key: cord-1032897-lmc9sskw authors: Dassie-Leite, Ana Paula; Gueths, Tatiane Prestes; Ribeiro, Vanessa Veis; Pereira, Eliane Cristina; Martins, Perla do Nascimento; Daniel, Christiane Riedi title: Vocal signs and symptoms related to COVID-19 and risk factors for their persistence date: 2021-08-11 journal: J Voice DOI: 10.1016/j.jvoice.2021.07.013 sha: ba54733da8dba26f7deeb6b52f5c5d6bf8c0ca4e doc_id: 1032897 cord_uid: lmc9sskw Objective: To compare the occurrence of vocal signs and symptoms before, during, and after coronavirus disease (COVID-19) and analyze possible risk factors for the persistence of these signs and symptoms after disease resolution. Method: This was an observational, analytical, and cross-sectional study. The participants were 45 individuals of both sexes, with a mean age of 44 years, who were previously affected by COVID-19. All participants answered a questionnaire about sociodemographic data, smoking history, disease course, vocal complaints, and the vocal signs and symptoms list (SSL), referring to three timepoints (before, during, and after COVID-19). Results: The most commonly reported vocal signs and symptoms before COVID-19 were phlegm (26.67%; n=12) and dry throat (24.44%; n=11). During COVID-19, the most frequent vocal signs and symptoms were tired voice after short-term use (73.33%; n=33) and dry throat (71.11%; n=32). After the disease, the most reported vocal signs and symptoms were dry throat (57.78%; n=26) and phlegm (53.33; n=24). The self-perception of vocal signs and symptoms before COVID-19 was lower than that during and after COVID-19 (p<0.001). Vocal complaints after COVID-19 and oxygen therapy were predictors of self-perception of vocal signs and symptoms after COVID-19. Conclusion: Individuals affected by COVID-19 had a higher frequency of vocal signs and symptoms during the disease. However, after remission, the frequency of vocal signs and symptoms was higher than that at baseline. The need for oxygen therapy may indicate a risk for a higher occurrence of vocal signs and symptoms after COVID-19. ABSTRACT Objective: To compare the occurrence of vocal signs and symptoms before, during, and after coronavirus disease and analyze possible risk factors for the persistence of these signs and symptoms after disease resolution. Method: This was an observational, analytical, and cross-sectional study. The participants were 45 individuals of both sexes, with a mean age of 44 years, who were previously affected by COVID-19. All participants answered a questionnaire about sociodemographic data, smoking history, disease course, vocal complaints, and the vocal signs and symptoms list (SSL), referring to three timepoints (before, during, and after . Results: The most commonly reported vocal signs and symptoms before COVID-19 were phlegm (26.67%; n=12) and dry throat (24.44%; n=11). During COVID-19, the most frequent vocal signs and symptoms were tired voice after short-term use (73.33%; n=33) and dry throat (71.11%; n=32). After the disease, the most reported vocal signs and symptoms were dry throat (57.78%; n=26) and phlegm (53.33; n=24). The self-perception of vocal signs and symptoms before COVID- 19 was lower than that during and after COVID-19 (p<0.001). Vocal complaints after COVID-19 and oxygen therapy were predictors of self-perception of vocal signs and symptoms after COVID-19. Conclusion: Individuals affected by COVID-19 had a higher frequency of vocal signs and symptoms during the disease. However, after remission, the frequency of vocal signs and symptoms was higher than that at baseline. The need for oxygen therapy may indicate a risk for a higher occurrence of vocal signs and symptoms after COVID-19. KEYWORDS: COVID-19, dysphonia, signs and symptoms, voice. COVID-19 is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus has a clinical spectrum ranging from asymptomatic infections to deaths 1 . Approximately 80% of COVID-19 patients may be asymptomatic or oligosymptomatic (few symptoms). Of the 20% who require hospital care because they have difficulty breathing, approximately 5% may require oxygen therapy due to hypoxemia 1 . Acute symptoms of COVID-19 include cough, fever, dyspnea, musculoskeletal symptoms (myalgia, joint pain, fatigue), gastrointestinal symptoms, anosmia, and dysgeusia [2] [3] [4] . COVID-19 can lead to respiratory complications, which in turn may result in cardiac (arrhythmias and myocardial), renal (acute kidney injury), gastrointestinal, neurological (neuropathy, encephalopathy), endocrine, and musculoskeletal consequences (weakness, pain, and fatigue) 5, 6 . Despite numerous studies on the acute form of COVID-19, to date, there is no established deadline to describe the slow and persistent condition in individuals with long-term sequelae of COVID-19 7 . Abnormal signs and symptoms or parameters that persist for more than 2 weeks after the onset of COVID-19 and do not resolve (baseline values) may have potential long-term effects 8 . These symptoms occur mainly in survivors of severe and critical COVID-19, and long-lasting effects also occur in individuals with mild infection and those who require no hospitalization 9 . Patients who had COVID-19 and required medical hospitalization often have symptoms after approximately 2 months 10,11 , especially those who needed intensive care unit (ICU) care 11 . The main symptoms are fatigue 1010,11 , dyspnea 10,11 , joint pain 10 , chest pain 10 , and psychological distress 11 . Voicerelated symptoms, more specifically related to laryngeal sensitivity and vocal changes, have also been described 11 . Regarding vocal symptoms, a single study specifically on this topic analyzed the prevalence of dysphonia in 702 European patients with mild to moderate COVID-19. The data showed that 27% of the patients had dysphonia. Dysphonic patients had a higher occurrence of cough, chest pain, sticky sputum, arthralgia, diarrhea, headache, fatigue, nausea, and vomiting. The severity of dyspnea, dysphagia, ear pain, facial pain, sore throat, and nasal obstruction was higher in the dysphonic group than in the non-dysphonic group 12 . It is believed that the vocal symptoms present after COVID-19 may not only be related to orotracheal intubation 13 but also to respiratory sequelae. In clinical practice, vocal complaints associated with respiratory complaints have been observed. This is because the integrity of the respiratory system is fundamental for proper voice production with respect to providing the air pressure necessary for phonation [14] [15] [16] [17] . Moreover, in the new scenario imposed by COVID-19, some laryngeal occurrences have been described, with scarcely known causes, as paradoxical movement of the vocal fold 12 . It is necessary to understand more deeply the occurrence of vocal signs and symptoms before, during, and after COVID-19. Thus, it is possible to contribute to the management of symptoms and maximize the functional recovery of patients 11 . Therefore, this study aimed to compare the occurrence of vocal signs and symptoms before, during, and after coronavirus disease (COVID-19) and analyze possible risk factors for the persistence of these symptoms after disease resolution. This study has an observational, analytical, cross-sectional, and hybrid design. The study was approved by the Ethics Committee on Research with Human Beings of the institution of origin, under number 4.319.245. Individuals referred by the health department of a Brazilian municipality to the evaluation and rehabilitation service after COVID-19 developed by the home institution participated in the study. The service is composed of speech therapists and physiotherapists. The inclusion criteria were as follows: both sexes, age ≥18 years, a diagnosis of COVID-19 confirmed by reverse transcription polymerase chain reaction (RT-PCR), and referral from the public health service of the city where the institution proposing this research is located. Exclusion criteria were: asymptomatic persons; invasive mechanical ventilation; history of respiratory disorders or other health changes that impacted voice and communication before COVID. The eligibility criteria were applied using direct questions. All participants answered a questionnaire about sociodemographic data (sex, age, weight, and height), smoking history, course of the disease (date of diagnosis, need for hospitalization, type and duration of hospitalization, noninvasive mechanical ventilation, oxygen therapy), and vocal complaints (before, during, and after COVID-19). Following this, the individuals answered the vocal signs and symptoms list (SSL), which investigates the presence or absence of 14 vocal signs or symptoms 18 . A brazilian portuguese translation of the instrument was used 19 . Each symptom was addressed with respect to three distinct timepoints: before, during, and after COVID-19. According to the authors' instructions, the total score of the questionnaire was calculated using a simple sum. Moreover, a descriptive analysis of individual symptoms was conducted. The vocal symptoms were self-reported based on the following questions: Vocal signs and symptoms before COVID-19 -participant should answer considering whether the sign/symptom was recurrent or persistent in his/her day-to-day before the diagnosis of the disease; Vocal signs and symptoms during COVID-19 -participant should respond considering if the sign/symptom questioned occurred during the active period of the disease, which comprised the interval between the 3rd and 11th day; Vocal signs and symptoms after a COVID-19 -participant should respond considering whether the sign/symptom was recurrent or persistent from the day of remission of the disease to the current day (day of data collection). Data were tabulated and statistically analyzed using SPSS 25.0. The inferential analysis was performed using the Friedman test to compare the results obtained with the SSL before, during, and after COVID-19. Multiple pairwise comparisons with Bonferroni corrections were performed for cases of significance. Multiple linear regression with the selection of variables by the stepwise method was performed to analyze the factors related to the maintenance of symptoms after COVID-19. For all inferential analyses, a significance level of 5% was adopted. Forty-five individuals participated in this study, with a mean age of 44 years and 10 months, 24 females and 21 males. The descriptions of the other variables independent of sociodemographic data, disease course, and vocal complaints are shown in Tables 1 and 2 . Table 4 indicates a significant difference in self-perception of vocal signs and symptoms before, during, and after COVID-19 (p<0.001). The selfperception of vocal signs and symptoms before COVID-19-19 was lower than during (p<0.001) and post-disease (p<0.001). Moreover, the self-perception of vocal signs and symptoms after COVID-19 was lower than during the disease (p<0.001). Regression to verify whether the variables (age, body mass index, time since COVID diagnosis, days of hospitalization, days of intensive care unit (ICU) stay, hospitalization, noninvasive ventilation, oxygen therapy, smoking history, vocal complaints before, during, and after COVID-19), were related to self-perception of vocal signs and symptoms after COVID-19 resulted in a statistically significant model (F(2,43) = 18.076; p<0.001; R2 = 0.422). Vocal complaint after COVID-19 (β = 0.549; t = 4.508; p <0.001) and oxygen therapy (β = 0.333; t = 2.737; p=0.009) were predictors of self-perception of vocal signs and symptoms after having COVID-19 (Table 5) . 4. DISCUSSION Pulmonary function is directly related to subglottic airflow, which is fundamental for phonation and pneumo-phono-articulatory coordination [21] [22] [23] [24] [25] . The dry throat and phlegm symptoms are related to dehydration and inflammatory processes in the upper airways and vocal folds 26, 27 . In general, symptoms related to vocal tract sensations have been observed in other studies investigating patients with COVID-19 at varying frequencies [28] [29] [30] [31] . Otorhinolaryngological symptoms, in general, may be present in almost 60% of patients during the disease 30 . Cough is one of the most common symptoms of the disease and may be present in approximately 76% of cases 29 , causing irritation, edema, and even phonotrauma in the vocal folds. Regarding the period after COVID-19, there is a possibility that 25% of individuals will continue experiencing laryngeal sensitivity 11 . This study hypothesized that respiratory sequelae and vocal tract symptoms related to COVID-19 might be risk factors for the development of dysphonia. This study indicates that hoarseness was present in 48.89% of the cases during the disease, higher rates than those described in the literature regarding dysphonia, which is 27% 12 . In this study, 26.67% of patients presented with symptoms of hoarseness after the disease. No specific studies on this symptom were found, but the results are compatible with those of a study that showed that approximately 25% of patients reported persistent vocal changes after the disease 11 . Some atypical cases of dysphonia during or after COVID-19 have been reported, including vocal fold immobility, paradoxical movement of vocal folds, and psychogenic dysphonia 12, 28, 32 . For this reason, in addition to the possibility of vocal disorders due to respiratory sequelae or vocal tract symptoms commonly related to the disease, each case must be analyzed individually according to clinical history and vocal manifestations. The highest frequency of vocal signs and symptoms was observed during COVID-19, with differences compared to those before and during the disease. The frequency of vocal signs and symptoms after COVID-19, although lower than during COVID-19, was higher than that before COVID-19. Thus, it was confirmed that many signs and symptoms persisted even after curing the disease. A median of one symptom was noted before COVID-19, which is compatible with that in the general population 18 . The median of seven vocal signs and symptoms during COVID-19 was compatible with the numbers presented for individuals with dysphonia in general 18 . After COVID-19, the median of three symptoms, although lower than that commonly presented by individuals with vocal disorders 18 , is similar to that presented by Brazilian teachers, a group whose profession historically indicates the presence of great symptomatology and vocal risk 19 . Individuals who used oxygen therapy had a higher frequency of vocal signs and symptoms after COVID-19. The prescription of oxygen therapy is widely described in the literature to treat respiratory failure as it improves O 2 supply to cells by increasing the partial pressure of oxygen in the arterial blood through a higher oxygen concentration in the inspired air [33] [34] [35] [36] . In cases of COVID-19, it is a frequently used and important procedure for recovery 37, 38 . One of the side effects of this type of therapy is the dryness due to inadequate humidification 39 . Dryness of the mucous membranes of the vocal tract can be hypothesized as a cause, and dehydration may increase vocal symptomatology. Individuals with vocal complaints after COVID-19 also had a higher frequency of vocal signs and symptoms. This result was expected, and there is already a consensus on this aspect in the literature [40] [41] [42] . This study presented a risk of memory bias due to data collection performed after COVID-19 from the moments before and during the disease. Individuals affected by COVID-19 have a higher frequency of signs and symptoms during the disease; however, they still maintain a higher frequency than baseline after remission. The most reported vocal signs and symptoms during and after COVID-19 indicate a relationship with pulmonary sequelae and upper airway, and vocal symptoms commonly present in the acute phase of the disease. The need for oxygen therapy may indicate a risk for a higher occurrence of after COVID-19 vocal signs and symptoms. de 3 de Fevereiro de 2020. Declara Emergência Em Saúde Pública de Importância Nacional (ESPIN) Em Decorrência Da Infecção Humana Pelo Novo Coronavírus (2019-NCoV). Brazil: Diário Oficial da União Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical Characterisation Protocol: prospective observational cohort study Mitigate the effects of home confinement on children during the COVID-19 outbreak The New Challenge of Geriatrics: Saving Frail Older People from the SARS-COV-2 Pandemic Infection Impact of the COVID-19 Pandemic on Mental Health and Quality of Life among Local Residents in Liaoning Province, China: A Cross-Sectional Study How COVID-19 Affects the Brain. JAMA Psychiatry Long-term effects of COVID-19: a systematic review and meta-analysis. medRxiv Symptom Duration and Risk Factors for Delayed Return to Usual Health Among Outpatients with COVID-19 in a Multistate Health Care Systems Network -United States Persistent Poor Health Post-COVID-19 Is Not Associated with Respiratory Complications or Initial Disease Severity Persistent Symptoms in Patients After Acute COVID-19 Postdischarge symptoms and rehabilitation needs in survivors of COVID-19 infection: A crosssectional evaluation Post-COVID-19 paradoxical vocal fold movement disorder Vocal Cord Ulcer Following Endotracheal Intubation for Mechanical Ventilation in COVID-19 Pneumonia: A Case Report from Northern Italy Voz: O Livro Do Especialista Tempos máximos fonatórios e sua relação com sexo, idade e hábitos de vida em idosos saudáveis Handicap, vocal complaints and maximum phonation time in women smokers Influence of the speech-language pathologist's orientation on maximum phonation times Voice Disorders in Teachers and the General Population Epidemiology of voice disorders in teachers and nonteachers in Brazil: prevalence and adverse effects 6-month consequences of COVID-19 in patients discharged from hospital: a cohort study The physics of small-amplitude oscillation of the vocal folds Changes in phonation threshold pressure with induced conditions of hydration Relevance of subglottic pressure in normal and dysphonic subjects Lung Vital Capacity of Choir Singers and Nonsingers: A Comparative Study Association Between Subglottic Pressure and Pulmonary Function in Individuals With Parkinson's Disease The Vocal Cord Nodule: Complication of Severe COVID-19 Infection. Arch Anesth Crit Care New-Onset Dysphonia: A Silent Manifestation of COVID-19 Sudden and persistent dysphonia within the framework of COVID-19: The case report of a nurse Using psychoneuroimmunity against COVID-19 Otolaryngological symptoms in COVID-19 Voice Quality Evaluation in Patients With COVID-19: An Acoustic Analysis. J Voice Dysphonia as the main presenting symptom of COVID-19: a case report The use of high-flow nasal oxygen therapy in the management of hypercarbic respiratory failure High-flow Oxygen Therapy in Acute Respiratory Failure Papel de la oxigenoterapia de alto flujo en la insuficiencia respiratoria aguda Efficacy and safety of high-flow nasal cannula oxygen therapy in moderate acute hypercapnic respiratory failure. Rev Bras Ter Intensiva Hyperbaric oxygen therapy in preventing mechanical ventilation in COVID-19 patients: a retrospective case series Oxygen therapy strategies and techniques to treat hypoxia in COVID-19 patients Oxigenoterapia domiciliar prolongada (ODP) Vocal tract discomfort in teachers: Its relationship to self-reported voice disorders Voice Improvement in Patients with Functional Dysphonia Treated with the Proprioceptive-Elastic (PROEL) Method The Relationship Between Vocal Fatigue Index and Voice Handicap Index in University Professors With and Without Voice Complaint