Dysphagia as a predictor of voice handicap and voice restoration in unilateral vocal fold immobility.

OBJECTIVE: Dysphagia is multifactorial in unilateral vocal fold immobility (UVFI). Severe dysphagia could indicate greater functional deficits in UVFI. The purpose of this study is to evaluate the association of dysphagia with the need for surgical voice restoration in patients with UVFI. STUDY DESIGN: Retrospective chart review. SETTING: Single-institution, tertiary referral center. METHODS: Records of UVFI patients from 2008 to 2018 were examined. Dysphagia severity was extracted from patient history. Etiology of UVFI and other relevant variables were analyzed to determine their association with dysphagia. Dysphagia severity and other clinical variables were then analyzed for their association with surgical voice restoration. RESULTS: Eighty patients met selection criteria out of 478 patients with UVFI. There was significant concordance between dysphagia severity extracted from patient history and patient-reported EAT-10 scores (R = 0.59, p = 0.000035). Patients' EAT-10 scores were correlated with VHI-10 scores (R = 0.45, p = 0.011). Severe dysphagia (p = 0.037), high VHI-10 score on presentation (p = 0.0009), and longer duration of hoarseness before presentation (p = 0.008) were associated with surgical voice restoration in UVFI patients. CONCLUSION: In this pilot study, severe dysphagia and increased voice handicap on presentation were associated with the need for surgical voice restoration in UVFI patients. Presenting dysphagia may be an additional variable for clinicians to consider for management of UVFI.

Cost-Effectiveness of Steroids for Prolonging the Surgery-Free Interval in Subglottic Stenosis.

OBJECTIVES: Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied. METHODS: Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI. RESULTS: Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%. CONCLUSIONS: SILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED. LEVEL OF EVIDENCE: NA Laryngoscope, 133:3436-3442, 2023.

Vocal Fold Pathologies Among Undergraduate Singing Students In Three Different Genres.

OBJECTIVE: This study aimed to compare the prevalence and incidence of vocal fold pathologies among undergraduate classical, musical theatre, and contemporary commercial music (CCM) students over two-time points. METHODS: This study is part of a longitudinal investigation. Videostroboscopic examinations were rated, with consensus among three of four expert blinded raters confirming the presence of pathology. Association between genre of singer and the presence of pathology, interrater reliability, and intra-rater reliability were calculated. Prevalence and incidence of pathologies were compared across genres. RESULTS: During first-year evaluations, 32% of musical theatre, 18% of CCM, and 0% of classical students had vocal pathologies. The prevalence at third-year evaluations showed 22% of classical, 39% of musical theatre, and 27% of CCM participants having vocal fold pathologies. The incidence of pathologies was 67% of musical theatre students compared to 22% of classical students and 27% of CCM students. The four raters demonstrated fair to moderate interrater agreement. Singing Voice Handicap Index-10 scores were normal for CCM singers at both time points but elevated for musical theatre and classical singers. CONCLUSION: No classical singers were found to have pathology during first-year evaluations, although CCM and musical theatre singers showed evidence of vocal fold pathologies. At third-year evaluations, all three genres had an apparent increase in prevalence of pathologies. Implications of this study suggest that more time in the field and intense voice usage may lead to a greater risk of pathology for all singers, regardless of genre. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:2317-2324, 2023.

Independence of Vocal Load From Vocal Pathology Across Singing Genres.

OBJECTIVE: To investigate the extent to which vocal load is associated with previous diagnosis of a vocal pathology among four major genres of singers (primarily classical, primarily musical theatre (MT), classical and MT combined, and contemporary commercial music only). STUDY DESIGN: Cross sectional survey. METHODS/DESIGN: An anonymous online survey was sent out to about 1000 professional singers through convenience sampling to touring companies, opera companies, MT companies, agents, directors and musical directors. Social media and email were used to solicit participation in the study. We utilized means and standard deviations for continuous characteristics and frequencies and percentages for categorical characteristics and calculated P values to assess whether differences were statistically significant. RESULTS: A total of 396 professional singers completed the survey, yielding a 40% response rate. Nonprofessional singers, incomplete surveys, and respondents <18 years old were excluded, resulting in a total of 238 responses. Among the 238 participants, 32% were performing in the classical style primarily, 33% in the MTstyle primarily, 15% in both classical and MT, and 20% in other contemporary styles only. Mean age was highest among CV + MT and lowest among primarily MT. Combined classical/MT singers were most likely to have a career outside of vocal performance and continue to work in that career followed by other contemporary styles, classical and MT (P = 0.02). Participants in the combined classical/MT group were most likely to have a reported history of vocal pathology followed by classical, other contemporary styles and MT (not statistically significant). However, participants in the contemporary styles were most likely to have a history of more than one type of vocal pathology. Mean vocal load was highest for the MT group. Other nonsinging factors proved significant such as allergy, hydration and acid reflux. Symptoms of allergies were found to be significant across singing genres. A possible reverse causality association was identified in regards to water intake. Participants with acid reflux were three times more likely to have ever reported vocal pathology. CONCLUSION: Vocal load was not significantly associated with vocal pathology across singing genres; however other nonsinging factors such as allergy, reflux and water intake were significantly associated with vocal pathology.

An Updated Review of Subglottic Stenosis: Etiology, Evaluation, and Management.

Purpose of Review: To assimilate the newly published literature regarding subglottic stenosis (SGS), including basic science and translational research on mechanisms of etiology, clinical diagnostics, and therapeutic treatments. Recent Findings: The role of inflammation in development of iatrogenic and idiopathic SGS (iSGS) is continuing to be studied. The IL-23/IL-17A inflammatory axis appears to be a potential mechanism for development of iSGS. Additionally, as anticipated in an inflammatory milieu, PD-1/PD-L1 expression is upregulated. If the PD-1/PD-L1 axis is important in SGS pathogenesis, then it may represent a potential target for immunotherapeutic inhibition, given its success in cancer treatment. In terms of surgical management, prospective studies show that endoscopic approaches have more frequent recurrence compared to open techniques. Summary: SGS arises from various etiologies, and further understanding of its pathogenesis can aid in the development of novel therapies. It is imperative to obtain a thorough history for each patient presenting with respiratory complaints, as misdiagnosis can delay proper treatment. Endoscopic and open surgical techniques continue to be investigated in a growing number of prospective clinical trials to determine optimal treatment protocols. In-office injections are gaining popularity and show promise in the treatment of SGS.

Quantifying Subjective and Objective Measures of Singing After Different Warm-Up Durations.

BACKGROUND: Performing vocal warm-ups prior to singing repertoire has been shown to change the perceived quality and acoustic parameters of the voice. To date, there are no studies that specifically compare singers' and listeners' perceptions of vocal quality after various warm-up durations. OBJECTIVE: To determine if specific warm-up durations (0, 5, 10, or 15 minutes) change subjective and objective measures of voice. STUDY DESIGN: Prospective cohort study. METHODS: Information related to demographics, singing practice, medical history, and vocal hygiene were collected. First- and second-year collegiate classical voice majors completed a series of four warm-up times, 1 week apart, prior to singing Caro mio ben in a standard key for their voice type. A modified Voice Range Profile (mVRP), and the Evaluation of the Ability to Sing Easily (EASE) scale were completed. Participants blindly rated 30-second recorded audio clips using the Auditory-Perceptual Rating Instrument for Operatic Singing. Four independent expert blinded listeners rated all audio clips for each participant in random order. RESULTS: Six first-year and three second-year classical vocal performance majors completed all measures. Results of the EASE scale showed decreased scores with 5- and 10-minute warm-up duration, compared to 0 and 15 minutes of warm-up (P = 0.029 for the total EASE score and P = 0.044 for Rasch score). Delayed perceptual analysis of voice yielded nearly equal medians between warm-up durations for both self and expert-listener ratings. The mVRP showed that both 5 and 10 minutes of warm-up duration led to increased highest fundamental frequency for females (P = 0.017). CONCLUSION: This pilot study demonstrates the immediate self-perceived benefit for all participants and increased frequency range for females after performing 5 and 10 minutes of vocal warm-up. No significant differences were found in delayed perceptual analyses completed by the participants or the expert raters after the different warm-up durations. Future investigations should include a larger population and different levels of education and genres of singing.

Identification of abstract features presented at the combined otolaryngology spring meeting predicting publication in impactful peer-reviewed journals.

OBJECTIVES: Review abstracts presented at the Combined Otolaryngology Society Meeting (COSM) to determine subsequent publication and identify abstract features predictive of publication in high impact journals. METHODS: A selection of abstracts accepted in the 2015 COSM scientific programs were retrospectively reviewed. MEDLINE searches via PubMed and Google Scholar were performed to determine publication rates. The Journal of Citation Reports was used to determine impact factors for published abstracts. Binomial regression analyses were used to identify factors related to publication in high impact journals. RESULTS: 62.4% of reviewed abstracts (n = 623) were subsequently published, with a mean publication time of 14 ± 12 months. Abstract features predictive of publication were basic science type, other science type, prospective studies, multi-institutional involvement, and presentation at the American Laryngologic Association and American Otologic Society meetings. Based on Wald score, podium presentation was found to have the biggest effect on publication. Factors positively associated with publication in high impact (impact factor > 2.272) journals were increased author number and sample size. CONCLUSIONS: Overall publication rate of abstracts selected for presentation at COSM in 2015 was on the higher end of previously reported otolaryngology meetings. Abstracts detailing basic science, other science, prospective and multi-institutional studies were more likely to lead to future publication. Additionally, increased number of authors and sample size lead to publication in higher impact journals. LEVEL OF EVIDENCE: N/A.

Glottic Keratosis: Significance and Identification of Laryngoscopic Findings.

OBJECTIVE: Glottic keratosis poses a challenge because a decision to biopsy must weigh the likelihood of dysplasia and cancer against the voice outcome after biopsy. We determined the significance of laryngoscopic findings and agreement among clinicians to identify those specific findings. STUDY DESIGN: Retrospective case-control study. SETTING: Tertiary care university hospital. METHODS: Adults with glottic keratosis with preoperative office laryngoscopies were included. Preoperative videostroboscopies were reviewed by a blinded reviewer. Multivariable logistic regression was used to examine the correlation between laryngoscopic appearance of glottic keratosis and presence or absence of high-grade dysplasia or carcinoma on biopsies. Consensus among head and neck cancer surgeons to detect specific laryngoscopic findings was evaluated by presenting representative laryngoscopies to a blinded cohort. Interrater reliability was calculated using Fleiss's κ. RESULTS: Sixty glottic keratotic lesions met inclusion criteria. On logistic regression, both erythroplakia and aberrant microvasculature like vascular speckling were significantly associated with high-grade dysplasia and carcinoma, P = .002 and P = .03, respectively. Interrater reliability among clinicians to identify erythroplakia and aberrant microvasculature was minimal, κ = 0.35 and κ = 0.29, respectively. Interrater reliability was improved with the use of virtual chromoendoscopy. CONCLUSION: The presence of erythroplakia and aberrant microvasculature in glottic keratosis is associated with the presence of high-grade dysplasia or carcinoma. Virtual chromoendoscopy can be used to improve reliability for detecting erythroplakia and vascular speckling, and this is a potential area for practice-based learning. Clinicians should identify and consider immediate diagnostic biopsy of suspicious glottic keratosis.

Hispanic Ethnicity as a Predictor of Voice Therapy Adherence.

BACKGROUND: Voice therapy is a well-studied, evidence-based treatment in the management of voice disorders, yet it is known that adherence rates are generally decreased due to a variety of identified factors. In light of this fact, a high rate of nonadherence to voice therapy has been anecdotally observed in the Hispanic community comprising a sizable portion of the patient population in South Florida. OBJECTIVE: We sought to analyze the rates of voice therapy attendance for patients who underwent treatment for benign vocal fold nodules at a single tertiary-care academic medical center. Based on our anecdotal observations, we hypothesized that Hispanic patients would have a significantly lower rate of voice therapy attendance compared to non-Hispanic patients. STUDY DESIGN: Retrospective cohort study. METHODS: A retrospective chart review was performed for Hispanic and non-Hispanic patients aged 18 years and older who were diagnosed in a single hospital-based otolaryngology department with benign vocal fold nodules between 2013 and 2018. Patients with other glottic pathology or those who were not recommended voice therapy as initial treatment were excluded. Demographic data, including ethnicity, home address, and preferred language by self-report (English vs. Spanish), were obtained and analyzed. Median income levels for patients were determined by postal codes. "Adherent" status was given to patients who attended at least one voice therapy session. Statistical comparisons of continuous quantitative variables were made using Student's t test, ordinal quantitative variables using Mann-Whitney U test, and categorical variables using Fischer's exact test. Statistical significance was determined as P < 0.05. RESULTS: One hundred eleven patients met inclusion criteria. The population was 85% female, with an average age of 41 years. Overall voice therapy adherence rate was 68%. Forty-eight percent of patients self-identified as Hispanic, and of this cohort, 42% spoke Spanish as a preferred language. Differences in annual income levels were noted between non-Hispanic and Hispanic patients ($61,799 vs. $51,697, P = 0.017), as well between English-preferring and Spanish-preferring patients ($60,276 vs. $43,504, P = 0.0014). Thirty of 53 (57%) of Hispanic patients were adherent to voice therapy, compared to 45 of 58 (78%) non-Hispanic patients (P = 0.025). No significant differences were found in age, Voice Handicap Index-10 score, or number of sessions attended between the therapy-adherent patients in the Hispanic and non-Hispanic groups. Further differences in adherence rates were noted when the Hispanic group was subclassified into English and Spanish language preferences. Fifteen of 31 (48%) English-preferring Hispanic patients attended voice therapy compared to 45 of 58 (78%) non-Hispanic patients (P = 0.0085), while Spanish-preferring Hispanic patients had a 68% therapy adherence rate (15 of 22, P = 0.4). English-preferring Hispanic patients had higher average Voice Handicap Index-10 (22.0 vs. 14.9, P = 0.018) and lower total attended sessions (2 vs. 3.6, P = 0.024) than their non-Hispanic counterparts. CONCLUSION: We believe this is the first study demonstrating a significantly lower rate of voice therapy adherence in Hispanic versus non-Hispanic patients. Decreased utilization of a proven treatment strategy for vocal fold nodules puts these patients at increased risk of treatment failure and decreased voice-related quality of life. Clinicians must be aware of ethnicity-based healthcare disparities and encourage proven treatment adherence to ensure highest quality of life.

The Role of Observation and Mentorship in Voice Pedagogy Training.

BACKGROUND: Voice teachers are seeking increasing amounts of pedagogical instructions in the form of observerships, coursework, and clinical experiences. Yet to date there has been no formalized attempt to categorize or set guidelines for these educational experiences. OBJECTIVES: The aim of this study was to investigate (a) the number of hours of observations required or electively completed during pedagogical training (voice lessons, masterclasses) and clinical observations; (b) the number of hours of mentorship (critical observation of a student by a mentor) during pedagogical training; and (c) differences in the training backgrounds of voice teachers based on the level of training, position, and genre. METHODS: We distributed a survey to 700 voice teachers (102 respondents) of various levels from private to university and across age range of students. The surveys contained questions about the role of observation in the teacher's training. We ran descriptive analysis and examined whether the proportion of participants with ≥10 observation and mentorship hours was different for classical versus the other musical genres. RESULTS: The number of respondents actively observing and being observed during their training was low. Most observations occurred within the classical and musical theater singing styles. Mentored critical observations of students were lower across genres than student observations, with the majority of respondents (67-92%) reporting no hours in genres other than classical. For all genres except classical, there was a larger percentage of respondents who reported teaching the genre than who reported receiving pedagogical training in the genre. Reported clinical voice observation hours were low (28.4% with ≥10 hours), and few respondents had >0 hours of operating room observation experience (11.8%). CONCLUSIONS: There is wide disparity across genres in the number of hours of observation and critical mentoring, and voice teachers' genre of instruction does not frequently match with the genre of pedagogical instruction they have received. More research is needed to determine the significance of this mismatch and whether increased hours of observation and mentoring would benefit voice instruction.

Prevalence of Vocal Fold Pathologies Among First-Year Singing Students Across Genres.

OBJECTIVES/HYPOTHESIS: The purpose of the study was to compare the prevalence of vocal fold pathologies among first-year singing students from the classical, musical theatre, and contemporary commercial music (CCM) genres. STUDY DESIGN: Prospective cohort study. METHODS: Videostroboscopic examinations were rated by blinded expert raters. Vocal pathology was defined as a vocal fold abnormality on the membranous or cartilaginous portions of the vocal folds or hypomobility. Consensus among three of four raters confirmed presence of pathology. Association between genre of singer and presence of pathology, interrater reliability, and intrarater reliability were calculated. Differences in singing voice handicap, and voice use and vocal hygiene were compared. RESULTS: Fifty-seven participants were included. Seventeen percent of CCM, 40% of musical theatre, and 0% of classical singers were found to have vocal fold pathology. Interrater reliability was 0.522 between all four raters, 0.591 between the two laryngologists, and 0.581 between the two speech-language pathologists, showing a moderate agreement (P < .0001). Intrarater reliability was 1.000 (P < .0001) for the two laryngologists and 0.452 (P = .949) and 0.622 (P = .828) for the two speech-language pathologists. Singing Voice Handicap Index-10 data across genre showed differences between CCM and classical singers. No significant differences were found in voice usage or vocal hygiene. CONCLUSIONS: No classical students were found to have vocal fold pathology, whereas CCM and musical theatre students had significantly higher prevalence of pathologies. Voice use, vocal hygiene, and physiologic phonatory differences among classical, musical theatre, and CCM genres may be risk factors for development of vocal pathology. LEVEL OF EVIDENCE: 2b Laryngoscope, 130: 1996-2002, 2020.

Office-based corticosteroid injections as adjuvant therapy for subglottic stenosis.

OBJECTIVE: Subglottic stenosis (SGS) is a serious, potentially life-threatening disorder that is difficult to treat due to significant recurrence rates. While conventional treatment of SGS relies heavily on serial endoscopic dilation procedures, this study aims to characterize the efficacy of incorporating subglottic corticosteroid injections in increasing surgery-free intervals (SFIs) for a cohort of patients at a university-based medical system. STUDY DESIGN: Retrospective chart review. METHODS: All SGS patients who underwent endoscopic dilation and at least one adjuvant office-based serial intralesional steroid injection (SILSI) were reviewed. Patients were excluded if they had synchronous airway lesions or stenosis outside of the subglottis. Charts were reviewed for demographic and treatment-specific data. The SFI was calculated for patients both prior to the initiation of SILSI and after. Groups were compared via Mann-Whitney U test, with P < .05 as the threshold for significance. RESULTS: Thirteen patients met criteria, with mean age 50.1 ± 14.1 years and 7:6 female to male ratio. Eight of the thirteen (61.5%) had intubation-related stenosis, while 4/13 were idiopathic and 1/13 was due to Wegener's granulomatosis. Mean follow-up was 20.4 months. Patients underwent an average of 4.2 ± 2.2 postoperative injections, beginning 45.9 ± 19.0 days after surgery. The mean SFI prior to initiating SILSI was 288.6 ± 362.0 days; while after receiving SILSI, the mean interval was significantly longer (545.5 ± 152.7 days, P = .0041). CONCLUSIONS: We demonstrate that office-based corticosteroid injection for SGS was associated with a statistically significant improvement in the SFI and is a promising adjuvant approach. Future prospective studies should evaluate if the efficacy is reproducible on a large scale and if SILSI can and/or should be incorporated into the standard management paradigm for SGS treatment. LEVEL OF EVIDENCE: 4.

Presbyphonia and Minimal Glottic Insufficiency.

Presbyphonia is defined as aging of the voice, and its growing attention as a medical concern parallels the continuing increase of the geriatric population worldwide. It results from physiologic changes to several laryngeal structures, including the musculature, surrounding cartilage, and lamina propria of the vocal folds. Characterized by glottic insufficiency, dysphonia in the elderly typically presents as a deterioration of voice quality, altered pitch and fundamental frequency, vocal fatigue, and strain. Fortunately, there are multiple treatment options that have proven successful in improving quality of life and restoring vocal stability for these patients.

Common practices in botulinum toxin injection for spasmodic dysphonia treatment: A national survey.

OBJECTIVES/HYPOTHESIS: Although no clear guidelines exist, protocols in the treatment of spasmodic dysphonia (SD) vary among physicians. Previously published work comes from relatively few centers. STUDY DESIGN: A descriptive survey among experts (laryngologists who practice Botulinum toxin injections for SD). METHODS: An online 58-item survey was sent to all otolaryngologists who self-identify as laryngologists on the American Academy of Otolaryngology-Head and Neck Surgery website. Items surveyed included botulinum toxin injection technique, laterality, and dosage. RESULTS: An 80% response rate was achieved (70 completed the survey). Participants collectively reported treating >4,000 SD patients in the past year (mean, 71 ± 68 patients/laryngologist). Eighty-seven percent perform injections exclusively in the office; the remainder both in the office and operating room. For adductor SD injections, 88% use electromyographic (EMG) guidance alone via cricothyroid approach. The remainder use anatomical landmarks alone (9%) or EMG with endoscopic guidance (3%). Sitting is the preferred patient position (70%; supine, 30%). A substantial majority (87%) begin with bilateral injections (starting dosage mode, 1.25 units/side). For abductor SD injections, 67% use EMG guidance alone and 31% use endoscopic guidance with or without EMG. Sitting is the preferred patient position (84%; supine, 16%). The preferred approach is anterior-translaryngeal (51%), followed by lateral-retrolaryngeal with rotation (34%). A considerable majority (79%) begin with unilateral injections (starting dosage mode, 5 units). When deciding on initial dosage, the most influential factor was balancing patients' desire/needs, followed by patients' frailty and risk of aspiration. The typical planned interval between injections is 3 to 4 months. CONCLUSIONS: Laryngologists follow fairly uniform protocols in the treatment of SD with some important and previously unpublished differences. This study documents areas of agreement and discordance among laryngologists in the United States for the treatment of SD. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1650-1656, 2019.

Oncologic outcomes of KTP laser surgery versus radiation for T1 glottic carcinoma.

OBJECTIVES/HYPOTHESIS: To characterize outcomes for patients who underwent transoral microsurgery with potassium titanyl phosphate (KTP) laser resection of early glottic cancers and to compare outcomes with patients who received external beam radiation therapy. STUDY DESIGN: Retrospective cohort study. METHODS: The history of patients with T1 glottic carcinoma treated with curative primary radiation or transoral KTP laser resection was reviewed. Oncologic outcomes for both radiation and surgery cohorts including disease-free and overall survival were calculated. RESULTS: Eighty-seven patients met inclusion criteria from 2011 to 2016; 47 patients (54%) received primary KTP laser ablation, and 40 patients (46%) received primary external beam radiotherapy. The average length of follow-up was 924 ± 529 days in the KTP laser group and 994 ± 603 days in the radiation group (P = .26). There were no significant differences between the two treatment groups in terms of medical or demographic variables. There were six recurrences in the KTP laser group (13%), versus six in the radiotherapy group (15%) (P = .77). The laryngeal preservation rate for the cohort of patients who initially received KTP laser treatment was 46 out of 47 patients (98%). Of the cohort that received primary radiation therapy, the laryngeal preservation rate was 36 out of 40 patients (90%, P = .18). Disease-free and overall survival were 88% and 98% in the KTP laser cohort and 85% and 95% in the radiation cohort (P = .78, P = .56), respectively. CONCLUSIONS: KTP laser ablation is a modality equivalent to primary radiation therapy in oncologic outcomes for T1 glottic squamous cell carcinoma. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1052-1056, 2018.

Open airway reconstruction in adults: Outcomes and prognostic factors.

PURPOSE: The purpose was to assess the success of open tracheal resection and re-anastomosis for non-malignant tracheal stenosis in adults. Successful operations were defined as T-tube or tracheostomy-free status by 6months post-operatively. MATERIALS AND METHODS: Retrospective chart review was performed and data were recorded in a de-identified manner. The primary outcome was T-tube or tracheostomy-free status by 6months following tracheal resection. Clinical and demographic characteristics were evaluated as potential prognostic variables. RESULTS: Thirty-two patients met inclusion criteria, with a median age of 46. Seven patients underwent tracheal resection with primary closure, without stenting. Successful tracheal resection was defined as tracheostomy or T-tube free by 6months post-operation, and this was possible in 21 patients (66%). Eighty-two percent of patients with cricoid cartilage-sparing tracheal resection had a successful outcome, versus 30% of patients who underwent cricoid cartilage resection (HR 5.02, 95% CI 1.46-17.3; p=0.011). Patients with a history of tracheostomy-dependence were four times more likely to remain tube-dependent at 6months (HR 4.15, 95% CI 1.56-10.86; p=0.004). CONCLUSIONS: Tracheal stenosis remains a very difficult problem to treat. In our series, we confirm that patients with cricoid involvement or with a history of tracheostomy were more likely to be tube dependent at 6-months post-operation.

Initial Experience With Low-Dose Methotrexate as an Adjuvant Treatment for Rapidly Recurrent Nonvasculitic Laryngotracheal Stenosis.

Importance: Adult laryngotracheal stenosis (LTS) is typically managed surgically, but some patients fail treatment because of rapid restenosis or granulation tissue formation. The need for frequent surgery or tracheostomy reduces the quality of life in these patients and poses a significant challenge for the treating physician. New adjuvant treatments are required to reduce the surgical burden of this condition. Objective: To examine whether patients with rapidly recurrent nonvasculitic LTS who fail surgical management of their stenosis (ie, requiring dilation more frequently than every 6 months) experience longer intervals between surgical procedures when receiving adjuvant treatment with low-dose methotrexate. Design, Setting, and Participants: This study was a retrospective case series study of patients treated with methotrexate from January 2014 to January 2016 at a tertiary academic medical center. Participants were 10 patients with LTS without any diagnosis of vasculitis or granulomatous disease who underwent low-dose methotrexate therapy. Interventions: Once-weekly treatment with oral methotrexate, 15 or 20 mg. Main Outcomes and Measures: The mean number of days between operations before and after starting methotrexate therapy was compared. Clinical courses and adverse effects of each patient were also reviewed. Results: Among 10 patients, the mean (SD) age at the outset of study inclusion was 52 (19) years; 8 were female and 2 were male. All 10 patients experienced some clinical improvement. Three patients who were previously tracheostomy dependent were able to be decannulated. Two other patients who were tracheostomy dependent and had failed endoscopic management of their granulation tissue had complete resolution. In 6 patients who underwent at least 1 surgical procedure before and after the initiation of methotrexate treatment, the mean (SD) interval between operations increased from 61 (35) days (95% CI, 26-96 days) before starting methotrexate therapy to 312 (137) days (95% CI, 175-449 days) after starting methotrexate therapy, for an absolute difference of 251 (58) days (95% CI, 193-309 days). The median number of days between surgical procedures was 44 days before starting methotrexate therapy and 289 days after starting methotrexate therapy. Adverse effects observed included mild hair thinning and onychomycosis in 2 patients and herpes zoster infection in 1 patient. Conclusions and Relevance: Low-dose methotrexate appears to be an effective adjunct to surgery in select patients with LTS that is resistant to surgical management and leads to a substantial increase in the number of days between surgical procedures. The patient and clinician must be aware of the adverse effects of methotrexate therapy and balance these factors against the risk of poorly controlled airway stenosis. Randomized, placebo-controlled, double-blind trials are needed to examine whether the clinical efficacy in this series of patients translates to a larger population.

Review of adult laryngotracheal stenosis: pathogenesis, management, and outcomes.

PURPOSE OF REVIEW: Adult laryngotracheal stenosis (LTS) is a potentially life-threatening disorder that can be difficult to diagnose and treat. Much is unknown regarding the etiology of airway stenosis, and while many patients do well with standard surgical management, the recurrence rate is significant. Few medical therapies exist, but there is a growing need. RECENT FINDINGS: Several basic science studies have shown a role of inflammatory signaling pathways in the development of LTS. Infectious processes may also play a role in development of stenosis, while treatment with anti-inflammatory and immunosuppressive medications has shown some promise in preventing disease. Several risk factors, such as diabetes, BMI, length of stenosis, and need for T-tube, have been identified that portend worse surgical outcomes and may assist physicians in choosing appropriate treatment. SUMMARY: While adult LTS is a complex, challenging clinical entity, there is promising research into the inflammatory origins of the disorder, which may open up groundbreaking new avenues of medical treatment.

A Survey of Equipment in the Singing Voice Studio and Its Perceived Effectiveness by Vocologists and Student Singers.

OBJECTIVES: Speech-language pathologists have long used technology for the clinical measurement of the speaking voice, but present research shows that vocal pedagogues and voice students are becoming more accepting of technology in the studio. As a result, the equipment and technology used in singing voice studios by speech-language pathologists and vocal pedagogues are changing. Although guides exist regarding equipment and technology necessary for developing a voice laboratory and private voice studio, there are no data documenting the current implementation of these items and their perceived effectiveness. This study seeks to document current trends in equipment used in voice laboratories and studios. METHODS: Two separate surveys were distributed to 60 vocologists and approximately 300 student singers representative of the general singing student population. The surveys contained questions about the inventory of items found in voice studios and perceived effectiveness of these items. Data were analyzed using descriptive analyses and statistical analyses when applicable. RESULTS/CONCLUSIONS: Twenty-six of 60 potential vocologists responded, and 66 student singers responded. The vocologists reported highly uniform inventories and ratings of studio items. There were wide-ranging differences between the inventories reported by the vocologist and student singer groups. Statistically significant differences between ratings of effectiveness of studio items were found for 11 of the 17 items. In all significant cases, vocologists rated usefulness to be higher than student singers. Although the order of rankings of vocologists and student singers was similar, a much higher percentage of vocologists report the items as being efficient and effective than students. The historically typical studio items, including the keyboard and mirror, were ranked as most effective by both vocologists and student singers.

The economic impact of vocal attrition in public school teachers in Miami-Dade County.

OBJECTIVES/HYPOTHESIS: Teachers are a known at-risk population for voice disorders. The prevalence and risk factors for voice disorders have been well studied in this population, but little is known about the associated economic cost. The purpose of this study is to assess the economic impact of voice dysfunction in teachers and understand the difference between the cost of absenteeism and presenteeism as a direct result of voice dysfunction. STUDY DESIGN: Cross-sectional analysis via self-administered online questionnaire. METHODS: A total of 14,256 public school teachers from Miami-Dade County, Florida, were asked to participate. Questions were formatted based on the previously validated Work Productivity and Activity Impairment: Specific Health Problem questionnaire adapted for hoarseness and voice disorders. Additional demographic questions were included in the questionnaire. RESULTS: A total of 961 questionnaire responses were received. The demographic characteristics of respondents closely matched known statistics for public school teachers in Miami-Dade County. Economic calculations were performed for each questionnaire respondent and summed for all respondents to avoid bias. Per week, absenteeism-related costs were $25,000, whereas presenteeism-related costs were approximately $300,000. These figures were used to extrapolate annual cost. Per year, absenteeism-related costs were $1 million, whereas presenteeism-related costs were approximately $12 million. CONCLUSION: The economic impact of voice dysfunction on the teaching profession is enormous. With the above calculations only including lost wages and decreased productivity, the actual figures may in fact be larger (cost of substitute teachers, impact on nonwork activities, etc.). Research investigating preventative measures for voice dysfunction in teachers is necessary to reduce this costly issue. LEVEL OF EVIDENCE: 2C. Laryngoscope, 126:665-671, 2016.