The first study included all patients who presented to the ENT and thoracic medicine departments with severe and persistent dysphonia while receiving inhaled steroids for asthma. A careful history of dysphonia was recorded, with particular reference to the onset and its relation to the start of treatment with inhaled steroids. The type and total daily dose of inhaled and oral treatment were noted and the patient's inhaler technique was scrutinised and graded " efficient" or " inefficient." "Efficiency" was recorded if the following criteria were fulfilled: (1) mixture of the aerosol contents by shaking; (2) depression of the actuator shortly after the start of a deep inspiration, followed by (3) breath holding for at least four seconds.In each patient an independent assessment of dysphonia was made by two speech therapists after an interview and analysis of the patient's voice recordings. Specific inquiry was made about smoking, shouting, coughing, loud voice, noise during work, family deafness, and excessive throat clearing.The patient was considered to have vocal abuse if three or more of these factors were present. The same criteria for vocal abuse were applied to a 813 on 7 April 2019 by guest. Protected by copyright.

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the Bence Jones proteins resulted in excellent recovery of renal function with survival much longer than expected on conventional treatment alone.We would like to thank Professor J S Cameron of Guys Hospital for his encouragement and advice.Reprint requests should be sent to SLC.

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