Effectiveness of Injection Laryngoplasty for Aspiration in Acute Iatrogenic Vocal Fold Paralysis: A Systematic Review.

OBJECTIVE/HYPOTHESIS: To review current evidence on effectiveness of injection laryngoplasty on aspiration outcomes in acute unilateral vocal fold paralysis. STUDY DESIGN: Systematic review. METHODS: A literature search was performed on MEDLINE, Embase, Scopus, and the Cochrane Library from inception of each database to May 2019. Inclusion criteria included case series, case-control studies, prospective cohort studies, and randomized controlled trials assessing the outcomes of early injection laryngoplasty on aspiration in unilateral vocal fold paralysis, in the acute setting. Only English articles with adult study populations were included. Two independent investigators screened all abstracts and manuscripts. Data on study design, patient demographics, interventions, and outcome measures were systematically extracted by both authors for included studies. RESULTS: Fourteen case series studies comprising 582 patients were included. Results were not quantitatively synthesized due to the heterogeneity of outcome measures. Eleven studies reported that a majority (ranging 50%-100%) of patients in each respective study showed improvement in diet intake (progression from nil per os to oral) or Penetration-Aspiration Scale (PAS) scores after injection laryngoplasty. However, none of the investigations used a control group, and therefore, did not account for the possibility of improvement of function related to placebo or Hawthorne effects rather than attributed to intervention. CONCLUSIONS: No robust evidence was found to support injection laryngoplasty as an effective measure to improve aspiration outcomes in acute iatrogenic vocal fold paralysis. Current practices rely on empirical observations and scarce expert opinions. Further prospective investigations with controlled objective measures are necessary to definitively demonstrate the effectiveness of IL for aspiration management. Laryngoscope, 132:813-821, 2022.

Evaluation of Laryngeal Motor Neuropathy Using Transcranial Magnetic Stimulation-Mediated Evoked Potentials.

OBJECTIVES/HYPOTHESIS: Contemporary evaluation of vocal fold motion impairment largely relies on clinical laryngoscopy, with the diagnoses of vocal fold paresis (VFPa) and paralysis (VFP) being based on identification of partial and complete restriction of gross vocal fold motion, respectively. No consensus exists on the diagnostic criteria of VFPa. Laryngeal electromyography does not offer any insight into nerve conduction velocity without the adjunction of nerve conduction studies, which are impractical to perform on laryngeal nerves due to their anatomic location. The present study aims to assess the feasibility of laryngeal nerve conduction studies using transcranial magnetic stimulation (TMS)-mediated myogenic evoked potentials in the evaluation of laryngeal motor nerve function. STUDY DESIGN: Prospective controlled cohort study. METHODS: Enrollment of three groups of subjects defined as healthy volunteers, subjects with clinically diagnosed unilateral VFP, and subjects with clinically diagnosed unilateral VFPa of peripheral etiology. Electrodiagnostic studies consisting of bilateral stimulation of the laryngeal motor cortex, proximal cisternal, and peripheral portions of the vagus nerves were performed using figure-of-eight magnetic stimulation coils, and myogenic evoked potentials recorded from bilateral thyroarytenoid, cricothyroid, and posterior cricoarytenoid muscles using indwelling hook wire electrodes. Conduction latencies were plotted against demographic and anthropometric variables. Values obtained in healthy volunteers were used as normative references and compared to aggregated latencies of VFP and VFPa groups. RESULTS: Enrolled subjects included 19 healthy volunteers, 5 subjects with VFP, and 4 subjects with VFPa. Normative laryngeal nerve conduction latency ranges measured in healthy subjects were comparable to prior published values, and recorded latencies increased in positive correlation with age. VFPa subjects exhibited increased latencies in affected nerve sites, while VFP subjects presented more variability in electrophysiologic manifestations, mostly dependent on their degree of compensatory reinnervation. Aberrant and synkinetic reinnervation patterns were more predominant in the VFP group than the VFPa group. CONCLUSIONS: Laryngeal nerve conduction studies using TMS-mediated myogenic evoked potentials are safely feasible. They may serve as a useful complement to laryngeal electromyography in the evaluation of motor laryngeal neuropathy and represent a promising diagnostic modality in the evaluation of VFPa. Based on the present study's findings, the commonly accepted notion of VFPa as a manifestation of a less severe form of neuropathy than VFP may be unsubstantiated. Aging may contribute to progressive motor nerve dysfunction. Future investigations are needed to ascertain the role of nerve conduction studies in clinical laryngology practice. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:S1-S12, 2022.

Laryngeal cancers in paediatric and young adult patients: epidemiology, biology and treatment.

PURPOSE OF REVIEW: The aim of thi study was to review the recent literature on epidemiology, biology and treatment of laryngeal cancer in paediatric and young adult patients. RECENT FINDINGS: Epidemiological studies reported that 2-10% of patients with laryngeal cancer are younger than 40-year-old, while the prevalence of laryngeal cancer remains unknown in the paediatric population. The development of laryngeal cancer in young adults is multifactorial and may be linked to common carcinogens (tobacco and alcohol), occupational factors, laryngopharyngeal reflux, immunosuppression, human papillomavirus infection and genetic polymorphism. A substantial number of cohort studies reported a significant lower proportion of drinkers and smokers in young populations with laryngeal cancer, supporting the higher prevalence of chromosomal losses or abnormalities predisposing to cancer in this group. The development of laryngeal cancer in paediatric patients is strongly associated with genetic syndromes with DNA repair abnormalities. The pathological, clinical and survival outcome differences between young and old patient groups vary significantly between studies, depending on epidemiological, genetic features and therapeutic strategies used. SUMMARY: Paediatric and adult populations with laryngeal cancer present different clinical, pathological and survival outcomes. In the adult population, the patient age at the time of disease development underlies genetic and etiological differences with different mutation patterns between young and old patients, the latter being more frequently individuals with a history of tobacco and alcohol abuse. The differences between age groups regarding stage of cancer at initial presentation, as well as clinical and survival outcomes, are unclear, which may be due to demographic, ethnicity and population genetic differences.

Performers' Perceptions of Vocal Function During Oral Steroid Treatment of Vocal Fold Edema.

OBJECTIVES: Acute vocal fold edema (VFE) is often a consequence of illness, allergy, or voice overuse, causing dysphonia. Although VFE typically resolves with voice rest and treatment of predisposing causes, oral glucocorticoids are often considered for performers with imminent performance demands. There are limited data about performers' perceptions of vocal change during treatment and how this relates to their ability to perform. This study aims to examine performers' self-perceptions of vocal function with steroid treatment. METHODS: Fifty-five performers (34 F; 21 M) diagnosed with VFE who chose treatment with a 6-day methylprednisolone taper were prospectively assessed. They completed the Evaluation of the Ability to Sing Easily (EASE) and reported on their voice use, regimen, performance obligations, and ability to perform. Findings were compared between Day 1 and Day 6 using paired t-tests and nonparametric Wilcoxon signed-rank tests. RESULTS: Nearly all subjects completed scheduled performances without interruption. Following treatment, all subscales of the EASE were decreased at Day 6 (Vocal Function 29.78-20.59; Pathologic Risk Indicator 26.60-17.33; Vocal Concerns 6.10-4.20). These differences were statistically significant (p < 0.0001) and greater in subjects with performances scheduled and subjects who consistently completed vocal warmups. These findings demonstrate significant improvement in several facets of performers' self-perception of function. CONCLUSION: Subjects reported significant improvement in vocal function with oral steroid treatment and were able to meet performance obligations. It remains important that steroids are not prescribed without laryngeal examination. Examination should be repeated when dysphonia persists, recurs swiftly, or when patients seek repeated treatment, as there may be increased risk of adverse outcomes, and continued steroid use may mask underlying chronic pathology that is best treated by other means. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:2434-2441, 2022.

Transoral Laser Microsurgical Excision of a Laryngeal Schwannoma Located in the Paraglottic Space.

OBJECTIVES/HYPOTHESIS: To report the first case of transoral excision of a paraglottic laryngeal schwannoma. METHODS: Case report. RESULTS: Laryngeal schwannomas are rare tumors, with approximately 75 cases reported to date worldwide. Most cases involve superficial supraglottic tumors excised transorally, and some have been found in deeper compartments and treated using transcervical approaches. This report describes the first excision of a schwannoma of the paraglottic space via endoscopic laser laryngotomy. The procedure allowed return to normal function, without recurrence within 8 months, after which the patient was lost to follow-up. CONCLUSIONS: Transoral excision of benign paraglottic tumors is safe and feasible. LEVEL OF EVIDENCE: NA Laryngoscope, 131:2729-2731, 2021.

Prospective Evaluation of Safety of Singing on Steroids: Testing the Truth of Received Wisdom.

OBJECTIVES/HYPOTHESIS: Performing while on steroids is widely considered to increase risk of vocal injury. This study aims to determine incidence and type of injury, and changes in performers' voices after treatment of vocal fold edema (VFE) with glucocorticoids. STUDY DESIGN: Prospective Cohort. METHODS: Fifty-five performers (34 female; 21 male) treated for acute VFE with short-course oral glucocorticoids were prospectively evaluated pre- and post-treatment. Subjects underwent videostroboscopy, acoustic/aerodynamic assessment, and functional assessment with the Singing Voice Handicap Index-10 (SVHI-10) and Evaluation of the Ability to Sing Easily (EASE). Blinded reviewers rated videostroboscopic examinations and performed audio-perceptual assessment. Chi-square tests and Wilcoxon signed rank tests were applied for analyses of treatment changes. RESULTS: Following glucocorticoid treatment, two instances of vocal fold hemorrhage (3.6%) and three instances of glottic thrush (5.5%) were observed. These resolved without consequence. Mucosal wave dynamics and edema improved. Nearly all subjects completed scheduled performances, and significant improvement was noted on the EASE, reflecting improved function after treatment. These were further supported by statistically significant improvements in CAPE-V and some acoustic and aerodynamic outcomes (semitone pitch range for females, airflow measures for males). CONCLUSIONS: Oral glucocorticoids appear to be generally safe for performers presenting with acute VFE. The incidence of adverse effects, specifically hemorrhage and thrush, was low and the effects transient. Vocal fold examination should be considered obligatory before prescribing glucorticoids to working performers. A treatment strategy for acute VF edema incorporating glucocorticoids when appropriate appears to result in significant improvements in measures of glottal function including videostroboscopic appearance, subject perception, and auditory perception. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2298-2304, 2021.

Spasmodic Dysphonia.

Spasmodic dysphonia (SD) is a rare focal laryngeal dystonia. It is characterized by task-specific voice dysfluency resulting from selective intrinsic laryngeal musculature hyperfunction. Symptoms may be attenuated by a sensory trick. Although SD can be seen at times in generalized dystonia syndromes, it is typically a sporadic phenomenon. Involvement of the laryngeal adductor muscles is more common than abductor muscles. The standard treatment of this disorder is with botulinum toxin injection, usually electromyography-guided, which must be repeated periodically as the toxin wears off. A number of non-reversible surgical procedures have also been described to mitigate the symptoms. Other treatment modalities are under investigation, including implantable electrical stimulation devices and deep brain stimulation.

Contemporary Management of Benign Parapharyngeal Lesions Using Minimally Invasive Techniques: Case Discussion and Review of the Literature.

Branchial anomalies can present in the parapharyngeal space, creating unique challenges in management. Historically, this approach warranted an open approach, including transcervical, transparotid with total parotidectomy and retromandibular dissection, or transmandibular dissection with mandibulotomy. However, the advent of minimally invasive transoral techniques and laser resection have allowed for successful resection of masses in this anatomical region without an external approach. We illustrate these advancements with the case of a 30-year-old man with globus sensation and throat discomfort, found to have a mass of the right posterolateral oropharynx causing severe airway obstruction. Imaging showed a parapharyngeal mass with extension to the carotid sheath and retropharyngeal space, which was successfully resected with potassium-titanyl-phosphate (KTP) laser using a minimally invasive transoral approach with no major complications. Transoral excision offers decreased morbidity and a cosmetically favorable outcome compared to transcervical excision. KTP laser may be safely used for transoral excision of a benign parapharyngeal mass.

Phonotraumatic Injury in Fitness Instructors: Risk Factors, Diagnoses, and Treatment Methods.

Fitness instructors are at risk for phonotraumatic injury caused by a combination of occupation-driven environmental and physiologic factors. OBJECTIVES: This study analyzes phonotraumatic injury in a cohort of fitness instructors to define the spectrum of disease, inform treatment, and make educational recommendations. STUDY DESIGN: Retrospective chart review. METHODS: Fitness instructors seen over a 2-year period comprised the study population. Stroboscopic findings, recommended treatment modalities, and treatment outcomes, including postoperative recurrence (when applicable) were analyzed. Demographic information (gender, age), past medical history, VHI-10 scores, and concurrent relevant vocal demands (performer vs. non-performer) were reviewed. Descriptive statistics and bivariate analyses with Fisher's exact test and Wilcoxon rank sum test were used to determine statistical significance of various factors in relation to phonotraumatic injury and response to treatment. Cochran-Armitage trend tests were performed to analyze trends in injuries across fitness types in relation to increased vocal demand. Occupational concerns reported by subjects were analyzed descriptively. RESULTS: The subject cohort consisted of 24 fitness instructors (20F; 4M) who taught a variety of fitness methods. Thirteen subjects (54.2%) were diagnosed with pseudocysts (five unilateral, eight bilateral), five (20.8%) with bilateral midfold masses, five (20.8%) with polyps (four unilateral, one bilateral), and one (4.2%) with cyst. Fourteen subjects (58.3%) were prescribed medication (oral steroids, reflux medication, and/or allergy medication). All were referred for behavioral management. Ten (41.7%) chose surgical intervention after failure to return to satisfactory function with behavioral management; Four (40%) experienced postoperative lesion recurrence. There were no statistically significant findings in relation to demographic information, past medical history, concurrent relevant vocal demands, or occupational vocal demands with choice for surgery. Trend test analysis found that lesions that are typically more likely to require surgical intervention (eg, polyps) tended to be found more frequently as vocal demand increased. The primary occupational concerns reported by subjects were related to amplification (lack of amplification, inadequate amplification/amplification problems) and scheduling (too many consecutive classes without adequate breaks). CONCLUSION: Fitness instructors are subject to a variety of phonotraumatic vocal fold injuries, nearly half which require surgical treatment. One in four recurs after such intervention. Instructors could benefit greatly from education on vocal health, strategies to improve and/or reduce voice use while in the fitness environment, and to help aid in recognizing early "red flags" for phonotraumatic injury. Occupational factors that place fitness instructors at risk for phonotraumatic injury (scheduling, environment, amplification) may be improved with education directed to studio owners and managers.

Cardiac metastasis after squamous cell carcinoma of the base of tongue.

OBJECTIVES: Metastases to the heart are rare. We report a case of squamous cell carcinoma of the base of tongue secondarily complicated with cardiac metastasis 6 months after surgical treatment resulted in successful local control. METHODS: The lesion was found using computerized axial tomography in a patient with minimal cardiologic symptoms. RESULTS: The patient died shortly due to complications of his metastatic disease. No curative treatment was possible. CONCLUSIONS: Cardiac metastasis should be suspected when new cardiovascular symptoms are observed in patients with a history of head and neck neoplasm. The prognosis of the condition typically is inevitably fatal.

Type I Posterior Glottic Stenosis: Natural History and In-Office Management.

OBJECTIVES: To review the natural history of type I posterior glottic stenosis (PGS-I) and its treatment outcomes through a case presentation and demonstrate the feasibility of in-office management of PGS-I. METHODS: The case of a middle-aged woman who developed PGS-I after prolonged intubation is presented. A review of the literature on management and treatment outcomes of PGS-I is also performed. RESULTS: Initially presenting with a large granuloma that failed conservative management, the patient deferred surgical intervention and developed unilateral vocal fold hypomobility with posterior glottic synechia. The adhesion was successfully ablated in the office with potassium-titanyl-phosphate (KTP) laser; however, vocal fold hypomobility persisted after treatment. CONCLUSIONS: This case illustrates the natural history of the development of PGS-I, demonstrates the feasibility of office-based management of this condition, and provides further evidence that lysis of PGS-I synechia does not uniformly lead to restoration of normal laryngeal function and mobility.

Granulomas of the membranous vocal fold after intubation and other airway instrumentation.

OBJECTIVES/HYPOTHESIS: We describe the clinical features of granulomas of the membranous vocal fold secondary to endotracheal intubation, bronchoscopy or esophagogastroduodenoscopy. STUDY DESIGN: Retrospective case series. METHODS: Review of cases at a single tertiary institution with evaluation of patient demographic characteristics, time to presentation, time to treatment, and clinical outcomes. RESULTS: Thirteen adult patients were identified with postintervention granuloma of the membranous vocal fold. All patients were female, with a mean age of 60 years (range, 28-81 years). None noted hoarseness prior to the intervention, and all noted significant hoarseness postoperatively. Conservative treatment with proton pump inhibitors and vocal rest was initially implemented in all patients. Four cases resolved without further intervention. Nine underwent surgical management because of airway symptoms, failure to improve, or patient request. One patient had injury to the contralateral vocal fold upon intubation. None experienced recurrence. Five had complete recovery of voice postoperatively, four did not. CONCLUSION: Iatrogenic granulomas of the membranous vocal fold after intubation or other upper airway instrumentation are rare complications presenting in the early postprocedure period with worsening hoarseness. Initial conservative treatment may be sufficient to yield resolution, and surgical treatment is effective for those failing medical management. Permanent voice damage may result from the original injury. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:441-447, 2019.

Time Course of Recovery of Iatrogenic Vocal Fold Paralysis.

OBJECTIVE: To clarify the time course of recovery in patients with iatrogenic vocal fold paralysis. STUDY DESIGN: Retrospective chart review. METHODS: Medical records for all patients with iatrogenic vocal fold paralysis over a 10-year period were reviewed to obtain demographic and clinical information, including onset of disease and recovery of vocal function. Stroboscopic exams of patients who recovered voice were reviewed blindly to assess return of vocal fold motion. RESULTS: One hundred and two patients of 114 (89%) recovered vocal function. Time to recovery could be assessed in 39 patients who did not undergo injection augmentation. The mean time to recovery was 181.8 ± 109.3 days (left: 166.4 ± 106.7 days; right: 221.8 ± 115.6 days; P value = 0.095). Patients were analyzed according to anatomical site of surgery (skull base, carotid endarterectomy, thoracic, neck and intubation); there was no significant difference in time to recovery (P value = 0.60). Twelve of the 39 patients had recovery of vocal fold motion. The mean time to vocal recovery did not differ between patients with return of motion versus no return of motion (140.6 ± 118.0 days vs. 200.1 ± 102.2 days; P value = 0.147). CONCLUSION: Age, gender, laterality, and anatomical site of injury do not influence recovery rate in iatrogenic vocal fold paralysis. The probability of recovery decreases over time but more slowly in comparison with idiopathic vocal fold paralysis, reflecting the greater heterogeneity of injury type in the iatrogenic population. Commonly available aggregate recovery rates overstate the potential for recovery. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1159-1163, 2019.

In-office procedures for the treatment of benign vocal fold lesions in the awake patient: A contemporary review.

OBJECTIVES: To review available information regarding in-office procedures for benign vocal fold lesions (BVFL). METHODS: PubMed term search on office/awake laryngeal procedures for any of the following specific lesions: Reinke's edema (RE), polyps, nodules, varices, vocal process granuloma, and vocal fold (VF) scar. RESULTS: In-office ablative and nonablative laser procedures have been described for BVFL, including RE, polyps, varices, and granuloma. Fiber-based lasers used include potassium titanyl phosphate, pulsed dye laser, and more recently CO2 . In-office intralesional steroid injection (ISI) for BVFL targets the inflammatory process involved with the lesion and may induce regression of polyps, nodules, RE, and granuloma. Botulinum toxin-induced "voice rest" has been described as adjunctive treatment for refractory VF nodules or vocal process granuloma. Most in-office techniques for treating BVFL rely on induction of lesion regression rather than complete lesion removal, as in conventional operative microsurgery. When treating VF scarring, in-office procedures aim to alter the wound-healing process; ISI targets the inflammatory phase and angiolytic lasers target the proliferative phase. CONCLUSION: In-office procedures for BVFL apply new technology that can potentially lower risk and cost. Although numerous case series have shown the potential of these procedures, data that thoroughly compares outcomes with those of microlaryngoscopic techniques is needed. Laryngoscope, 129:2131-2138, 2019.

Endoscopic endonasal surgery simulator as a training tool for ophthalmology residents.

PURPOSE: Surgical training on the endoscopic endonasal surgery simulator had proven efficacy for otorhinolaryngology residents in preparation for endoscopic endonasal and sinus surgery. Its use for ophthalmology residents in preparation for endoscopic endonasal dacryocystorhinostomy has not been previously studied. METHODS: Eight of 15 ophthalmology residents recruited for this experimental study underwent training on the endoscopic endonasal surgery simulator, completing the novice and intermediate modules. All 15 residents then participated in cadaver surgical training, performing defined surgical tasks including endoscopic navigation, identification of nasal anatomy, endonasal injection, and middle turbinate medialization. Performance on these tasks was videotaped and graded by 2 masked observers. Total mean scores and variance by task category were compared between subjects and controls and interobserver variance was compared between observers. RESULTS: Correlation between the 2 masked observers' scores was strong (R = 0.677), with total mean scores of 2.34 and 2.38, respectively. Total mean scores were 2.79 for subjects, and 1.86 for controls (F value 0.735, p = 0.01). Residents who trained on the simulator performed significantly better during endonasal navigation (mean scores 2.58 for subjects versus 1.74 for controls, p = 0.04) and endonasal injection (mean scores 2.73 for subjects versus 1.72 for controls, p = 0.03) and minimally better at identification of nasal anatomy (mean scores 2.93 for subjects versus 1.88 for controls, p = 0.18) and middle turbinate medialization (mean scores 3.13 for subjects versus 2.78 for controls, p = 0.36). CONCLUSIONS: Ophthalmology residents who trained on the surgical simulator had significantly enhanced endoscopic endonasal surgical skills for endonasal navigation and injection.

The Voice of Autoimmunity: Antisynthetase Syndrome Manifesting as Vocal Fold Bamboo Nodes.

OBJECTIVES: To describe a case of vocal fold bamboo nodes leading to the diagnosis of antisynthetase syndrome, a rare autoimmune disorder. To highlight the link between these laryngeal lesions and autoimmunity. METHODS: A case of vocal fold bamboo nodes in a patient with long-standing interstitial lung disease is presented. The presence of these characteristic lesions prompted a rheumatologic workup that led to the diagnosis of a rare autoimmune disorder. RESULTS: The patient was ultimately diagnosed with antisynthetase syndrome, a rare condition characterized by inflammatory myositis and interstitial lung disease. She was treated with steroids and immunosuppressive agents with improvement in her symptoms and clinical findings. CONCLUSIONS: Vocal fold bamboo nodes are pathognomonic signs of autoimmunity. Management consists primarily of medical treatment of the underlying systemic disorder. Intralesional steroid injection or phonomicrosurgical excision may be considered for refractory cases.

A prospective crossover trial of botulinum toxin chemodenervation versus injection augmentation for essential voice tremor.

OBJECTIVES/HYPOTHESIS: Botulinum toxin chemodenervation (BTX) is used to treat essential voice tremor (EVT), but results are not uniformly satisfactory. This study sought to assess the comparative utility of injection augmentation (IA) for EVT. STUDY DESIGN: Prospective crossover treatment study. METHODS: Patients with EVT underwent BTX. After washout patients underwent IA. Multidimensional assessment carried out prior to and 30 days after each treatment included 1) videostroboscopy graded by the Vocal Tremor Scoring System (VTSS), 2) acoustic and aerodynamic assessment (cepstral peak prominence, cepstral spectral index of dysphonia, cepstral peak prominence fundamental frequency, airflow, peak air pressure and intensity, maximum phonation time, and amplitude/frequency of tremor), 3) audio-perceptual assessment via Consensus Audio-Perceptual Evaluation of Voice (CAPE-V), and 4) patient self-assessment via Voice Handicap Index-10 (VHI-10) and Percent of Normal Function (PNF) scale. Findings were analyzed via paired t tests and Wilcoxon rank sum tests. RESULTS: Seven patients (five female and two male; mean age 67 years old; range, 46-82 years old) participated. VTSS grading showed divergent outcomes for certain individual sites of tremor, but without significant differences. Airflow increased following BTX and decreased following IA, and VHI-10 scores indicated slight improvement post-BTX (26.29-23.57), and decline post-IA (25.86-29.86), although differences were not significant. Only changes in audio-perceptual ratings of loudness achieved significance, which decreased with BTX and increased with IA. Five patients chose to resume BTX; two elected long-term IA. No findings supported patient preferences. CONCLUSIONS: IA demonstrated no advantage over BTX in the treatment of EVT. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:437-446, 2018.

Time course of recovery of idiopathic vocal fold paralysis.

OBJECTIVES/HYPOTHESIS: To clarify the time course of recovery in patients with idiopathic vocal fold paralysis. STUDY DESIGN: Retrospective chart review. METHODS: Medical records for all patients with idiopathic vocal fold paralysis over a 10-year period were reviewed to obtain demographic and clinical information, including onset of disease and recovery of vocal function. Stroboscopic exams of patients who recovered voice were reviewed blindly to assess return of vocal fold motion. RESULTS: Thirty-eight of 55 patients (69%) recovered vocal function. Time course of recovery could be assessed in 34 patients who did not undergo injection augmentation. The mean time to recovery was 152.8 ± 109.3 days (left, 179.8 ± 111.3 days; right, 105.3 ± 93.7 days; P = .088). Two-thirds of patients recovered within 6 months. Probability of recovery declined over time. Five of 22 patients who recovered voice had return of vocal fold motion; 17 did not. The mean time to recovery did not differ between these groups (return of motion, 127.4 ± 132.3 days; no return of motion, 160.1 ± 105.1 days; P = .290). CONCLUSIONS: Sixty-nine percent of patients with idiopathic vocal fold paralysis recovered vocal function, two-thirds doing so within 6 months of onset. Age, gender, laterality, use of injection augmentation did not influence recovery rate. Declining probability of recovery over time leads us to consider framework surgery after 6 months in patients with idiopathic paralysis. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:148-152, 2018.

Construct validity of the endoscopic sinus surgery simulator: II. Assessment of discriminant validity and expert benchmarking.

OBJECTIVES: To establish discriminant validity of the endoscopic sinus surgery simulator (ES3) (Lockheed Martin, Akron, Ohio) between various health care provider experience levels and to define benchmarking criteria for skills assessment. DESIGN: Prospective multi-institutional comparison study. SETTING: University-based tertiary care institution. PARTICIPANTS: Ten expert otolaryngologists, 14 otolaryngology residents, and 10 medical students. INTERVENTIONS: Subjects completed the ES3's virtual reality curriculum (10 novice mode, 10 intermediate mode, and 3 advanced mode trials). Performance scores were recorded on each trial. Performance differences were analyzed using analysis of variance for repeated measures (experience level as between-subjects factor). MAIN OUTCOME MEASURES: Simulator performance scores, accuracy, time to completion, and hazard disruption. RESULTS: The novice mode accurately distinguished the 3 groups, particularly at the onset of training (mean scores: senior otolaryngologists, 66.0; residents, 42.7; students, 18.3; for the paired comparisons between groups 1 and 2 and groups 1 and 3, P = .04 and .03, respectively). Subjects were not distinguished beyond trial 5. The intermediate mode only discriminated students from other subjects (P = .008). The advanced mode did not show performance differences between groups. Scores on the novice mode predicted those on the intermediate mode, which predicted advanced mode scores (r = 0.687), but no relationship was found between novice and advanced scores. All groups performed equally well and with comparable consistency at the outset of training. Expert scores were used to define benchmark criteria of optimal performance. CONCLUSIONS: This study completes the construct validity assessment of the ES3 by demonstrating its discriminant capabilities. It establishes expert surgeon benchmark performance criteria and shows that the ES3 can train novice subjects to attain those. The refined analysis of trial performance scores could serve educational and skills assessment purposes. Current studies are evaluating the transfer of surgical skills acquired on the ES3 to the operating room (predictive validity).

The role of virtual reality in surgical training in otorhinolaryngology.

PURPOSE OF REVIEW: This article reviews the rationale, current status and future directions for the development and implementation of virtual reality surgical simulators as training tools. RECENT FINDINGS: The complexity of modern surgical techniques, which utilize advanced technology, presents a dilemma for surgical training. Hands-on patient experience - the traditional apprenticeship method for teaching operations - may not apply because of the learning curve for skill acquisition and patient safety expectation. The paranasal sinuses and temporal bone have intricate anatomy with a significant amount of vital structures either within the surgical field or in close proximity. The current standard of surgical care in these areas involves the use of endoscopes, cameras and microscopes, requiring additional hand-eye coordination, an accurate command of fine motor skills, and a thorough knowledge of the anatomy under magnified vision. A surgeon's disorientation or loss of perspective can lead to complications, often catastrophic and occasionally lethal. These considerations define the ideal environment for surgical simulation; not surprisingly, significant research and validation of simulators in these areas have occurred. SUMMARY: Virtual reality simulators are demonstrating validity as training and skills assessment tools. Future prototypes will find application for routine use in teaching, surgical planning and the development of new instruments and computer-assisted devices.