ARTICLE IN PRESS

The Prevalence of Dysphonia and Dysphagia in Patients with

Vitamin D Deficiency
*Abdul-Latif Hamdan, *Elie Khalifee, *Nader Al Souky, *Bakr Saridar, *Pierre Richard Abi Akl,
*Anthony Ghanem, and †Sami Azar, *yLebanon

Abstract: Objective. To investigate the prevalence of phonatory and swallowing symptoms in patients with
hypovitaminosis D.
Methods/Design. All patients presenting to the endocrinology clinic and investigated for vitamin D deficiency
between January 2018 and April 2018 were asked to participate in this study. Demographic data included age,
gender, allergy, and history of smoking. Patients filled Voice handicap Index (VHI-10) and Eating Assessment
Tool (EAT-10).
Results. A total of 136 consecutive subjects presenting to the endocrinology clinic for vitamin D testing were
included: 60 with hypovitaminosis D and 76 with no hypovitaminosis D. The mean vitamin D level in the study
group and controls was 13.25 ng/mL and 31.91 ng/mL, respectively. There was no significant difference in the
mean score of VHI-10, nor in the mean score of EAT-10 in patients with hypovitaminosis D versus those with no
hypovitaminosis D (P value >0.05).
Conclusion. There was no significant difference in the prevalence of phonatory and dysphagia symptoms using
VHI-10 and EAT-10 questionnaires between subjects with hypovitaminosis D and those with normal serum vita-
min D levels.
Keywords: Vitamin D deficiency−Dysphonia−Dysphagia−EAT-10−VHI-10.

INTRODUCTION associated with pain in the musculoskeletal structures.

Vitamin D deficiency, also referred to as hypovitaminosis
D, is defined as inadequate blood level of 25-hydroxy vita-
min D of less than 20 ng/mL.1,2 It is a common health prob-
lem in the world affecting millions of subjects of various
ethnicity.2 The predictors of this clinical condition have
been related to many factors such as older age, female gen-
der, multi-parity, low socioeconomic status, inadequate
vitamin D intake, and insufficient exposure to the sun due
to conservative clothing.3,4
Hypovitaminosis D has been associated with numerous
diseases such as hypertension, cardiovascular diseases, oste-
omalacia, osteoporosis in adults, and rickets in children.2,5
It has also been related to dysfunction in the muscular sys-
tem with symptoms of weakness, decreased activity, and
hypotonia often reported by affected patients.6−8 To that
end, several investigators examined the correlation between
Vitamin D deficiency and muscle strength and function.9−12
A cross-sectional study by Gschwind et al looking at the
association between vitamin D level and functional mobil-
ity, showed a decrease in physical performance in subjects
with hypovitaminosis D.11 Likewise, Wicherts et al reported
a decline in physical activity and a poor performance
with age in patients with low vitamin D.12 In keeping with
the aforementioned, hypovitaminosis D has also been
Accepted for publication March 14, 2019.
(There is no conflict of Interest or financial support in relation to this paper).
From the *Department of Otolaryngology Head & Neck Surgery, American Uni-
versity of Beirut Medical Center, Beirut, Lebanon; and the yDepartment of Internal
Medicine, American University of Beirut Medical Center, Beirut, Lebanon.
Correspondence and reprint requests to Sami Azar, MD, American University of
Beirut Internal Medicine Department, P.O.Box: 11-0236, Beirut Lebanon E-mail:
sazar@aub.edu.lb
Journal of Voice, Vol. &&, No. &&, pp. &&−&&
0892-1997
© 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jvoice.2019.03.007
Based on the investigation by Gerwin, 89% of patients with
chronic musculoskeletal pain had low vitamin D levels.13
Another study by Heath and Elovic on the implications of
vitamin D deficiency in the rehabilitation setting showed
that 93% of patients presenting with musculoskeletal pain
were deficient in vitamin D.14 The musculoskeletal symp-
toms and the decrease in physical activity in affected sub-
jects have been linked to a decrease in muscle tissue vitamin
D receptors (VDRs).15
Despite the numerous studies ascertaining Vitamin D
deficiency-induced muscular dysfunction and the well-estab-
lished similarity between the laryngopharyngeal complex
and other musculoskeletal structures in the body, the litera-
ture is sparse on the effect of vitamin D deficiency on swal-
lowing and phonation. Based on a literature review, only
one study on the association between vitamin D deficiency
and voice has been reported.16 This study carried out on
19 patients with vitamin D deficiency in comparison to
19 controls with no vitamin D deficiency revealed no signifi-
cant difference in the mean or frequency of any of the pho-
natory symptoms between the two groups. Moreover, there
was no statistically significant difference in the mean of the
Voice Handicap Index (VHI-10) or any of the acoustic vari-
ables analyzed in patients with vitamin D deficiency in com-
parison to controls. One main limitation of that study was
the sample size which could have masked any significant dif-
ference in the phonatory symptoms between patients with
vitamin D deficiency versus those with no vitamin D defi-
ciency. Careful examination of the data shows that both
the mean score as well as the frequency of vocal fatigue and
phonatory effort were higher in the group with vitamin
D deficiency in comparison to those with no deficiency.
Moreover, the lack of significant difference in the acoustic
 ARTICLE IN PRESS
2 Journal of Voice, Vol. &&, No. &&, 2019
measures was attributed to the limited vocal sample ana-
lyzed, namely the sustained vowel /a/ and the lack of a read-
ing passage.
Given the scarcity of studies on the association between
vitamin D deficiency and symptoms related to the laryngo-
pharyngeal complex, and in view of the aforementioned lim-
itations of the study previously published by the same
authors, this investigation is intended to cast further infor-
mation on this topic using self-reported questionnaires in a
larger group of patients with vitamin D deficiency present-
ing to the endocrinology clinic in a tertiary referral center.
The prevalence of phonatory and swallowing symptoms as
reported by the patients will be reported.
METHODOLOGY
Participants
After obtaining Institutional Review Board approval, all
patients presenting to the endocrinology clinic at a tertiary
medical referral center between January 2018 and April
2018, and who have been investigated for vitamin D defi-
ciency were asked to participate in this study. Exclusion cri-
teria included age below 18 years, recent onset of upper
respiratory tract infection, and history of neurogenic disor-
ders or laryngeal manipulation.
A total of 136 subjects were included in this study. These
were divided into two groups, those with vitamin D defi-
ciency or insufficiency (n = 60) referred to as hypovitamino-
sis D and those with no vitamin D deficiency (n = 76).
Vitamin D deficiency or insufficiency was defined as a blood
level of 25-OH <20 ng/dL.1,2 Demographic data included
age, gender, smoking, and history of allergy. All patients
were asked to fill the VHI-10 and the Eating Assessment
Tool (EAT-10). The VHI-10 is a self-reported questionnaire
on the impact of dysphonia on quality of life with a score
above 11 being significant.5 Similarly, EAT-10 is a self-
administered questionnaire for assessment of dysphagia
with a score above three being significant.17
Statistical analysis
Means (§standard deviation) and frequencies were calcu-
lated to describe continuous and categorical variables,
respectively. The dependent variable was if the patient had
normal serum vitamin D levels or vitamin D deficiency,
whereas the independent variables were the phonatory and
dysphagia scores reported by the patients. Mann-Whitney
U test was used to compare the means of the continuous
variables between patients and controls. Data was analyzed
using SPSS version 23 (SPSS Inc, Chicago, Ill).
RESULTS
Demographic data
A total of 136 patients were enrolled in the study. These
were divided into 60 subjects with hypovitaminosis D (study
group) and 76 subjects with normal serum vitamin D level
(control group). The mean age of the study group was
TABLE 1.
Demographic Data
Study group Control group
(n = 60) (n = 76)
Age (y)
Mean §SD 45.9 § 12.1 49.5 § 12.2
Gender, N (%)
Male 22 (36.6) 19 (25)
Female 38(63.3) 57 (75)
Social history, N (%)
Smoking 25(41.6) 32 (42)
Allergy 13 (21.6) 24 (32)
45.9 years with a SD of 12.1 years, while that of the control
group was 49.5 years with a SD of 12.2 years. The preva-
lence of smoking history was 41.6% and 42%, in the study
and control group respectively. In regard to other comor-
bidities, refer to Table 1.
Level of vitamin D in the study group and controls
In the study group, the mean vitamin D level was
13.25 ng/mL with a SD of 4.02 ng/mL, whereas in the con-
trol group, the mean vitamin D level was 31.91 ng/mL with
a SD of 11.20 ng/mL. It is worth noting that 26.66% and
61.8% of the study and control groups were on treatment.
Means and frequencies of VHI-10
There was no significant difference in the mean score of
VHI-10 in patients with hypovitaminosis D versus those
with no vitamin D deficiency (Mean VHI-10 1.2 vs 1.68, P
value >0.05). Similarly, there was no statistically significant
difference in the frequency of subjects with VHI-10 > 11
between the study and control groups (1.66% vs 3.94%
respectively; P-value >0.05). See Table 2.
Means and frequencies of EAT-10
There was no significant difference in the mean score of
EAT-10 in patients with hypovitaminosis D versus controls
(Mean EAT-10 1.16 vs 1.71, P value >0.05). Similarly, there
was no statistically significant difference in the frequency of
subjects having an EAT-10 score ≥3 between the study and
control groups (16.66% vs 22.36% respectively; P value
>0.05). See Table 2.
DISCUSSION
Vitamin D is essential to one's well-being. It is known to
stimulate the immune system, contribute to cardiovascular
health, and to improve physical performance.18 The pan-
demic increase in the prevalence of vitamin D deficiency
over the last few decades has led to the emergence and
perpetuation of numerous diseases.19 Among the various
systems affected, the musculoskeletal system has been thor-
oughly investigated with numerous studies on the impact of
 ARTICLE IN PRESS
Abdul-Latif Hamdan, et al Prevalence of Dysphonia and Dysphagia in Patients with Vitamin D Deficiency
TABLE 2.
Mean Score and Frequencies of VHI-10 and EAT-10 in the
Study Group and Control
Study group Control group
(N = 60) (N = 76) P value
VHI-10
Mean §SD 1.20 § 2.69 1.68 § 3.85 0.655
No (%) with 1(1.66) 3 (3.94)
VHI-10 > 11
EAT-10
Mean §SD 1.16 § 2.60 1.71 § 3.01
No (%) with 10 (16.66) 17 (22.36) 0.703
EAT-10 ≥ 3
vitamin D deficiency on muscle function, exercise capacity,
and morphology being reported.6,20−22 Hypotonia, muscle
weakness, and fatigability have been described as the most
common musculoskeletal symptoms in affected sub-
jects.11,12,23 The molecular mechanism of vitamin D action
on muscle tissue is complex. Several mechanisms have been
suggested, among which are the genomic and nongenomic
pathways. The genomic pathway starts with the activation
of nuclear VDR, which is a transcription factor, via 1,25
(OH)2D. As a result, synthesis of muscular cytoskeletal pro-
teins important for muscle function, such as insulin-like
growth factor binding protein and calmodulin, is
increased.24−27 Activation of nuclear VDR is also thought
to affect phospholipids’ metabolism which is likely to
impact muscle contraction.21,28 On the other hand, the non-
genomic pathway consists of 1,25 (OH)2D activating
plasma-membrane VDR's, which involve invaginations of
the plasma membrane, referred to as caveolae. This allows
for a rapid cascade of signaling pathways, taking seconds to
minutes for a response as compared to hours for protein
synthesis in the genomic pathway.29−31 Both pathways stim-
ulate muscle proliferation and differentiation. Another pro-
posed mechanism of the action of Vitamin D on muscle
cells, is through the activation of mitogen-activated protein
kinase signaling pathway.19 In humans, mitogen-activated
protein kinase pathways control cellular processes such as
cell proliferation, apoptosis, myogenesis, and differentia-
tion. As such, vitamin D sufficiency is thought to stimulate
cellular growth and proliferation whereas vitamin D defi-
ciency has been associated with fatty infiltration, type II
fiber atrophy, fibrosis, and increased inter fibrillar spaces as
reported by Pfiefer et al6,21 These noted histologic findings
lead to prolonged time for muscle relaxation and for peak
muscle contraction resulting in decreased physical perfor-
mance and fatigability.
Given all the aforementioned evidence on the impact of
vitamin D deficiency on the musculoskeletal system, and
given that the laryngopharyngeal complex is a musculoskel-
etal structure potentially equally prone to vitamin D defi-
ciency induced muscle dysfunction, the authors of this
manuscript hypothesized that patients with hypovitaminosis
3
D are more likely to exhibit symptoms of laryngopharyng-
eal dysfunction. Indeed, the intricate anatomy of the larynx
and the cross-cutting in its performance of various tasks,
puts it at high risk for laryngeal muscle dysfunction
in patients with hypovitaminosis D, at least hypothetically.
As phonation is governed by a complex interplay of neuro-
muscular processes32,33 any alteration in laryngeal muscle
performance, particularly at the level of the vocal folds,
may lead to dysphonia and voice related complaints. Simi-
larly, any dysfunction of the pharyngeal muscles may
impair the pharyngeal phase of swallowing and lead to dys-
phagia and throat related symptoms. Contrary to the
hypothesis set forth in the introduction, the results of this
investigation showed no significant difference in the preva-
lence of phonatory and swallowing symptoms in patients
with hypovitaminosis D in comparison to those with no
hypovitaminosis D, as evidenced by the mean score of
VHI-10 and EAT-10. A possible explanation for the lack of
laryngopharyngeal symptoms in the affected group is the
histologic difference between the intrinsic muscles of the lar-
yngopharyngeal complex and muscles of the extremities.
Skeletal muscle fibers in adults can be classified, using histo-
chemical techniques of staining for myofibrillar ATPase,
into three fiber types with different mechanical properties,
namely type I, type IIa, and type IIb fibers.34 In a study by
Rosenfield et al, laryngeal muscles were found to be com-
posed of a higher percentage of type 1 fibers which are
slow-twitch capable of generating low forces and are highly
resistant to fatigue.35 The thyroarytenoid muscle, made of
type I, type IIa, and hybrid fibers, has a distinguished histo-
logic architecture in terms of fiber arrangement (fast fibers
located medially) which makes it more fatigue-resistant.36
Similarly, Malmgren and Gacek found that a normally
innervated human posterior cricoarytenoid muscle con-
tained more slow-twitch type I fibers than fast-twitch type
II fibers.37 To add, Rosenfield et al demonstrated unique
morphologic and histochemical features in normal laryn-
geal muscles not present in limb skeletal muscles such as
smaller fiber size, higher size variability, basophilia, and
increased concentration of mitochondria and fibrous tis-
sue.35 These differences in comparison to limb muscles,
namely the fiber size, type, distribution as well as the mito-
chondrial content, are suitable for the intricate role of laryn-
geal muscles in regard to respiration, phonation, and
swallowing. Another potential explanation for the lack of
significant difference in the prevalence of phonatory and
swallowing symptoms between the study and control groups
is the fact that the questionnaires used in this study were not
filled following vocal fatiguing tasks. Vocal loading may
precipitate a muscular functional impairment as commonly
reported in patients with impaired mobility of the vocal
folds.38,39
The results of this investigation, though do not show a
significant difference in the self-reported prevalence of vocal
complaints in patients with hypovitaminosis D in compari-
son to normal subjects, do not preclude the presence of
objective phonatory changes. Vitamin D deficiency induced
 ARTICLE IN PRESS
4 Journal of Voice, Vol. &&, No. &&, 2019
myopathy can hypothetically affect any musculoskeletal
structure including the laryngeal muscles, leading to
decrease in muscle endurance and vocal fatigue in various
degrees. Based on the report by Welham and Maclagan,
neuromuscular dysfunction in addition to increased vocal
fold viscosity and respiratory dysfunction, is one of the
most plausible causes of vocal fatigue.40 Affected patients
can display stroboscopic changes such as incomplete glottic
closure and decrease in mucosal waves and amplitude
excursion as reported by Mann et al in a group of 42 sub-
jects 5 days following vocally loading exercises.41 In parallel
with these endoscopic findings, there is an increase in the
perturbation parameters, namely in cycle to cycle variation
in intensity and frequency. Airflow measurements often
reveal an increase in the mean flow rate and a decrease in
glottal resistance and maximum phonation time. To that
end, a more comprehensive evaluation that includes mainly
stroboscopic examination, in addition to aerodynamic and
acoustic measures, is needed in order to assert or negate any
effect of vitamin D deficiency on the phonatory apparatus.
Given the known effect of vitamin D deficiency on skele-
tal muscle strength, performance, and endurance, early
detection of any adverse effect on laryngeal and pharyngeal
muscles is important. In a study by Cho et al on reliable
indicators of physical fatigue in a group of 73 volunteers,
the authors reported that VHI was related to physical
fatigue in women and that acoustic parameters in addition
to self-rated symptoms are more indicative of mental
fatigue.42 The association between body fatigue and vocal
fatigue is even more crucial in professional voice users where
adequate physical endurance and optimal muscle function
are paramount during performance. In keeping with the
aforementioned, maintaining a therapeutic level of vitamin
D is important not only for proper limb muscles perfor-
mance but also for adequate phonation and swallowing.
Should future studies using a comprehensive phonatory
evaluation indicate a higher risk for phonatory and or swal-
lowing symptoms in those with hypovitaminosis D, vitamin
D replacement should be advocated the earliest in order to
increase the serum concentration of 25-hydroxyvitamin D.
Indeed, several studies have substantiated the strong associ-
ation between this latter and muscle performance, more so
in the geriatric population.43−45 In an examination survey
conducted by Bishoff-Ferrari et al, poor muscle perfor-
mance was reported in those with low 25-hydroxyvitamin D
levels of vitamin D and high performance in those with
elevated levels.45 In another study, the performance reached
its peak when the mean 25-hydroxyvitamin D level was
50 nmol/L.46
This study has two main limitations. One is the subjective
nature of the data collected using the self-reported question-
naires on dysphagia and impact of dysphonia on quality of
life. A more comprehensive evaluation of the different com-
ponents of phonation is invaluable if we were to assert the
effect or no-effect of vitamin D deficiency on voice. Second
is the lack of information on the duration of hypovitamino-
sis D. All patients were diagnosed with hypovitaminosis D
based on the laboratory result whereas the deficiency could
have been long standing prior to the laboratory testing.
CONCLUSION
Several studies concur that vitamin D deficiency impairs
muscular function and strength. The results of this investiga-
tion showed no significant difference in the prevalence of
phonatory and dysphagia symptoms between subjects with
hypovitaminosis D and those with normal serum vitamin D
levels. A larger study using a comprehensive voice evalua-
tion, subjective, acoustic, and aerodynamic will elucidate fur-
ther the association between hypovitaminosis D and voice.
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