Voice outcome in medialisation thyroplasty with and without arytenoid adduction: a prospective comparison using intraoperative voice measurements.

PURPOSE: Arytenoid adduction as an addition to medialisation thyroplasty is highly advocated by some surgeons in selected cases but deemed less necessary by others in patients with unilateral vocal fold paralysis. This study aims to evaluate the additional benefits on voice outcome of arytenoid adduction in patients with unilateral vocal fold paralysis undergoing medialisation thyroplasty using intra-operative voice measurements. DESIGN/METHODS: A prospective study was conducted. Voice audio recordings were obtained at 4 moments; 1. direct prior to the start of surgery, 2. during surgery after medialisation thyroplasty, 3. during surgery after medialisation and arytenoid adduction, 3 months postoperative. At these same timepoints patients rated their own voice on a numeric rating scale between 0 and 10. The blinded recordings were rated by consensus in a team of experienced listeners, using the Grade of the GRBAS scale. Furthermore, the Voice Handicap Index was administered before and at 3 months after surgery. RESULTS: Ten patients who underwent medialisation and arytenoid adduction at our tertiary referral hospital between 2021 and 2022, were included. One patient was excluded after surgery. The intraoperative measurements showed a Grade score of 1.4 preoperatively, improving to 1.2 after medialisation, 1.2 after medialisation and arytenoid adduction, and further improving to 0.4 at 3 months postoperative, which was a not statistically significant improvement (p = 0.2). The intraoperative subjective numeric rating scale showed a statistically significant improvement from 3.9 preoperatively, to 6.1 after medialisation, 7.1 after medialisation and arytenoid adduction and a 7.6 at 3 months postoperative (p = 0.001). The Voice Handicap Index total score showed a statistically significant improvement from 71 points before surgery to 13 at 3 months after surgery (p = 0.008). CONCLUSIONS: Our study using intraoperative voice measurements indicate that the addition of arytenoid adduction to medialisation thyroplasty is a benefit in selected patients although more studies are needed due to the many limitations inherent to this field of investigation.

Acoustics and aerodynamic effects following glottal and infraglottal medialization in an excised larynx model.

OBJECTIVE: This study aimed to investigate the impact of the implant's vertical location during Type 1 Thyroplasty (T1T) on acoustics and glottal aerodynamics using excised canine larynx model, providing insights into the optimal technique for treating unilateral vocal fold paralysis (UVFP). METHODS: Measurements were conducted in six excised canine larynges using Silastic implants. Two implant locations, glottal and infraglottal, were tested for each larynx at low and high subglottal pressure levels. Acoustic and intraglottal flow velocity field measurements were taken to assess vocal efficiency (VE), cepstral peak prominence (CPP), and the development of intraglottal vortices. RESULTS: The results indicated that the implant's vertical location significantly influenced vocal efficiency (p = 0.045), with the infraglottal implant generally yielding higher VE values. The effect on CPP was not statistically significant (p = 0.234). Intraglottal velocity field measurements demonstrated larger glottal divergence angles and stronger vortices with the infraglottal implant. CONCLUSION: The findings suggest that medializing the paralyzed fold at the infraglottal level rather than the glottal level can lead to improved vocal efficiency. The observed larger divergence angles and stronger intraglottal vortices with infraglottal medialization may enhance voice outcomes in UVFP patients. These findings have important implications for optimizing T1T procedures and improving voice quality in individuals with UVFP. Further research is warranted to validate these results in clinical settings.

An Integrated Experimental-Computational Study of Vocal Fold Vibration in Type I Thyroplasty.

Subject-specific computational modeling of vocal fold (VF) vibration was integrated with an ex vivo animal experiment of type 1 thyroplasty to study the effect of the implant on the vocal fold vibration. In the experiment, a rabbit larynx was used to simulate type 1 thyroplasty, where one side of the vocal fold was medialized with a trans-muscular suture while the other side was medialized with a silastic implant. Vocal fold vibration was then achieved by flowing air through the larynx and was filmed with a high-speed camera. The three-dimensional computational model was built upon the pre-operative scan of the laryngeal anatomy. This subject-specific model was used to simulate the vocal fold medialization and then the fluid-structure interaction (FSI) of the vocal fold. Model validation was done by comparing the vocal fold displacement with postoperative scan (for medialization), and by comparing the vibratory characteristics with the high-speed images (for vibration). These comparisons showed the computational model successfully captured the effect of the implant and thus has the potential for presurgical planning.

The Long Term Results of Hyaluronic Acid/Dextranomer Injection Laryngoplasty in Unilateral Vocal Fold Paralysis.

OBJECTIVE: This study was conducted to present the long-term functional outcomes of injection laryngoplasty (IL) with hyaluronic acid/dextranomer (HA/D) in unilateral vocal fold paralysis (UVFP). METHODS: A total of 40 patients who underwent HA/D injection for UVFP were enrolled. The acoustic analysis of the voice was evaluated with jitter percentage, shimmer percentage, maximum phonation time, harmonics-to-noise ratio, and fundamental frequency. The psychosocial effect of the voice was determined using the Voice Handicap Index-10. Fiberoptic endoscopic evaluation of swallowing was performed and 2 scales were used for quantification: a modified penetration-aspiration scale and a dysphagia score. All measurements were performed at preoperative day and postoperative months 1, 6, and 24. RESULTS: A statistically significant improvement was observed for all of the evaluated parameters except the maximum phonation time for postoperative months 1, 6, and 24 (P < .05). In the evaluation of the maximum phonation time, although there was a significant improvement for the postoperative months 1 and 6, no significant difference was observed between the postoperative 24th month and the preoperative value. CONCLUSIONS: HA/D injection laryngoplasty is an effective method both in the short- and long-term to improve voice and swallowing functions in patients with UVFP.

Implementation of a prototype dynamic laryngoplasty system in standing sedated horses provided arytenoid abduction control at seven days postoperatively.

OBJECTIVE: Evaluate a prototype dynamic laryngoplasty system (DLPS) in horses; a feasibility study. ANIMALS: 7 healthy Standardbred adult horses. METHODS: This was an in vivo experimental study. Horses had a standing surgical procedure to induce complete laryngeal hemiplegia, which was subsequently treated using the dynamic laryngoplasty system (DLPS). Activation of the DLPS was achieved using an injection port exiting through the skin (n = 2) or a subcutaneous injection port (n = 5). For each horse, endoscopic examinations of the upper respiratory tract were performed preoperatively, intraoperatively, and 7 days postoperatively. Left-to-right quotient ratios calculated during inactivated and activated states were obtained from still images of the rima glottidis acquired during day 7. In 3 horses, the device was intentionally overinflated to evaluate for device failure, and postmortem examinations were performed on day 7. For the remaining 4 horses, upper respiratory tract endoscopy was repeated at 1 month postoperatively, with no subsequent postmortem exam. RESULTS: No perioperative complications occurred, and the DLPS was effectively delivered in all horses under standing sedation. The left-to-right quotient ratio at day 7 postoperatively could be altered from a resting position of 0.76 (± 0.06) to a maximum of 0.97 (± 0.06; P < .05). The degree of arytenoid abduction could not be significantly altered after 1 month of device implantation, suspected to be due to peri-implant fibrosis. No coughing nor tracheal contamination was observed at all time points or during inflation. CLINICAL RELEVANCE: The ability to alter the degree of abduction at 7 days postoperatively with the DLPS may be beneficial in selective cases.

Current approaches to gender-affirming vocal care.

PURPOSE OF REVIEW: This review addresses the challenges faced by transgender women in achieving congruence between gender identity and voice characteristics and emphasizes the importance of a multidisciplinary approach involving therapeutic and surgical interventions. RECENT FINDINGS: Recent literature on gender-affirming vocal care emphasizes key themes such as assessment, voice feminization therapy, and various surgical techniques, including glottoplasty and its modifications. Recent publications focused on outcomes, duration, and impact on vocal quality and scrutinized complications associated with surgical interventions. SUMMARY: Most publications in the last 18 months advocate for the integration of voice therapy and surgery for optimal outcomes. Utilising a combined approach is significantly more effective in terms of fundamental frequency gain compared to therapy alone. Modified Wendler's glottoplasty remains the preferred and most reliable surgical intervention. However, surgery is not without its complications and vocal trade-offs, in particular, its impact on vocal projection and the risk of long-term dysphonia. Postsurgery rehabilitation improves long-term outcomes. Recent publications on alternative surgical approaches, namely laser reduction glottoplasty and feminization laryngoplasty, show promise but the results are more difficult to generalise. FUTURE DIRECTION: Prospective multicentre studies with standardized protocols are needed to establish best evidence-based practices.

Adult Laryngomalacia: A Scoping Review.

OBJECTIVE: This review sought to determine the characteristics of adults diagnosed with new onset laryngomalacia including airway symptoms, laryngoscopic findings, treatments, and outcomes. Moreover, we wanted to highlight suspected limitations in the literature. DATA SOURCES: Studies were identified through CINAHL, Cochrane Review, PubMed, and Scopus published between 1966 and 2023. REVIEW METHODS: The search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews checklist by 2 independent investigators. A meta-analysis of proportions and continuous measures was conducted. RESULTS: Of the 1121 abstracts identified, 33 articles pertaining to laryngomalacia in the adult population were included. The most common presenting symptoms were stridor at rest (78.3%, 65.1-88.3) and dyspnea with exertion (83.8%, 64.8-96.3). The most suspected etiology was exercise-induced (86.0%, 69.4-95.5), and the most common description of laryngomalacia on visualization was collapse of supraglottic structures during exercise (93.3%, 79.0-99.1). Nonsurgical options were attempted in 87.0% (54.0-99.1), which included oral appliances, respiratory retraining, breathing techniques, and working with a speech pathologist. Surgical options were ultimately performed in 84.2% (75.0-91.0). Complete resolution of symptoms following therapy was seen in 61.9% (48.0-74.6). CONCLUSION: Adult onset laryngomalacia is difficult to characterize. It typically presents in patients during exercise, with neurological injury, or idiopathically. Surgical management can lead to improvement or complete resolution of symptoms. The need for a universal nomenclature is highlighted in this review, as it is inconsistently classified.

Long-term voice outcomes of medialization thyroplasty with adjustable implant for unilateral vocal fold paralysis.

OBJECTIVES: Medialization thyroplasty (MT) using various implants has been employed as a corrective procedure for unilateral vocal fold paralysis (UVFP). A newly developed APrevent® vocal implant system (VOIS) offers an innovative solution with a finely adjustable design. This study aimed to investigate the long-term functional voice outcomes and benefits of postoperative adjustments in patients receiving MT using the VOIS-implant. METHODS: This is a prospective case series study at single tertiary medical center. Fourteen adult patients diagnosed with UVFP received MT with the VOIS implant and were followed up for more than 1 year. Implant adjustment procedure by injecting 0.9% physiological saline solution was performed both during and after the surgery to optimize glottal closure and voice quality. Objective voice outcomes and acoustic parameters were assessed preoperatively and postoperatively at various timepoints. RESULTS: Thirteen patients (93%) received intraoperative balloon adjustment, ranging from 0.05to 0.12 ml. Four patients underwent adjustments postoperatively and exhibited a positive trend towards immediately improving acoustic voice quality. Our long-term results demonstrated a notable improvement after the surgery in voice quality, with significant decreases in VHI-30 and improvements in perceptual parameters of GRBAS scale, acoustic measures such as jitter and signal-to-noise ratio (p < 0.001) and cepstral peak prominence smoothed in sustained vowel and short sentences. The voice outcomes remained stable more than 1 year follow-up. CONCLUSIONS: Overall, MT with VOIS implantation provides a favorable long-term outcomes and stability in voice quality for patients with UVFP and also an effective tool for postoperative adjustment without major revision surgeries.

Improvement in swallowing safety after injection laryngoplasty in patients with unilateral vocal paralysis complicated with aspiration.

BACKGROUND: The benefit of injection laryngoplasty (IL) on voice for unilateral vocal fold paralysis (UVFP) is supported increasingly in literatures, yet less is known for swallowing. Also, prevalence of patient-reported dysphagia is substantially higher than instrumental studies. This prospective study focused on swallowing outcomes, with predetermined flexible endoscopic evaluation of swallowing (FEES) protocol that simulates daily life situation. METHODS: Adult patients with UVFP and aspiration receiving IL were recruited. Voice outcome measurements, as well as swallowing outcomes including Eating Assessment Tool (EAT-10) and FEES, which challenged patients with different fluid volumes: 10 mL, 20 mL, and 90 mL cup sipping were evaluated. RESULTS: Significant improvements were demonstrated in all voice outcomes. Significant changes were also presented inEAT-10 (P < 0.01). Pre-operatively, penetration-aspiration scale (PAS) was 1.5 ± 1.3, 1.9 ± 1.7 and 2.3 ± 1.8 for 10 mL, 20 mL and 90 mL serial sipping, and improved to 1.1 ± 0.3, 1.1 ± 0.4 and 1.4 ± 0.7 post-operatively (P < 0.01). Safe swallowing (PAS ≤ 2) was achieved in all, except for one patient, who presented with a post-injection PAS of 4 (material enters the airway, contacts the vocal folds, and is ejected from the airway) on 90 mL cup sipping, whose pre-injection PAS was 7 (residue in trachea). CONCLUSION: Maintaining swallowing function suitable for social environment is important. Our results demonstrated the feasibility of the predetermined FEES protocol, and positive effects of IL on both voice and swallowing outcomes.

Association of Sociodemographic Factors on the Presentation and Management of Unilateral Vocal Fold Immobility.

OBJECTIVE: To determine the association of social determinants of health (SDOH) on the presentation and management of unilateral vocal fold immobility (UVFI). METHODS: Retrospective chart review of 207 adult UVFI patients evaluated at a tertiary-care hospital between 2018 and 2019 was performed. Sociodemographic factors including gender, median household income, preferred language, and insurance type were recorded. Confounding clinical factors including etiology of UVFI, Voice Handicap Index-10 (VHI-10) score, laryngoscopic findings, and intervention history were extracted from medical records. Multivariable logistic regression was performed using sociodemographic and clinical factors. RESULTS: Patient demographics and socioeconomic status were not associated with time to presentation. Patients presenting with glottic insufficiency and UVFI due to malignancy or recurrent laryngeal nerve (RLN) sacrifice had a shorter time to presentation. Higher household income was associated with greater number of interventions (p = 0.02), but neither income nor insurance type affected intervention type or timing. Female patients were less likely to undergo injection medialization laryngoplasty (odds ratio [OR] 0.25, p = 0.005). Older patients were more likely to undergo injection (OR 1.04, p = 0.027). Patients with large glottic gaps (OR 21.2, p = 0.014) and higher VHI-10 scores (OR 1.06, p = 0.047) were more likely to undergo surgery. CONCLUSION: Higher household income was associated with greater number of interventions and longer duration of care at a private tertiary-care hospital. RLN sacrifice, known malignancy, and glottic insufficiency significantly reduced the time to presentation. Type of intervention received was a complex interplay of both demographic and clinical factors. Large prospective studies should examine the role of SDOH in the presentation and management of UVFI. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:297-304, 2024.

Transcervical Epiglottopexy: A versatile technique for managing epiglottic prolapse.

OBJECTIVE: Epiglottic prolapse (EP) presents a unique management challenge. The objective of the present case series is to present clinical outcomes using a novel technique of transcervical epiglottopexy (TCE) in etiologically diverse cases of EP and to discuss the evolution of the surgical technique with technical modifications to optimize the surgical procedure. STUDY DESIGN: A retrospective case series review. SETTING: Tertiary care academic setting. METHODS: Pediatric cases with EP over a 3-year period. Demographic data including age, sex, presenting symptoms, operative details, and polysomnographic indices were collected. RESULTS: A total of 18 patients with a mean age of 48.88 ± 37.3 months underwent TCE. Sixty-seven percent of patients had high-grade EP (grades 3 and 4). A previous endolaryngeal epiglottopexy had been performed in 5 (28%) patients. Fourteen (78%) patients had a concurrent airway procedure performed including 4 undergoing single-stage laryngotracheal reconstruction. The mean suspension time only for the TCE part ranged from 8 to 17 minutes with a mean of 11.23 ± 3.4 minutes. A stable EP defined as a healed glossoepiglottic adhesion was achieved in all but 1 case with an overall success rate of 95%. All cases with previous failed endoscopic epiglottopexy had a stable epiglottopexy. No immediate complications were noticed. Among the late complications, the most common was the formation of granulation tissue at the site of silastic disc placement which was seen in 3 patients. CONCLUSION: TCE using an exo-endolaryngeal technique can achieve stable epiglottopexy in children with EP and can be adapted for any kind of EP.

Quantitative Evaluation of Vocal Bowing Following Bilateral Thyroplasty in Age-Related Vocal Atrophy.

OBJECTIVE: Age-related vocal atrophy (ARVA) is associated with vocal fold bowing, persistent glottal gap during phonation, and dysphonia. Bilateral medialization thyroplasty is sometimes performed in patients with ARVA to improve vocal fold closure and voice. We set out to quantify stroboscopic changes in vocal fold bowing, glottal closure, and abduction angle following bilateral thyroplasty and determine how these changes affect voice quality among patients with ARVA. METHODS: Fifteen individuals with ARVA who underwent bilateral medialization thyroplasty were included in this study. Two independent investigators calculated bowing index (BI), normalized glottal gap area (NGGA), and maximum abduction angle from laryngostroboscopic exams using ImageJ™. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and patient-reported measures were collected before and after thyroplasty. RESULTS: Thyroplasty resulted in a 10-point improvement in overall CAPE-V (Mean dif -10; 95% CI -17, -3.3, p < 0.01) and VHI-10 (mean dif -3.8; 95% CI -9.8, 2.3, p = 0.19, n = 8). NGGA and BI significantly decreased following surgery (mean dif -78; 95% CI -155, -1.5, p = 0.05; and mean dif -2.1; 95% CI -2.4, -0.84, p < 0.01, respectively). BI correlated with CAPE-V scores (r = 0.66, 95% CI 0.22, 0.87, p < 0.01). When considering the normalized combined contributions of both NGGA and BI, there was a stronger correlation in CAPE-V scores (r = 0.87, 95% CI 0.50, 0.97, p < 0.01) compared with either measure alone. CONCLUSIONS: Thyroplasty resulted in a decrease in vocal fold bowing, glottal gap area, and CAPE-V scores in patients with ARVA. Correction of vocal bowing and glottal gap, following bilateral thyroplasty, improved voice measures following surgery. Quantitative evaluation of vocal fold morphology may be valuable when assessing the severity and treatment-response in patients with ARVA following bilateral thyroplasty. Laryngoscope, 134:835-841, 2024.

Surgical Outcomes by Early Airway Endoscopy Findings after Pediatric Staged Laryngotracheoplasty.

OBJECTIVES: To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP. METHODS: A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal. RESULTS: Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63). CONCLUSIONS: Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:963-967, 2024.

Validation of a 3D-Printed Percutaneous Injection Laryngoplasty Simulator: A Randomized Controlled Trial.

OBJECTIVE: Simulation may be a valuable tool in training laryngology office procedures on unsedated patients. However, no studies have examined whether existing awake procedure simulators improve trainee performance in laryngology. Our objective was to evaluate the transfer validity of a previously published 3D-printed laryngeal simulator in improving percutaneous injection laryngoplasty (PIL) competency compared with conventional educational materials with a single-blinded randomized controlled trial. METHODS: Otolaryngology residents with fewer than 10 PIL procedures in their case logs were recruited. A pretraining survey was administered to participants to evaluate baseline procedure-specific knowledge and confidence. The participants underwent block randomization by postgraduate year to receive conventional educational materials either with or without additional training with a 3D-printed laryngeal simulator. Participants performed PIL on an anatomically distinct laryngeal model via trans-thyrohyoid and trans-cricothyroid approaches. Endoscopic and external performance recordings were de-identified and evaluated by two blinded laryngologists using an objective structured assessment of technical skill scale and PIL-specific checklist. RESULTS: Twenty residents completed testing. Baseline characteristics demonstrate no significant differences in confidence level or PIL experience between groups. Senior residents receiving simulator training had significantly better respect for tissue during the trans-thyrohyoid approach compared with control (p < 0.0005). There were no significant differences in performance for junior residents. CONCLUSIONS: In this first transfer validity study of a simulator for office awake procedure in laryngology, we found that a previously described low-cost, high-fidelity 3D-printed PIL simulator improved performance of PIL amongst senior otolaryngology residents, suggesting this accessible model may be a valuable educational adjunct for advanced trainees to practice PIL. LEVEL OF EVIDENCE: NA Laryngoscope, 134:318-323, 2024.

Swallowing Function After Epiglottopexy in Children.

OBJECTIVE: Epiglottopexy has been an increasingly utilized intervention in children with epiglottic prolapse and airway obstruction. Given the role of the epiglottis in protecting the airway during swallowing and the potential effect of repositioning the epiglottis on the passage of the bolus, we aimed to compare swallowing outcomes before and after epiglottopexy in children. STUDY DESIGN: A retrospective cohort study. SETTING: Tertiary care children's hospital. METHODS: Data were extracted from charts of children who underwent epiglottopexy and had a subsequent instrumental swallowing evaluation between January 2018 and September 2022. RESULTS: A total of 93 patients underwent epiglottopexy. Of these, 38 patients met inclusion requirements. The mean age at surgery was 41 ± 47 months. Most patients (n = 37, 97.4%) had significant comorbidities such as secondary airway lesions (n = 33, 91.7%), a genetic or syndromic disorder (n = 25, 69.4%), and dysphagia (n = 29, 76.3%). All patients had a concurrent procedure at the time of epiglottopexy with supraglottoplasty (n = 24, 63.2%) and lingual tonsillectomy (n = 16, 42.1%) being the most common. No changes in initiation or patterns of swallowing were noted postoperatively. A total of 7 (18.4%) patients had worsening swallow function: 2 had new-onset dysphagia, and 5 had worsening pre-existing dysphagia. Liquid or food textures penetrated remained unchanged or improved in most cases. No risk factors for worsening dysphagia were identified in our cohort. CONCLUSION: Children with medical comorbidities undergoing epiglottopexy with additional airway interventions may experience new or worsening dysphagia. However, the procedure is generally safe without notable patterned changes in the swallowing mechanism.

Scoping Review of Surgical Rehabilitation of Post Intubation Phonatory Insufficiency.

OBJECTIVES: Post intubation phonatory insufficiency (PIPI) or posterior glottic diastasis describes posterior glottic insufficiency (PGI) caused by prolonged intubation causing medial arytenoid ulceration, mucosal scarring, and incomplete cricoarytenoid joint adduction. The purpose of this review is to showcase diagnostic findings, surgical rehabilitation, and gaps in our treatment algorithm of PIPI. DATA SOURCES: Embase, PubMed, Scopus, Web of Science. REVIEW METHODS: Two independent reviewers completed a systematic search of the literature studying PIPI. Reported intubation history, laryngeal defect, clinical symptoms, surgical intervention, and outcomes were gathered from included studies. RESULTS: Nine studies met our inclusion criteria for full review, (45 patients) all of which were case reports/series. All patients had posterior glottic defects, most commonly loss of medial arytenoid tissue, causing varying degrees of PGI. Eleven patients had vocal fold (VF) immobility or hypomobility. Treatment interventions were observation (1), speech therapy (2), VF or posterior glottic injection augmentation (15), medialization laryngoplasty (4), arytenoid repositioning (6), endoscopic (19) or open (3) posterior cricoid reduction, local mucosal rotation flap (11), or free mucosal graft (2) to fill the glottic defect. Observation, voice therapy, and augmentation or type 1 laryngoplasty failed to improve symptoms. Other surgical techniques improved symptoms with varying outcomes. CONCLUSION: PIPI is a difficult injury to diagnosis and treat. Conservative measures and augmentation/laryngoplasty often fail to fix the PGI. Our review supports symptom improvement with reconstruction of the posterior glottic defect with cricoid reduction or mucosal grafts. Future investigation is needed to better define the diagnosis and successful treatment algorithm. Laryngoscope, 134:2048-2058, 2024.

Preliminary Experience with 3-Dimensional Exoscope-Assisted Laryngoplasty.

OBJECTIVE: Laryngoplasty requires the manipulation of the vocal folds, which are not visible during the operation. The widespread use of this technique is limited by the need for adequate knowledge of anatomy, the small surgical field, and the high level of skill required for the procedure. An exoscope has been developed to provide a stereoscopic view similar to that of a microscope while using the same compact endoscopic tool. This study aimed to determine whether the three-dimensional (3D) exoscopic surgical technique could be applied to laryngoplasty and explore its possibility to ultimately replace the current approach. METHODS: This was a retrospective case series analysis, which included 28 patients with hoarseness who underwent surgery with (Exoscope; n = 12) or without (Macrosurgery; n = 16) a 3D exoscope between July 2018 and February 2021. The feasibility of performing all surgical steps with the 3D exoscope was evaluated. The Exoscope and Macrosurgery groups were compared for surgical time, vocal function outcomes, and complications. Questionnaires were completed by medical staff regarding the usefulness of medical education. RESULTS: No intraoperative or postoperative complications occurred in either procedure. The operative time was similar in both groups. The vocal function outcomes were also comparable between the groups. Questionnaires revealed that the exoscope was useful in terms of sharing information on surgical procedures and anatomy, as well as functioning as an educational tool. CONCLUSION: While this was a preliminary study, our results indicated that the exclusive use of the 3D exoscope was feasible for open approaches. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:1813-1819, 2024.