Most patients presenting with dysphonia show a certain degree of dysregulation of intrinsic and extrinsic laryngeal muscles activity, which may be primary in purely functional cases, or secondary to organic laryngeal or neuro-muscular diseases [1,2]. Voice therapy aims to educate the patient to achieve an economic and effective use of voice, working on awareness of easy and effortless vocal emission. As a result, voice therapy for dysphonia being a form of behavior-changing treatment, patient adherence represents a key for rehabilitation success [3]. Current evidence shows that treatment attendance has a relevant impact on functional outcome, and that the efficacy of voice therapy can be hampered by patients' resistance to comply with the therapist's indications [[4], [5], [6]]. Treatment dropouts are frequent in patients with dysphonia, usually because of low motivation, but also due to logistical issues, making the follow-up after therapy sessions difficult to attend [[7], [8], [9]]. In particular, logistical issues, including difficulties getting off work, childcare, transportation, and expenses are responsible for a significant part of treatment discontinuity [8,10]. Moreover, changes in clinical conditions may affect patients' motivation: those who subjectively feel significantly better and those who feel too ill to travel may decide to stop their rehabilitation [8].

As a result, a non-negligible part of patients undergoing phoniatric evaluation for dysphonia, and subsequently requiring voice therapy, will not be able to complete their rehabilitation program. Delivering voice therapy remotely may be a strategy to potentially reduce the issue of voice therapy dropouts, allowing patients to find an easier way to access healthcare [11].

Recently, the medical community witnessed an increased interest in telemedicine. The advent of COVID-19 and the introduction of containment measures forced healthcare to reorganize, in order to ensure continuity of care while observing the restrictions. Consequently, telemedicine has become the first choice to avoid the suspension of non-urgent services [12]. Telerehabilitation is a field of telemedicine, defined as the delivery of a range of rehabilitation services, including evaluation, assessment, monitoring, prevention, intervention, supervision, education, consultation and coaching, remotely via the use of various technological means [13]. During the COVID-19 pandemic, telerehabilitation allowed speech therapists and other health professionals to cope with the impossibility of providing face-to-face therapy. Although there is preliminary evidence supporting telerehabilitation as an effective method to achieve significant results in various areas of speech therapy and overcome transportation problems, geographic barriers or insufficient family support, also with reference to the logistical disruption caused by COVID-19 pandemic [14], showing promising outcomes in terms of both treatment adherence and clinical effectiveness [[15], [16], [17]], only a few studies have focused on the use of tele-speech therapy in voice disorders [[18], [19], [20], [21], [22], [23]].

Based on this background, in our retrospective investigation, we started from the hypothesis that telerehabilitation might yield a significant clinical benefit also for patients with dysphonia, as already demonstrated in other clinical scenarios concerning speech language pathology [14]. Consequently, the main aim of this study was to investigate the clinical efficacy of speech therapy, delivered via tele-practice to patients with dysphonia during the pandemic period. A secondary aim was to verify whether a telerehabilitation-only protocol could have a clinical efficacy similar to a combined telerehabilitation and in-person approach.