growing presence of third-party reimbursement. It has been suggested that third-party payers may require more specific diagnoses other than those reflecting psychogenic disorders. As a result of such policies, disorders may not

15 438 SUZANNE M. COYLE ET AL be classified as functional to meet the requirements for insurance coverage. When data were analyzed with definitions of functional and psychogenic disorders constant in Herrington-Hall et al 13 and the current study, shifts in frequency of occurrence were apparent. Functional was found to be a more frequent diagnosis in the current study, and psychogenic was more frequently diagnosed in the findings of Herrington-Hall et al. 13 It is interesting to note that Fitz-Hugh et al 18 reported confusion in nomenclature when attempting to diagnose laryngeal pathology. Today, over 40 years after the publication of their study, confusion still exists. Shifts in demographic variables Age variable Several shifts were reported in the demographic analysis of the population examined by Herrington- Hall et al 13 and the current study. Among these is the shift that has occurred in the ages of the sample population. The population of the current sample was found to be older than the sample examined by Herrington-Hall et al. 13 In both studies pathologies were found to be more common in older age groups (those over 45 years). The current study, however, found an increase in individuals in both the and over 64 years categories. A possible explanation for this shift is the overall aging of society in the United States. In the next two decades the baby boom generation (America s largest generation) will cause the largest population growth in the United States to be in middle-aged and older Americans. 19 This continued growth in the number of older adults may be reflected in the shifts toward older age groups seen in the current study. Occupation variable Shifts occurred in the distribution of occupations reported by Herrington-Hall et al 13 and the current study. One example of such a shift is seen in the decrease in homemakers reported in the current study as compared to Herrington-Hall et al. 13 This finding mirrors a widespread change that has occurred in society. During the past decade the labor force participation rate of women over the age of 20 years has increased. In 1989, the participation rate was 57.2%, and increased to 59.7% in While these shifts in the distribution of occupation are of interest, the actual relationship between pathology and occupation must be investigated before conclusions can be drawn. It is tempting to state that the decrease in factory workers, for example, reported by the current study may be related to the decrease in nodules also reported in the current study. Such conclusions must be taken with caution. Clearly trends are seen in the relationships between laryngeal pathology and occupation. It cannot, however, be determined to be a causal relationship. A number of lifestyle factors may also interfere with these conclusions, such as tobacco and alcohol use and activities outside the workplace. Care must also be taken in drawing conclusions among the retired population. For example, prior occupations of retired and unemployed individuals were unknown in this study. Therefore, it is difficult to conclude that occupational history of these groups impacted the development of laryngeal pathologies. Consistency of interactions between pathologies and demographic variables No significant differences were found in the relationships between pathology and the demographic variables of age and gender. It is interesting to note that these relationships have remained constant while the relative prevalence of the pathologies and distribution of patient ages have shifted. From this observation it can be concluded that the gender and age-related risk factors associated with the pathologies examined (including nodules, edema, polyps, cancer, paralysis, and normal on exam) have remained constant. Pathology and occupation Some shifts were found in the relationships between pathology and occupation as reported by Herrington-Hall et al 13 and the current study. These may have resulted from several factors. These relationships may have been influenced by the differences in the distribution of laryngeal pathologies found in the two studies. This shift in occupation distribution may mirror changes that have occurred in society during the past 15 years. Nodules The shifts between pathology and occupation may also be outcomes of health promotion programs that have occurred in the workplace. For example, Herrington-Hall et al 13 found nodules to occur most of-

16 LARYNGEAL PATHOLOGY IN A TREATMENT-SEEKING POPULATION 439 ten in factory workers, possibly as a result of speaking over loud noise. Efforts to reduce the noise in this environment may have impacted the relationship between nodules and factory workers. Such noise reduction efforts may be a result of widespread policy changes implemented by the Occupational Safety and Health Administration (OSHA), or results of individual factory efforts. Paralysis Another interesting shift occurred in the number of homemakers with paralysis in the two studies. Herrington-Hall et al 13 reported 6.47% of homemakers had paralysis, while the current study found 22.62%. It is also noted that the current study found the prevalence of paralysis to increase with age, and to be slightly higher in females than males at all ages. Since 100% of homemakers were female, it is therefore possible that the prevalence of paralysis may be related to the prevalence of breast cancer. Garfinkel et al 21 reported that the incidence of breast cancer increased between the early 1980s and early 1990s, particularly for women over the age of 50 years. If surgical management, or the cancer itself, involved the left lung, damage to the vagus nerve is possible. As a result the left vocal fold may be paralyzed. Radiation treatments and/or chemotherapy may also alter the nerve supply to the left vocal fold. 1 Further study of the etiology for vocal fold paralysis in this population would be interesting. CONCLUSIONS The present study led to the following general conclusions: The most frequently occurring laryngeal pathologies, those found in more than 5% of the total sample, were reflux laryngitis, functional, vocal fold paralysis, nodules, laryngitis, polyps, and bowed vocal folds. Within the total sample, pathologies were found to occur more often in females than males. Nodules were found significantly more often in females, while laryngeal cancer, papilloma, and granuloma were more common in males. The majority of pathologies occurred in individuals over the age of 25 years. Pathologies were much less frequent in younger age categories. Individuals between the ages of years comprised the largest age group. Shifts have occurred in the relative distribution of pathology reported in the current study and in the population examined 15 years earlier by Herrington-Hall et al. 13 Reflux laryngitis was the most frequent pathology in the current study, yet was not reported by Herrington-Hall et al. 13 The prevalence of edema and cancer decreased, while the prevalence of paralysis increased in the current study. The treatment-seeking population investigated in the current study was older than the population investigated 15 years earlier by Herrington-Hall et al. 13 In the past 15 years there has been no significant difference in the distribution of males and females in the treatment-seeking population. A shift has occurred in the occupations reported by the treatment-seeking population of the current study as compared to the population from 15 years earlier. Homemaker was reported less often in the current study, while executive/manager, secretary/ clerical, student, and unemployed were reported slightly more often. No significant differences were found in the relationships between laryngeal pathology and the demographic variables of age and gender reported in the treatment-seeking population of Herrington- Hall et al 13 and the current study. Relationships between pathology and occupation reported by Herrington-Hall et al 13 differed from the relationships found in the current study. Within other geographic regions, prevalence studies for the variables included in this study would likely demonstrate variations from the southwestern Ohio region. Future research combining regional data may prove useful in giving a more national perspective. Acknowledgments: This research was conducted as a master s thesis by Suzanne Coyle at Miami University, Oxford, Ohio, under the direction of Dr. Barbara Weinrich and Dr. Joseph Stemple, and with the approval of the Institutional Review Board. The authors thank thesis committee members Ms. Lisa Kelchner, Blaine Block Institute for Voice Analysis & Rehabilitation, and Dr. Louise VanVliet, Miami University, for their valuable contributions. The statistical assistance provided by Mr. Michael Hughes, Department of Mathematics and Statistics, Mia-

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