Laryngeal dysfunction was commonly present and was persistent for months after recovery from coronavirus disease 2019 (COVID-19) in non-hospitalised and non-intubated patients, according to a study published in the American Journal of Otolaryngology.
“Our findings underscore the considerable long-term burden of laryngeal dysfunction in patients after recovery from COVID-19 infection of varying severity. To our knowledge, our study is the first in these patients to provide clinical insights by incorporating data from quality of life (QOL) indices, voice evaluations, and long-term follow-up clinical outcomes data after various interventions,” wrote Hemali P Shah, Yale University School of Medicine, New Haven, Connecticut, and colleagues.
All patients who presented to the Yale COVID clinic, a longitudinal care clinic for patients recovering from COVID-19 infection, between July 2020 and August 2021 were identified through retrospective chart review. Patients with a documented diagnosis of COVID-19 with a positive RT-PCR test who were referred for laryngeal dysfunction were included for analysis.
A total of 57 patients met inclusion criteria (mean age 52.7 years). Of the patients, 37 (64.9%) were hospitalised for COVID-19 infection. Among those who were hospitalised, 24 (64.9%) required intensive care unit admission, while 24 (64.9%) were intubated. Of the 24 patients who were intubated, 6 (25%) underwent tracheostomy after a median intubation period of 19 days and 18 (75.0%) were proned for a median duration of 3 days.
The average time from COVID-19 infection to initial presentation to a laryngologist was significantly shorter for patients who were intubated compared to those who were not intubated (175 ± 98 days versus 256 ± 150 days, respectively, P = 0.025). Of the total cohort, 37 (64.9 %) patients had more than one visit with a laryngologist. Average follow-up duration for patients who were intubated was 268 ± 150 days and 188 ± 128 days for those who were not intubated (P = 0.103).
The most common diagnosis was dysphonia, which was observed in 40 (70.2%) patients, whereas dysphagia and laryngotracheal stenosis (LTS) was diagnosed in 14 (25.0%) and 10 (17.5%) patients, respectively. A separate disease entity, COVID-related laryngeal hypersensitivity was reported in 13 (22.8 %) patients and significantly more prevalent in non-intubated patients compared to intubated patients (36.4 % vs 4.2 %, P = 0.004). Additionally, diagnosis of dyspnea of unknown etiology was made in 6 (10.5%) patients.
Of the 39 patients who underwent stroboscopy, a normal stroboscopy exam was observed in 7 (17.9%) patients. No significant differences were found in stroboscopy findings between patients who were and were not intubated. The most common abnormality observed on stroboscopy exam was an asymmetric mucosal wave, which was seen in 15 (38.5%) patients. With respect to other alterations, 11 (28.2%) patients had unilateral vocal fold paresis, 9 (23.1%) exhibited irregular periodicity, 8 (20.5%) patients had decreased amplitude, and 4 (10.3%) had incomplete glottic closure.
QOL indices were recorded for 45 (78.9 %) patients, of whom 18 (40.0%) had at least one follow-up appointment with QOL outcome survey data. On initial presentation to otolaryngology, the median scores for Voice Handicap Index-10 (VHI-10), Dyspnea Index and Reflux Symptom Index were 11/40, 21/40, and 22/45. Median baseline scores of 11/40 (interquartile range [IQR] 5.0–21.0) and 4/40 (IQR 1.0–12.0) were observed for Cough Severity Index (CSI), and Eating Assessment Tool-10, respectively. Notably, the patients with dysphonia appeared to have higher baseline VHI scores and lower CSI scores when compared to patients without dysphonia. Additionally, patients with LTS were also observed to have considerably higher baseline QOL scores across all the indices, indicating worse QOL. Further, patients with COVID-related laryngeal hypersensitivity had comparable scores across QOL indices relative to patients without this diagnosis.
Of the 17 patients who underwent voice therapy, 11 (64.7 %) reported improvement in their symptoms while 2 (11.8 %) patients reported resolution. VHI scores decreased for patients who reported symptom improvement. Meanwhile, 7 of 10 (70 %) patients with LTS required > 1 procedural intervention before symptom improvement.
“This study comprehensively describes laryngeal dysfunction in patients who have recovered from varying severities of COVID-19 infection (eg intubated, non-intubated, non-hospitalised). Even among non-intubated and non-hospitalised patients, laryngeal dysfunction commonly presents and is persistent for months after recovery from COVID-19,” the authors noted.
“Interventions such as procedures for laryngotracheal stenosis and voice therapy can be beneficial for these patients with post-COVID laryngeal sequelae. Future directions include assessing benefits of these interventions more objectively in larger cohorts,” the authors added.