The Association between Paradoxical Vocal Fold Motion and Dysphonia in Adolescents.

OBJECTIVE: Associations between dysphonia and paradoxical vocal fold motion (PVFM) have been previously reported in adults, but it is unclear whether similar associations exist for adolescents. The goals of this study were to identify the prevalence and severity of voice disorders in adolescent patients with PVFM, identify differences between those with and without clinician-identified dysphonia, and investigate what factors were associated with voice handicap in this population. METHODS: A retrospective review of eligible adolescent patients diagnosed with PVFM over a 1-year period at a single institution was undertaken. Data collected from the medical record included demographic background, medical history and workup, patient- and family-reported symptoms, and findings from the laryngeal examination. The presence or absence of clinician-diagnosed dysphonia was used to subdivide the sample for analysis. RESULTS: Forty-eight patients with PVFM were included. The sample was primarily female (73%) with a median age of 15 years. Few patients had voice complaints (5%), but clinician-diagnosed dysphonia was common (52%) and ranged from mild to moderate. Vocal hyperfunction was frequently observed (55%), but anatomic abnormalities associated with dysphonia were rare (6%). Adolescents with dysphonia were significantly older, more likely to have vocal hyperfunction on laryngoscopy, and more likely to return for therapy than those without dysphonia. No notable differences existed in the number of behavioral therapy sessions or in the likelihood of completing treatment between the two groups. The majority of participants (79%) had at least one "confounding factor" (i.e., were currently taking a medication for asthma, allergies, or reflux, or had a laryngeal abnormality) but this did not differ significantly between those with and without dysphonia. A minority of individuals (28%) had abnormal scores on the Voice Handicap Index (VHI). Age was positively correlated with dysphonia severity but no other significant associations were observed. CONCLUSION: Although voice complaints are rare, dysphonia among adolescents with PVFM is common and can occur in the absence of laryngeal abnormalities and medical comorbidities, typically as a result of vocal hyperfunction. Dysphonia does not appear to be a barrier to PVFM treatment and may be a useful target in therapy.

Functional Outcomes after Behavioral Treatment of Paradoxical Vocal Fold Motion in Adults.

OBJECTIVE: Paradoxical vocal fold motion (PVFM) is responsive to behavioral therapy, often resulting in a remission of symptoms, but little is known about whether treatment is beneficial with regard to PVFM-associated psychological symptoms or functional limitations. The goal of the study was to identify patient perceptions of the impact of treatment for PVFM and characteristics associated with treatment outcomes. METHODS: A survey was conducted of all adults who had received at least 1 session of treatment for PVFM in our outpatient clinic over a 2-year period. RESULTS: The 39 participants ranged in age from 18 to 82 and had received a median of 3 treatment sessions. At a median follow-up of 10 months following treatment, respondents reported improvements in a wide range of areas, including sports and leisure, daily activities, and social participation. The majority reported improvements in feelings of anxiety, helplessness, and control. Poorer outcomes were associated with more severe voice symptoms, fewer treatment sessions, and needing oral steroids for asthma control. CONCLUSION: There was a reduction in a wide range of activity limitations after treatment. Feelings of control were strongly associated with positive outcomes. The therapy appeared to be equally effective for adults with exercise-induced and environmental variants of PVFM.

Using pulmonary function data to assess outcomes in the endoscopic management of subglottic stenosis.

OBJECTIVE: This study aimed to examine the authors' experience with endoscopic management of idiopathic subglottic stenosis (iSGS), and to identify pulmonary function test (PFT) values that can be used to quantify outcomes. METHODS: Retrospective review. RESULTS: Twenty-five patients with a new diagnosis of iSGS were seen between 2006 and 2012. Median age at surgery was 45.3 years (interquartile range [IQR], 38.5-67.0), and median body mass index was 28.7 kg/m(2) (IQR, 23.5-32.1). Forty-five procedures were performed. Median preoperative stenosis was 56.8% (Cotton-Myer grade 2). The typical stenosis began 15 mm below the true vocal folds and was 12 mm long. Median follow-up was 21.4 months (IQR, 5.1-43.1). For patients receiving multiple dilations, median time between procedures was 23.7 months. Four PFT parameters demonstrated significant improvement after intervention: (1) PEF (absolute change = 2.54 L/s), (2) PIF (absolute change = 1.57 L/s), (3) FEV1/PEF (absolute change = 0.44), and (4) FIF50% (absolute change = 1.71 L/s). PIF was the only parameter affected by using a larger balloon (P = .047). CONCLUSION: PEF, PIF, FEV1/PEF, and FIF50% improved significantly after endoscopic incision and dilation of iSGS, and this could potentially be used as a metric by which to evaluate outcomes in the endoscopic management of subglottic stenosis.

Use of Perioperative Virtual Reality Experiences on Anxiety and Pain: A Randomized Comparative Trial.

OBJECTIVE: To evaluate the effect of different virtual reality (VR) experiences on perioperative anxiety and pain among patients undergoing head and neck surgery. METHODS: Prospective, randomized, comparative trial among patients undergoing outpatient head and neck surgery from December 2021 to April 2022 at a single academic institution. Group 1 utilized a preoperative VR gaming experience and a postoperative VR mindfulness experience, while Group 2 utilized the same interventions in the reverse order. Anxiety and pain were measured using visual analog scales (VAS). Primary outcomes were changes in post-intervention anxiety and pain. Secondary outcomes included vital sign changes and subjective patient experiences using a 5-point Likert scale. RESULTS: There were 32 patients randomized for inclusion, with 16 patients per group. The majority of patients were female (65.6%) and mean (standard deviation) age was 47.3 (16.7) years. After outlier exclusion, there were no differences in post-intervention preoperative anxiety reduction (Group 1 vs. Group 2, median [IQR]: -12.0 [15] vs. -10.5 [13], p = 0.62). There were minor differences in vital sign changes (p < 0.05). Among the 10 patients in Group 1 and 12 patients in Group 2 who completed postoperative VR use, there were no differences in post-intervention pain reduction (-8.5 [22.3] vs. -7.5 [19.3], p = 0.95) or vital sign changes (p > 0.05). There were no differences in questionnaire responses, with high satisfaction in both groups (p > 0.05). No adverse events encountered. CONCLUSIONS: Use of different VR experiences among patients undergoing outpatient head and neck surgery appears associated with similar reductions in perioperative anxiety and pain. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1197-1202, 2024.

Patterns of virtual reality and Fitbit wearable activity device use after skull base surgery.

KEY POINTS: Virtual reality (VR) and Fitbit devices are well tolerated by patients after skull base surgery. Postoperative recovery protocols may benefit from incorporation of these devices. However, challenges including patient compliance may impact optimal device utilization.

A cross-sectional analysis of the prevalence of Barrett esophagus in otolaryngology patients with laryngeal symptoms.

BACKGROUND: Populations at risk for esophageal adenocarcinoma remain poorly defined. Laryngeal symptoms can be secondary to laryngopharyngeal reflux (LPR) and can occur without associated gastroesophageal reflux symptoms such as heartburn and regurgitation. GOAL: We sought to determine the prevalence of Barrett esophagus (BE) in otolaryngology patients with laryngeal symptoms±typical gastroesophageal reflux disease (GERD) symptoms. STUDY: We performed a cross-sectional study of otolaryngology clinic patients who reported laryngeal symptoms. Symptoms, medications, and exposure histories were obtained. Unsedated transnasal endoscopy was performed. Suspected BE was biopsied and confirmed histologically. Risk factors and prevalence of BE were assessed. RESULTS: Two hundred ninety-five patients were enrolled [73% male, median age 60 y (interquartile range 51 to 68 y)]. The overall prevalence of BE was 11.8% (n=33). Antisecretory medication use was present in 56% (n=156) of patients at enrollment. Compared with patients without BE, patients with BE were more likely to be male (P=0.01) and to report occupational lung injury (P=0.001). Duration, but not severity of laryngeal symptoms, significantly increased the odds of BE (odds ratio, 5.64; 95% confidence interval, 1.28-24.83; for a duration of symptoms >5 y). Of patients with BE, 58% (n=19) had coexisting LPR and GERD symptoms and 30% (n=10) had only LPR symptoms. Presence and size of hiatal hernia and length of columnar-lined esophagus were significant risk factors for BE. CONCLUSIONS: Long-standing laryngeal symptoms are associated with the presence of BE in otolaryngology patients. Patients with chronic laryngeal symptoms and no identifiable ear, nose, or throat etiology for those symptoms may benefit from endoscopic screening regardless of whether typical GERD symptoms are present.

Subjective and objective parameters of the adult female voice after cricotracheal resection and dilation.

OBJECTIVES: We compared the voice outcomes after cricotracheal resection (CTR) and airway dilation in adult women. METHODS: We performed long-term comprehensive voice assessments in 23 adult women treated for laryngotracheal stenosis, including acoustic and perceptual measurements of voice, videostroboscopy, the Voice Handicap Index, and an open-ended subjective questionnaire. RESULTS: Voice measures were abnormal in both groups. Objective pitch and loudness measurements were significantly more impaired after CTR than after dilation. Perceptual ratings of voice were worse after CTR than after dilation, particularly with regard to breathiness, pitch, and loudness. The CTR group was more likely to report a voice disorder, reported significantly more voice symptoms, and had higher voice handicap scores. Videostroboscopy was frequently abnormal in both groups, with more evidence of vocal hyperfunction after CTR. Self-ratings of breathing and swallowing were generally high in both groups, but voice satisfaction was rated lower after CTR. CONCLUSIONS: Voice was more significantly negatively impacted by CTR than by dilation. Surprisingly, many individuals in both groups reported improvements--a finding that possibly highlights the impact of laryngotracheal stenosis on airflow and vocal function before surgery. The importance of patient selection and preoperative counseling is emphasized, along with the potential need for voice therapy.

Longitudinal Voice Outcomes and Neoglottic Function After Supracricoid Partial Laryngectomy: The Development of a New Scale.

OBJECTIVES: Supracricoid partial laryngectomy (SCPL) is an oncologically sound alternative to total laryngectomy that results in long-term alterations in vocal function. Little is known about long-term improvements in dysphonia and the mechanism of vocal recovery is unclear due to the lack of a standardized rating tool: The Pattern, Degree, and Vibration (PDV) Scale. METHODS: Data from 24 individuals were compared over 3 post-operative timepoints after SCPL: 3 to 11, 12 to 35, and over 35 months. Voice outcomes were assessed using the Voice Handicap Index (VHI) and the GRBAS scale. Laryngeal exams were deidentified and rated using a novel rating scheme developed using literature review and consensus panel discussions. RESULTS: There were significant improvements in VHI scores, Grade, and Strain over time. There was an increase in the Degree of Closure and a decline in Mucosal Vibration across timepoints. Pattern of Movement (P) was associated with dysphonia Grade. Better Degree of Closure (D) was associated with lower VHI scores and better Grade and Roughness. Mucosal Vibration (V) was associated with reduced Breathiness and Strain but variable Roughness. Age, T-stage, radiation treatment, surgery type, and time to feeding-tube removal were also associated with voicing characteristics. CONCLUSIONS: There is evidence of improvement in several voice parameters over time after the first post-operative year. Various subcomponents of the new PDV rating scale were associated with voice outcomes. Its utility for research and clinical practice merits further investigation.

Mucoepidermoid Carcinomas of the Larynx.

OBJECTIVES: Discussions regarding the specific management and outcomes for laryngeal MEC are limited to very small, single-institution case series. To look further into the diagnosis and management of these uncommon non-squamous cell carcinomas of the larynx, we present 3 recent cases of laryngeal MEC treated at our institution. METHODS: Patients at a tertiary hospital treated for MEC between October 2019 and December 2020 were retrospectively identified. Chart review, imaging analysis, and histologic slide creation were completed for all patients. RESULTS: We identified and treated 2 patients with high-grade supraglottic and 1 patient with intermediate-grade glottic MEC. These patients presented to our clinic with a primary complaint of either gradual, worsening dysphonia, dysphagia, or both. All patients underwent laryngovideostroboscopy as well as panendoscopy with directed submucosal biopsy, which was consistent with MEC. MRI was performed in 2 of the cases further elucidating the extent of submucosal spread. PET-CT was performed in all 3 cases, and none demonstrated evidence of regional or distal metastases. Surgically, high-grade MEC lesions were treated with a total laryngectomy. The intermediate MEC lesion was managed with a supracricoid partial laryngectomy (SCPL). Surgical margins were free of tumor in all cases with no nodal metastases by modified radical neck dissection. Radiation therapy was offered to both high-grade MEC patients and declined by one. Radiation was not recommended to the patient with intermediate-grade MEC as we believed that the risk of additional treatment outweighed the benefit. CONCLUSION: We believe that MEC of the larynx should be considered in patients with atypical submucosal laryngeal masses. Laryngovideostroboscopy, MRI, and PET imaging may be valuable in determining the extent of the lesions and planning appropriate surgery. Postoperative radiation therapy should be considered a per tumor grade in other more studied sites, as there is no data on efficacy in laryngeal MEC.

Long-term Follow-up After Radiation Therapy for Laryngeal Amyloidosis.

OBJECTIVES: Laryngeal amyloidosis (LA) is a rare disease characterized by extracellular protein deposition within the larynx. Treatment is difficult due to the frequently submucosal and multifocal nature of disease. The mainstay of treatment is surgical resection; however, recurrence rates are high. Recently, use of radiotherapy (RT), either alone or postoperatively, for LA has been adapted from the management of extramedullary plasmacytoma and has been shown to provide local disease control. Here, we describe the experience with adjuvant RT for LA at our center. STUDY DESIGN: Retrospective case series. METHODS: Retrospective study of patients with amyloidosis of the larynx, with or without other disease sites, seen at a tertiary academic center between 2011 and 2019. Outcomes included disease characteristics, recurrence rates, treatment modalities, and pre- and posttreatment voice handicap index (VHI)-10. RESULTS: Ten patients met eligibility criteria. Mean follow-up time for all patients was 62.0 ± 41.0 months; mean follow-up time after last treatment was 51 ± 55 months. All but one patient underwent surgical resection of disease. Seven patients underwent subsequent RT. Of these seven, six underwent RT at our institution; five received a dose of 45 Gray (Gy); and one received a dose of 20 Gy. All seven completed RT without toxicity-related interruption. Patients undergoing RT underwent 2.1 ± 1.3 surgical procedures prior to RT; no patients required surgery after RT. Mean pretreatment VHI-10 was 22.9 ± 8.1; mean posttreatment VHI-10 was 12.9 ± 13.3. CONCLUSION: RT after surgery for LA can provide good local control without unacceptable toxicity and may decrease the need for further surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1810-1815, 2021.

The impact of Lee Silverman Voice Treatment (LSVT LOUD®) on voice, communication, and participation: Findings from a prospective, longitudinal study.

BACKGROUND: Lee Silverman Voice Treatment (LSVT LOUD®), an intensive 4-week program of voice therapy, is regarded as the most well-researched, efficacious treatment for hypokinetic dysarthria in individuals with Parkinson's disease (PD). Although numerous studies have published acoustic and perceptual findings, there is comparatively little information about the impact of LSVT LOUD® on functional communication outcomes. METHODS: This prospective, longitudinal study investigated the impact of treatment on daily communication in 25 individuals with PD. Three validated communication measures (the Voice Handicap Index, the Communicative Effectiveness Scale, and the Communicative Participation Item Bank) were given before and after treatment and again 4-8 weeks and 3-6 months following treatment. Communication partners were also asked to rate communication effectiveness at all four timepoints. RESULTS: Significant improvements were found for all three self-reported scales which remained above baseline across all post-treatment timepoints. In addition, self-reported communicative effectiveness was significantly correlated with the assessments of communication partners. Particular benefits were reported for more complex communicative activities such as asking questions, giving detailed information, communicating in noisy situations, and speaking in groups. CONCLUSIONS: Overall, the findings suggested that LSVT LOUD® promotes an increased sense of personal control over the communication difficulties resulting from PD by decreasing voice handicap and improving communication effectiveness and communicative participation. For individuals with PD, LSVT LOUD® may reduce the risk of social isolation by improving communication and facilitating social participation. LEARNING OUTCOMES: As a result of this activity, the participant will be able to (1) describe the impact of PD on voice and communication, (2) discuss how these characteristics may be associated with more global measures of functional communication and particularly communicative participation, (3) explain which aspects of functional communication were affected by LSVT LOUD® as assessed by study participants and their communication partners.

Treatment Outcomes of Bilateral Medialization Thyroplasty for Presbylaryngis.

BACKGROUND: Presbylaryngis is a common cause of dysphonia in elderly patients. Type I thyroplasty serves to improve glottic closure and vocal quality by correcting bowing. Although unilateral and injection-based procedures are well-characterized in the treatment of broadly defined glottic insufficiency, there are insufficient outcomes data for bilateral medialization thyroplasty in the treatment of presbylaryngis. The aim of this study was to review the change in measures of vocal quality before and after bilateral medialization thyroplasty for presbylaryngis. STUDY DESIGN: This is a retrospective case series. METHODS: The records of 21 patients with presbylaryngis undergoing bilateral medialization thyroplasty between 2007 and 2014 were reviewed. Implant materials included silastic (n = 17) and hydroxyapatite (n = 4). Preoperative and postoperative comparison of vocal function was conducted using Voice Handicap Index, maximum phonation time, auditory-perceptual severity ratings, and blinded paired-comparison of Consensus Auditory-Perceptual Evaluation of Voice and Visual-perceptual stroboscopic ratings. Paired sample t tests were used to assess all outcome measures. RESULTS: Significant improvements were found in Voice Handicap Index scores (P < 0.007), maximum phonation time (P < 0.03), Consensus Auditory-Perceptual Evaluation of Voice (P < 0.04), and clinician rating of vocal quality (P < 0.0001). Blinded raters noted a significant improvement in audio (P < 0.05) and videostroboscopic (P < 0.003) samples after surgery. There were no operative complications observed, and median hospital stay was one night. CONCLUSIONS: Patients with presbylaryngis demonstrated significant improvement in both objective and subjective measures of vocal quality following bilateral medialization thyroplasty. These data suggest that medialization thyroplasty is a safe option that warrants consideration in the treatment of presbylaryngis.

Thyroid cartilage compression causing stroke.

We describe the diagnostic workup and surgical treatment of a patient presenting with the unique case of vertebral artery (VA) occlusion subsequent to head flexion leading to compression of an aberrant VA by the ipsilateral superior cornu of the thyroid cartilage. Imaging revealed ischemic infarcts as well as the presence of an aberrant right VA, which was compressed by the ipsilateral superior cornu of the thyroid cartilage upon neck flexion. The patient was managed with laryngoplasty involving removal of the right superior cornu of the thyroid cartilage. Laryngoscope, 129:E445-E448, 2019.

The Safety and Efficacy of Expiratory Muscle Strength Training for Rehabilitation After Supracricoid Partial Laryngectomy: A Pilot Investigation.

OBJECTIVES: Expiratory muscle strength training (EMST) is a safe, effective intervention that can be performed at home and may be beneficial for individuals with voice and swallowing disorders. To date there have been few studies of EMST in the head and neck cancer population, and there are no previous reports of its use after supracricoid partial laryngectomy (SCPL). The current prospective clinical pilot study was undertaken to determine the safety and efficacy of a 4-week treatment program. METHODS: Six participants were recruited who had previously undergone SCPL, were medically stable, and had no contraindications for use of the device. At baseline, objective respiratory measurements were collected, dietary status was recorded, and participants were asked to complete a series of validated self-report instruments relating to voice, swallowing, breathing, and cough. Following the completion of treatment, baseline measures were repeated, and participant feedback was solicited. RESULTS: The majority of individuals found the device easy to use (83%) and beneficial (83%). The side effects of treatment were relatively minor and included dizziness, muscle inflammation, and vocal fatigue. There were improvements in 2 measures from before to after treatment, namely, an average 21% increase in peak cough flow (from 371.67 to 451.33 L/min) and a 38% decrease on the Dyspnea Index (from 6.17 to 3.83). Other measures showed inconsistent changes. CONCLUSIONS: EMST appeared to improve cough strength and reduce dyspnea symptoms after SCPL. Further study of the relative efficacy of EMST compared to other rehabilitation protocols after SCPL is needed.

Association Between Sarcopenia and Mortality in Patients Undergoing Surgical Excision of Head and Neck Cancer.

Importance: Sarcopenia, or the loss of muscle mass, is associated with poor treatment outcomes in a variety of surgical fields. However, the association between sarcopenia and long-term survival in a broad cohort of patients with head and neck cancer (HNC) is unknown. Objective: To determine whether sarcopenia is associated with long-term survival in patients undergoing major head and neck surgery for HNC. Design, Setting, and Participants: A retrospective medical records review was conducted at a tertiary care academic hospital. Two hundred sixty patients undergoing major head and neck ablative procedures with cross-sectional abdominal imaging performed within 45 days prior to surgery were included in the analysis. The study was conducted from January 1, 2005, to December 31, 2016. Data analysis was performed from June 1, 2018, to February 28, 2019. Interventions: Measurement of cross-sectional muscle area at the L3 vertebra level. Main Outcomes and Measures: Two- and 5-year overall survival were the primary outcomes. Results: Of the 260 patients included in the study, 193 were men (74.2%); mean (SD) age was 61.1 (11) years. Sarcopenia was present in 144 patients (55.4%). Two-year overall survival was 71.9% of the patients (n = 82) in the sarcopenia group compared with 88.5% of the patients (n = 85) in the nonsarcopenia group (odds ratio [OR], 0.33; 95% CI, 0.16-0.70). At 5 years, overall survival was 36.5% in patients (n = 23) with sarcopenia and 60.5% in patients (n = 26) without sarcopenia (OR, 0.38; 95% CI, 0.17-0.84). On multivariate analysis, sarcopenia was a significant negative predictor of both 2-year (OR, 0.33; 95% CI, 0.14-0.77) and 5-year (OR, 0.38; 95% CI, 0.17-0.84) overall survival. Conclusions and Relevance: Sarcopenia appears to be a significant negative predictor of long-term overall survival in patients with HNC undergoing major head and neck surgery. Sarcopenia may be accurately assessed on cross-sectional imaging and may be useful clinically as a prognostic variable and as an area for intervention to improve treatment outcomes.

Swallowing and Secretion Management in Neuromuscular Disease.

Neuromuscular disease frequently leads to dysphagia and difficulty managing secretions. Dysphagia may lead to medical complications, such as malnutrition, dehydration, aspiration pneumonia, and other pulmonary complications, as well as social isolation and reduced overall quality of life. This review provides an overview of dysphagia associated with neuromuscular disease in adults, along with a concise review of swallowing assessment and intervention options.

Bilateral vocal fold paralysis and dysphagia secondary to diffuse idiopathic skeletal hyperostosis.

BACKGROUND: Diffuse idiopathic skeletal hyperostosis (DISH) is an idiopathic spinal disease common in the elderly and characterized by flowing ossification and osteophyte formation along the spinal column. Cervical hyperostosis is capable of producing dysphagia, stridor, and airway obstruction; however, there are no extant reports of true paralysis of bilateral vocal folds in patients fulfilling the criteria for DISH. METHODS AND RESULTS: We report a case of a 61-year-old man presenting with dysphagia and dyspnea. Flexible laryngoscopy revealed bilateral true vocal fold paralysis. Cervical radiograph showed flowing ossification of the anterior longitudinal ligament with preservation of intervertebral disc height. Tracheotomy and cervical osteophytectomy were performed, after which the patient showed improved swallowing and speaking ability and was decannulated without complication. CONCLUSION: In the case presented, cervical osteophytectomy dramatically reversed bilateral vocal fold paralysis and dysphagia secondary to hyperostosis, thus negating the need for prolonged tracheostomy and feeding tube dependence. © 2016 Wiley Periodicals, Inc. Head Neck 39: E1-E3, 2017.

Refractory Dysphonia Due to Isolated Cricothyroid Muscle Dystonia.

OBJECTIVE: To demonstrate the utility of electromyography (EMG) in the evaluation and management of treatment-resistant dysphonia. METHOD: We report a case of refractory dysphonia in which EMG was used to identify and treat isolated cricothyroid (CT) dystonia. RESULTS: The patient, a healthy 43-year-old woman, presented with 9 months of progressive hoarseness. Her symptoms were present across vocal tasks but were particularly bothersome while dictating. On presentation, her voice was rated grade 3, roughness 3, breathiness 1, asthenia 0, and strain 3 (G3R3B1A0S3). Videostroboscopy was remarkable for hyperfunction. Voice therapy was not beneficial despite appropriate effort. Microdirect laryngoscopy revealed no evidence of structural pathology. The patient was referred for EMG because of her normal examination and failure to improve with therapy. The CT muscle demonstrated an increased latency of 750 ms in all vocal tasks. One month after CT injection with 3 units of botulinum toxin (BTX), her voice was improved. Perceptual voice evaluation was rated G1R1B0A0S1. Voice Handicap Index improved from 87 to 35. CONCLUSIONS: In the absence of structural pathology, EMG can be a useful adjunct in the diagnosis of dysphonia that persists despite adequate trials of voice therapy. To our knowledge, this is the only report of laryngeal dystonia due to isolated CT dysfunction successfully treated with BTX.

The safety and efficacy of endoscopic Zenker's diverticulotomy: A cohort study.

OBJECTIVES/HYPOTHESIS: To determine whether the application of laser-assisted techniques for the treatment of Zenker's diverticulum would reduce the failure rate of endoscopic procedures without compromising safety or durability. STUDY DESIGN: Cohort study with long-term follow-up. METHODS: We performed a single-institution review of 106 consecutive patients in whom endoscopic laser-assisted diverticulotomy (ELD) or endoscopic stapler-assisted diverticulotomy (ESD) was attempted. The Eating Assessment Tool was collected pre- and postoperatively. Long-term follow-up was conducted on average 2.4 years postoperatively. RESULTS: The decision to use either ELD or ESD was made intraoperatively. An endoscopic procedure was successfully completed in 103 of 106 patients (97.2%). Eighty-three patients underwent ELD, 20 underwent ESD, and only three required use of an open approach. No serious complications occurred. Postoperatively, there was a significant reduction in dysphagia symptoms. At follow-up, most individuals had dysphagia scores within the normal range (69%) and were eating a regular diet (73%). Fourteen patients (14%) required revision. Compared to historical data from our institution for ESD alone, the addition of ELD resulted in a reduction in the failure rate without an increase in serious complications. Recurrence rates and long-term outcomes were equivalent. CONCLUSION: Through careful patient selection, appropriate workup, and judicious use of techniques, it was possible to perform endoscopic surgery in a majority of patients without serious complications. Both approaches resulted in short- and long-term symptom management with high levels of satisfaction. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2705-2710, 2016.

Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis.

OBJECTIVES/HYPOTHESIS: Idiopathic subglottic stenosis (iSGS) is a rare and potentially life-threatening disease marked by recurrent and progressive airway obstruction frequently requiring repeated surgery to stabilize the airway. Unknown etiology and low disease prevalence have limited the ability to characterize the natural history of iSGS and resulted in variability in surgical management. It is uncertain how this variation relates to clinical outcomes. STUDY DESIGN: Medical record abstraction. METHODS: Utilizing an international, multi-institutional collaborative, we collected retrospective data on patient characteristics, treatment, and clinical outcomes. We investigated variation between and within open and endoscopic treatment approaches and assessed therapeutic outcomes; specifically, disease recurrence and need for tracheostomy at last follow-up. RESULTS: Strikingly, 479 iSGS patients across 10 participating centers were nearly exclusively female (98%, 95% confidence interval [CI], 96.1-99.6), Caucasian (95%, 95% CI, 92.2-98.8), and otherwise healthy (mean age-adjusted Charlson Comorbidity Index 1.5; 95% CI, 1.44-1.69). The patients presented at a mean age of 50 years (95% CI, 48.8-51.1). A total of 80.2% were managed endoscopically, whereas 19.8% underwent open reconstruction. Endoscopic surgery had a significantly higher rate of disease recurrence than the open approach (chi(2) = 4.09, P = 0.043). Tracheostomy was avoided in 97% of patients irrespective of surgical approach (95% CI, 94.5-99.8). Interestingly, there were outliers in rates of disease recurrence between centers using similar treatment approaches. CONCLUSION: Idiopathic subglottic stenosis patients are surprisingly homogeneous. The heterogeneity of treatment approaches and the observed outliers in disease recurrence rates between centers raises the potential for improved clinical outcomes through a detailed understanding of the processes of care. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:1390-1396, 2016.