Patient Satisfaction and Acoustic Changes in Trans Women after Gender Affirming Voice Training.

OBJECTIVES: Gains in pitch from gender affirming voice training (GVT) alone in trans women have historically been shown to decline after 1 year. Currently no standard exists for length and type of GVT that yields meaningful behavioral change and patient satisfaction with voice outcomes in trans women. This study aims to determine whether GVT alone leads to sustained pitch elevation and patient satisfaction in trans women. METHODS: Retrospective review from 2016 to 2020 of trans women patients who underwent GVT alone for voice change. Charts were reviewed for acoustic analysis of pitch including sustained vowel fundamental frequency, speaking fundamental frequency, and quality of life data from the Trans Woman Voice Questionnaire at pre-therapy, immediate post-therapy, and extended post-therapy time intervals. RESULTS: A total of 157 patients presented to our Voice Center, of which 34 participated in the full course of GVT. Patients underwent an average of six sessions of GVT (range 5-7) over an average of 13.14 weeks (range 6-16). Average time between completing GVT and presenting for extended follow-up was 11.37 months (range 6-31). Compared to initial presentation prior to therapy, at extended follow-up after completing GVT average change in F0/a/, SF0, and TWVQ were 64.6 Hz, 31.3 Hz, and 32.45. No significant change was noted between immediate post-therapy and extended post-therapy acoustic measures. TWVQ demonstrated continued improvement between immediate post-therapy and extended post-therapy. CONCLUSIONS: In self-selected patients who present for extended follow-up, GVT alone can result in sustained pitch elevation and voice-related quality life in trans women. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2340-2345, 2023.

1-Year Results of Combined Modified Wendler Glottoplasty with Voice Therapy in Transgender Women.

BACKGROUND: To date, 1-year evaluation of pitch elevation in patients undergoing modified Wendler glottoplasty (WG) in combination with VT has not been assessed. OBJECTIVES: To determine whether 1-year pitch elevation is sustained in patients who undergo modified WG in combination with VT for voice feminization. METHODS: A retrospective review of patients who underwent WG in combination with voice therapy (VT) was performed from 2016 to 2020. Charts were reviewed for sustained vowel fundamental frequency (F0/a/), speaking fundamental frequency (SF0), and Trans Woman Voice Questionnaire (TWVQ) at preoperative, initial postoperative (3-6 months after surgery), and 12-month postoperative visits. RESULTS: Change in average F0/a/, SF0 and TWVQ was 50.25 Hz, 32.96 Hz, and 32.6 at 12-months postoperatively compared to preoperative values. Initial and 12-month postoperative SF0 were significantly higher than preoperative SF0 (Mann-Whitney U test p = 0.0042, p = 0.0010). There was no difference in initial postoperative and 12-month postoperative SF0 (p = 0.50). TWVQ at 12 months was significantly lower than preoperative TWVQ (ANOVA p < 0.001, Tukey honestly significant difference HSD p < 0.05). CONCLUSIONS: Pitch elevation remains sustained at one year in patients undergoing modified WG in combination with VT. Modified Wendler glottoplasty combined with VT results in relatively long-term improvements in voice-related quality of life and is possibly a beneficial addition in the long-term management of patients who desire voice feminization. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:615-620, 2023.

Positive Predictive Value of Endoscopic Findings to Diagnose Vocal Fold Paresis.

OBJECTIVE: Laryngoscopy corresponding with laryngeal electromyography (LEMG) is essential in diagnosing vocal fold paresis. However, baseline asymmetry or other diseases oftentimes confound the exam, making diagnosis difficult. There is currently no agreed upon endoscopic criteria proven to reliably correlate with LEMG findings. We define a set of endoscopic findings termed "paresis triad" that, when present together, reliably correlate with LEMG. The paresis triad consists of (1) hypocontraction of the weak side of the larynx with increased ventricular show, (2) hypercontraction of the intact side with bulging of the false fold covering the ventricle, and (3) tilting of the interarytenoid cleft to the weak side. METHODS: We performed a retrospective review of patients with laryngeal asymmetry on laryngoscopy. Patients were divided into two groups: those with consistent paresis triad findings across all pitches and intensities, and those without. All patients underwent LEMG by a neurolaryngologist blinded to the laryngoscopic findings. The endoscopies were then rereviewed in a blinded manner by a second laryngologist to assess inter- and intrarater reliability for identification of the triad. RESULTS: Twelve patients met inclusion criteria (age 50 +/-15, 7F:5M). Nine had the paresis triad. Three had an inconsistent triad. All patients with the paresis triad had LEMG findings consistent with neurologic injury on the suspected side. All patients with inconsistent triad findings had normal LEMG. CONCLUSIONS: Our findings suggest the proposed laryngoscopic paresis triad may be useful objective criteria to diagnose paresis without the need for LEMG. Further prospective studies should examine a larger series of patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1712-1716, 2023.

Long-Term Voice Outcomes After Type I, Type II, or Type V Cordectomy.

INTRODUCTION: We compare long-term voice outcomes in patients treated with European Laryngeal Society (ELS) classification Type I, Type II, or Type V cordectomy. The aim is to understand the impact of Type V cordectomy on voice outcomes in relation to Type I and Type II cordectomy. METHODS: A retrospective review of patients treated with Type I, Type II, or Type V cordectomy by a single surgeon over a 20-year period was performed. Voice Handicap Index-10 (VHI-10) scores, Cepstral Spectral Index of Dysphonia (CSID) measures from CAPE-V sentences, and two-rater GRBAS scores were analyzed. RESULTS: Sixty-two patients were identified with a mean follow-up of 52 months. Of these, there were 43 Type I and 19 Type II cordectomies, including 8 in each group with Type V resections. Significant differences in all parameters were noted between the Type I (VHI 5.7, CSID 20.6, Grade 1.3) and the Type II cohorts (VHI 12.6, CSID 36.3, Grade 1.8) who did not undergo Type V cordectomy. Patients undergoing Type V cordectomy demonstrated voice outcomes (VHI 9.4, CSID 35.6, Grade 1.7) which fell between those of Type I and Type II cordectomies. CONCLUSIONS: Better long-term subjective, objective, and computer-analyzed voice outcomes are noted for patients undergoing Type I rather than Type II cordectomy. When Type V cordectomy is performed, voice outcomes are comparable to those of both Type I and Type II cordectomy, a surprising finding given the expectation of worsened dysphonia in longer resections. Further work is needed to explain this finding and define voice outcomes after Type V cordectomy.

Long-term upper aerodigestive sequelae as a result of infection with COVID-19.

Objectives: Respiratory, voice, and swallowing difficulties after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may result secondary to upper airway disease from prolonged intubation or mechanisms related to the virus itself. We examined a cohort who presented with new laryngeal complaints following documented SARS-CoV-2 infection. We characterized their voice, airway, and/or swallowing symptoms and reviewed the clinical course of their complaints to understand how the natural history of these symptoms relates to COVID-19 infections. Methods: Retrospective review of patients who presented to our department with upper aerodigestive complaints as sequelae of prior infection with, and management of, SARS-CoV-2. Results: Eighty-one patients met the inclusion criteria. Median age was 54.23 years (±17.36). Most common presenting symptoms were dysphonia (n = 58, 71.6%), dysphagia/odynophagia (n = 16, 19.75%), and sore throat (n = 9, 11.11%). Thirty-one patients (38.27%) presented after intubation. Mean length of intubation was 16.85 days (range 1-35). Eighteen patients underwent tracheostomy and were decannulated after an average of 70.69 days (range 23-160). Patients with history of intubation were significantly more likely than nonintubated patients to be diagnosed with a granuloma (8 vs. 0, respectively, p < .01). Fifty patients (61.73%) were treated for SARS-CoV-2 without requiring intubation and were significantly more likely to be diagnosed with muscle tension dysphonia (19 vs. 1, p < .01) and laryngopharyngeal reflux (18 vs. 1, p < .01). Conclusion: In patients with persistent dyspnea, dysphonia, or dysphagia after recovering from SARS-CoV-2, early otolaryngology consultation should be considered. Accurate diagnosis and prompt management of these common underlying etiologies may improve long-term patient outcomes. Level of evidence: 4.

Acute Vocal Fold Paresis and Paralysis After COVID-19 Infection: A Case Series.

OBJECTIVE: Evidence demonstrates neurotropism is a common feature of coronaviruses. In our laryngology clinics we have noted an increase in cases of "idiopathic" vocal fold paralysis and paresis in patients with no history of intubation who are recovering from the novel SARS-Cov-2 coronavirus (COVID-19). This finding is concerning for a post-viral vagal neuropathy (PVVN) as a result of infection with COVID-19. Our objective is to raise the possibility that vocal fold paresis may be an additional neuropathic sequela of infection with COVID-19. METHODS: Retrospective review of patients who tested positive for COVID-19, had no history of intubation as a result of their infection, and subsequently presented with vocal fold paresis between May 2020 and January 2021. Charts were reviewed for demographic information, confirmation of COVID-19 infection, presenting symptoms, laryngoscopy and stroboscopy exam findings, and laryngeal electromyography (LEMG) results. RESULTS: Sixteen patients presented with new-onset dysphonia during and after recovering from a COVID-19 infection and were found to have unilateral or bilateral vocal fold paresis or paralysis. LEMG was performed in 25% of patients and confirmed the diagnosis of neuropathy in these cases. CONCLUSIONS: We believe that COVID-19 can cause a PVVN resulting in abnormal vocal fold mobility. This diagnosis should be included in the constellation of morbidities that can result from COVID-19 as the otolaryngologist can identify this entity through careful history and examination.

How can we make better decisions about dystonic voice management?

PURPOSE OF REVIEW: The optimal diagnosis and management of dystonic voice disorders are rooted in the nuanced understanding of their phenomenology. Distinguishing between subtypes of vocal dystonia is challenging, not only because the audible and physical presentations of these dystonia's can seem similar, but also because there is a lack of scientific consensus regarding the diagnostic criteria for these conditions. To help improve the clinician's acumen we focus on outlining the classification of the top three neurological voice disorders, notably: spasmodic dysphonia, (2) spasmodic dysphonia with tremor, and essential tremor of the voice. We also provide an algorithmic approach based on current evidence-based literature to guide practitioners through the clinical diagnosis and management of each possible etiology. RECENT FINDINGS: Much remains unknown about the subtypes of vocal dystonia, and this gap in our knowledge likely limits our ability to advance clinical management. Still, continued experience evaluating and treating these patients yields refined clinical evaluations and decision making. SUMMARY: Improvements in our clinical decision-making can be made by acknowledging that our limited understanding of vocal dystonia may hinder what therapeutic interventions we can offer, yet our ability to accurately diagnose the dystonia is central to providing optimal patient management.

Voice assessment of fat injection vs medialization laryngoplasty in nonparalytic dysphonia.

OBJECTIVE: Compare long-term voice outcomes in patients treated with FIM or BML for nonparalytic dysphonia. There is controversy whether fat injection medialization (FIM) is a durable alternative to bilateral medialization laryngoplasty (BML) for nonparalytic dysphonia (atrophy, sulcus, scar, paresis). Both interventions yield improved voice quality, yet comparison of patients' long-term perceptions of their voice after these procedures has not been performed. METHODS: Retrospective review of patients who underwent FIM or BML for nonparalytic dysphonia was performed from 2008-2018. Charts were reviewed for demographic information, preoperative diagnosis, intervention, Voice Handicap Index-10 (VHI-10), and follow-up time. RESULTS: Forty-nine patients met our criteria. Fifty procedures were performed (25 FIM, 25 BML). One patient underwent BML with subsequent FIM. There was no significant difference in pre-treatment or post-treatment VHI-10 scores between both groups (Pre-FIM 21 Post-FIM 10.28; Pre-BML 22.48, Post-BML 10.88). Total median follow-up time was 11.3 months (FIM 14.8 months, BML 9.5 months). Using VHI-10 scores recorded at each patient's latest follow-up visit, both groups demonstrated significant decrease (P < .05) compared to preoperative scores: VHI-10 decreased by a mean delta of 10.72 in the FIM group and 11.6 in the BML group. There was no significant difference in pre, post and change in VHI between groups. CONCLUSIONS: In patients with nonparalytic dysphonia, FIM is a durable alternative to BML. Patients treated in both groups gained substantial improvement in vocal function. For both treatment groups, we should anticipate less than complete satisfaction with surgery and revision procedures in a minority of patients. LEVEL OF EVIDENCE: IV.

Determining the utility of standard hospital microbiology testing: Comparing standard microbiology cultures with DNA sequence analysis in patients with chronic sinusitis.

OBJECTIVE: To demonstrate DNA sequencing analysis (DNAsa) of sinus cultures in patients with CRS is a reliable method of detecting pathogens in polymicrobial CRS infections. METHODS: After obtaining Institutional Review Board approval for this prospective cohort study, we selected a random sample of 50 patients with CRS at Medstar Georgetown University Hospital between September 2016 and March 2017. We defined CRS as a history of rhinosinusitis refractory to maximal medical therapy and prior endoscopic sinus surgery. Patients demonstrating active purulence in a sinus cavity were prospectively selected to undergo standard hospital cultures (SHC) and DNAsa cultures. Organisms identified in both methods were compared for each patient. RESULTS: Specimens were obtained from 29 female and 16 male patients with a mean age of 50 years. A total of 45 cultures were included in our final analysis; five cultures were excluded after inappropriate laboratory processing. Results from these patients were compared and analyzed. Cohen's weighted kappa analysis showed agreement between the two testing methods in identifying predominant microorganisms. DNAsa detected 31.9% more microorganisms compared to SHC (P < 0.05). When multiple microorganisms were detected, DNAsa yielded more positive results compared to SHC (P < 0.05). CONCLUSIONS: DNAsa detects all microorganisms identified by SHC as well as predominant microorganisms not detected by SHC. Thus molecular pathogen identification may be more reliable for identifying multiple microorganisms as compared to standard culture techniques that identify only one or two microorganisms. In recalcitrant cases of CRS, DNAsa may provide better guidance in selection of appropriate antimicrobial treatment.

Voice Changes in the Elderly.

The impact of aging is as inevitable in the larynx as on all biologic systems. The muscles of larynx have the potential to atrophy, the elastin fibers of lamina propria thin with age, and mucous production diminishes. As a result, vocal folds fail to approximate appropriately and the stress on once-robust vocal folds increases. These changes present as poor voice quality, vocal tension, tremor, and altered fundamental frequency. Rather than consider presbyphonia as an immutable diagnosis, we must see it as an opportunity to elevate our standard of care and set goals to work for therapeutic improvement of voice quality.

Endoscopic Endonasal Management of Metastatic Lesions of the Anterior Skull Base: Case Series and Literature Review.

BACKGROUND: The anterior skull base is an uncommon site for brain metastases. A limited number of cases have been reported where a region of the skull base is accessed through an expanded/extended transsphenoidal route. In addition, reports of overall and progression-free survival rates are lacking. OBJECTIVE: To report progression-free and overall survival rates for skull base metastases treated with aggressive endoscopic endonasal surgery and radiation therapy. METHODS: We retrospectively review a prospective database of patients at New York Presbyterian Hospital undergoing expanded endoscopic endonasal surgery from 2004 to 2014. From this database, we identified all patients whose final pathology revealed a metastatic lesion in the midline skull base. RESULTS: Seven hundred forty-nine patients underwent endonasal endoscopic surgery. Final pathology in 12 patients (1.6%) revealed metastasis to the sellar or parasellar region. Tumors were located in the sella, suprasellar cistern, clivus, ethmoid sinuses, sphenoid sinus, cavernous sinus, and craniovertebral junction. Breast and lung cancers were the most common primary diagnoses. Gross total resection was achieved in 41.6% of patients. There were no postoperative cerebrospinal fluid leaks. Adjuvant radiation therapy was used in 92% of cases. Median follow-up was 14 months (range, 1-55). Median progression-free and overall survival were 18 and 16 months, respectively. CONCLUSIONS: The range of anterior skull base metastatic lesions that can be managed endonasally has increased with the advent of extended endonasal endoscopic surgical approaches. Favorable results can be obtained with this surgical approach as part of the overall management paradigm for patients with skull base metastases.