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Original Investigation
November 2017

Changes in Peak Airflow Measurement During Maximal Cough After Vocal Fold Augmentation in Patients With Glottic Insufficiency

Author Affiliations
  • 1NYU Voice Center, Department of Otolaryngology–Head and Neck Surgery, New York University School of Medicine, New York
  • 2NYU Department of Population Health, New York University School of Medicine, New York
  • 3Department of Mathematical Sciences, New Jersey Institute of Technology, Newark
JAMA Otolaryngol Head Neck Surg. 2017;143(11):1141-1145. doi:10.1001/jamaoto.2017.0976
Key Points

Question  Does vocal fold augmentation improve peak airflow during maximal cough in patients with glottic insufficiency?

Findings  In this case series study of 14 participants with glottic insufficiency, 11 participants experienced increased cough strength after vocal fold augmentation, with increased peak airflow ranging from 10 to 150 L/min.

Meaning  Change in peak airflow during maximal cough after vocal fold augmentation may lead to improved peak airflow during volitional cough, which is germane given the relationship between cough strength and aspiration, particularly in progressive neurologic disease.


Importance  Compromised cough effectiveness is correlated with dysphagia and aspiration. Glottic insufficiency likely yields decreased cough strength and effectiveness. Although vocal fold augmentation favorably affects voice and likely improves cough strength, few data exist to support this hypothesis.

Objective  To assess whether vocal fold augmentation improves peak airflow measurements during maximal-effort cough following augmentation.

Design, Setting, and Participants  This case series study was conducted in a tertiary, academic laryngology clinic. Participants included 14 consecutive individuals with glottic insufficiency due to vocal fold paralysis, which was diagnosed via videostrobolaryngoscopy as a component of routine clinical examination. All participants who chose to proceed with augmentation were considered for the study whether office-based or operative augmentation was planned. Postaugmentation data were collected only at the first follow-up visit, which was targeted for 14 days after augmentation but varied on the basis of participant availability. Data were collected from June 5, 2014, to October 1, 2015. Data analysis took place between October 2, 2015, and March 3, 2017.

Main Outcomes and Measures  Peak airflow during maximal volitional cough was quantified before and after vocal fold augmentation. Participants performed maximal coughs, and peak expiratory flow during the maximal cough was captured according to American Thoracic Society guidelines.

Results  Among the 14 participants (7 men and 7 women), the mean (SD) age was 62 (18) years. Three types of injectable material were used for vocal fold augmentation: carboxymethylcellulose in 5 patients, hyaluronic acid in 5, and calcium hydroxylapatite in 4. Following augmentation, cough strength increased in 11 participants and decreased cough strength was observed in 3. Peak airflow measurements during maximal cough varied from a decrease of 40 L/min to an increase of 150 L/min following augmentation. When preaugmentation and postaugmentation peak airflow measurements were compared, the median improvement was 50 L/min (95% CI, 10-75 L/min; P = .01). Immediate peak airflow measurements during cough collected within 30 minutes of augmentation varied when compared with measurements collected at follow-up (103-380 vs 160-390 L/min).

Conclusions and Relevance  Peak airflow during maximal cough may improve with vocal fold augmentation. Additional assessment and measurements are needed to further delineate which patients will benefit most regarding their cough from vocal fold augmentation.