Indications and Short-Term Outcomes for In-Office Therapeutic Superior Laryngeal Nerve Block.

OBJECTIVE: Superior laryngeal nerve (SLN) block consists of injection of steroid and anesthetic at the internal branch of the SLN entry site. Prior case series have demonstrated beneficial effects on neurogenic cough. SLN blocks have also recently shown benefit for paralaryngeal pain. We describe short-term outcomes for multiple symptoms of irritable larynx syndrome (ILS) including neurogenic cough, dysphonia related to laryngeal hypersensitivity, inducible laryngeal obstruction (ILO), paralaryngeal pain, and isolated globus. METHODS: Retrospective review from 2 institutions of patients undergoing a single SLN block for the indications listed. Variables include age, sex, indication(s), known vagus neuropathy, and patient-reported outcomes at short-term follow-up. RESULTS: A total of 209 patients were included (59 males, 150 females; age: 58 ± 13 years). Twenty-six patients (12%) had a history of a vagus nerve injury. Indications included neurogenic cough (n = 149), dysphonia related to laryngeal hypersensitivity (n = 66), paralaryngeal pain (n = 50), ILO (n = 23), and isolated globus (n = 3). Some patients had multiple indications. Significant improvements in patient-reported measures occurred after a single SLN block within 2 to 4 weeks for neurogenic cough (cough severity index; 25.2 ± 11.2 to 19.0 ± 12.8; P < .001), dysphonia (voice handicap index-10; 22.1 ± 12.2-18.0 ± 13.3; P = .005), and ILO (dyspnea index; 21.0 ± 14.9-14.7 ± 15.7; P = .017). Subjective pain improved in 23 of 39 patients with paralaryngeal pain. There was no observed improvement for isolated globus. Presence of known vagal neuropathy or therapy around the time of SLN block did not affect outcome. CONCLUSION: SLN block can be an effective component of treatment for a variety of ILS symptoms. Patients may experience some improvement after 1 injection. LAY SUMMARY: Symptoms of irritable larynx syndrome, such as neurogenic cough, paralaryngeal pain, inducible laryngeal obstruction, and dysphonia related to laryngeal hypersensitivity can be challenging to manage. In-office Superior Laryngeal Nerve blocks can serve as a quick, well tolerated, adjunctive treatment with positive short-term outcomes. LEVEL OF EVIDENCE: 4.

Membranous Vocal Fold Lesions in Patients With Chronic Cough: A Case Series.

OBJECTIVES: Trauma related to chronic cough and forceful glottal closure has been associated with lesions of the vocal process; however, there is limited description of cough leading to membranous vocal fold lesions. We present a series of mid-membranous vocal fold lesions in a cohort of patients with chronic cough, with a proposed mechanism of lesion formation. METHODS: Patients treated for chronic cough with membranous vocal fold lesions affecting phonation were identified. Presentation, diagnosis, treatment strategies (behavioral, medical, and surgical), patient-reported outcome measures (PROMs), and videostroboscopy were reviewed. RESULTS: Five patients are included (four females, one male, aged 56±16 years). Mean cough duration was 2.6±3.5 years. All patients were on acid suppressive medications for existing gastroesophageal reflux disease (GERD) prior to referral. All lesions were identified at the mid-membranous vocal folds and morphologically encompassed a wound healing spectrum between ulceration and/or granulation tissue (granuloma) formation. Patients were treated in an interdisciplinary fashion with behavioral cough suppression therapy, superior laryngeal nerve block, and neuromodulators. Three had persistent lesions requiring procedural intervention (one office-based steroid injection and two surgical excisions). At the completion of treatment, all five patients had improvement in Cough Severity Index with an average decrease of 15.2±4.8. All but one patient had improvement in their Voice Handicap Index-10 with an average decrease of 13.2±11.1. One patient undergoing surgical intervention was noted to have a persistent lesion on follow-up. CONCLUSION: Mid-membranous vocal fold lesions in patients with chronic cough are uncommon. When they do occur, they represent epithelial change arising in context of shear injury and are distinct from phonotraumatic lesions in the lamina propria. An interdisciplinary approach including behavioral cough suppression therapy, neuromodulators, superior laryngeal nerve block, and acid suppression are reasonable for initial management, reserving surgical intervention for refractory lesions once the inciting source of injury has been controlled.

In-Office Superior Laryngeal Nerve Block for Paralaryngeal Pain and Odynophonia.

OBJECTIVES: Pain localized to the thyrohyoid region may be due to neuralgia of the superior laryngeal nerve (SLN), inflammation of the thyrohyoid complex, or a voice disorder. We present outcomes of treatment of paralaryngeal pain and odynophonia with SLN block. STUDY DESIGN: Retrospective Review. METHODS: A retrospective chart review of patients undergoing in-office SLN block for paralaryngeal pain between 2015 and 2018 at two tertiary care centers was conducted. Patient demographics, indications, and response to treatment were analyzed. RESULTS: Thirty-eight patients underwent blockade of the internal branch of the SLN for paralaryngeal pain, with 10 excluded for incomplete medical records. Eighty-two percent (23/28) reported an improvement in their symptoms. Patients underwent an average of 2.5 blocks (SD = 1.88, range 1-8), with 10 patients (36%) undergoing a single procedure. Of the 18 patients who underwent multiple blocks, nine had eventual cessation of symptoms (50%) compared to resolution in 6/10 undergoing a single injection. Eleven patients (39%) noted odynophonia related to vocal effort, and all of these patients had improvement in or resolution of their symptoms and were more likely to improve compared to those without odynophonia (P = .006). Of the four patients who had a vocal process granuloma (VPG) at presentation, three had complete resolution of the lesion at follow-up. CONCLUSION: In-office SLN block is effective in the treatment of paralaryngeal pain. It may be used as an adjunct in the treatment of vocal process granulomas, as well as voice disorders where odynophonia is a prominent symptom. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:401-405, 2022.

Twenty-One for 2021: The Most Influential Papers in Laryngology Since 2000.

OBJECTIVES/HYPOTHESIS: To identify the most influential publications in laryngology since 2000. STUDY DESIGN: Modified Delphi process. METHODS: Samples of laryngologists drawn from editors of leading journals, organization officers, and thought leaders were invited to participate in a modified Delphi identification of influential laryngology papers. Influential was defined as follows: yielding meaningful practice changes, catalyzing further work as a foundation for an important topic, altering traditional views, or demonstrating durability over time. Quality and validity were not among the selection criteria. Each participant nominated 5 to 10 papers in Round 1. These nominations, augmented with papers from bibliometric analysis, were narrowed further in Round 2 as participants identified their top 20. The 40 papers with the most Round 2 votes were discussed by video conference and then subjected to Round 3 voting, with each participant again selecting their top 20 most influential papers. Final results were collated by the number of Round 3 votes. RESULTS: Sixteen of 18 invited laryngologists participated overall (all 16 in Rounds 1 and 3; 14 in Round 2). Twenty-one papers were identified as most influential. One paper appeared on all 16 Round 3 lists; three papers with eight (50%) votes each were lasted to make the list. Eleven of these 21 focused on voice; three each related to cancer, airway, and swallowing; and one encompassed all of these clinical areas. CONCLUSIONS: This list of 21 influential laryngology papers serves to focus further research, provides perspective on recent advances within the field, and is an educational resource for trainees and practicing physicians. LEVEL OF EVIDENCE: NA Laryngoscope, 132:406-412, 2022.

Effect of Medialization on Dyspnea Index in Unilateral Vocal Fold Paralysis.

OBJECTIVE: Patients with unilateral vocal fold paralysis commonly report dysphonia and dysphagia. Dyspnea also occurs, with studies on treatment-related change producing mixed results. Studies including patient-reported outcomes have focused on single-question global scales. The Dyspnea Index (DI) includes 10 questions, is specific to upper airway-related dyspnea, and may better capture these patients' symptoms. We evaluated change in DI after treatment. STUDY DESIGN: Retrospective review. SETTING: Academic medical center. METHODS: Forty-three patients with unilateral vocal fold paralysis underwent injection augmentation (n = 25) or framework surgery (n = 18). DI was recorded preprocedure, 2 to 4 weeks afterward, and at approximately 3 months afterward in 19 patients. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 were also recorded. Change in parameters and correlations were assessed. Obesity, cardiac disease, pulmonary disease, and procedure (injection vs framework surgery) were evaluated for effect on DI. RESULTS: Twenty-four patients had an abnormal baseline DI (>10). DI decreased from 14.9 ± 13.8 to 6.5 ± 9.3 after treatment (P < .001; 95% CI, 4.7-12.1). Twenty-eight scores decreased, 9 remained unchanged, and 6 increased. Change in DI was influenced by the presence of cardiac disease. Decreased DI persisted at 3-month follow-up. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 scores decreased and were correlated with change in DI. CONCLUSION: Upper airway-related dyspnea is common in unilateral vocal fold paralysis, occurring in half of this cohort. Correcting glottic insufficiency may alleviate symptoms. Treatment decision making should consider postprocedural change in dyspnea, especially in patients for whom dyspnea is a motivating factor for seeking treatment.

Practice Patterns and Barriers in Botulinum Toxin Injection for the Treatment of Voice Disorders.

Laryngeal botulinum toxin injection is an important treatment modality for spasmodic dysphonia and other laryngeal disorders. We sought to compare usage patterns of laryngeal botulinum toxin injections for voice disorders and to identify and quantify inefficiencies and barriers in providing this treatment. A 26 item survey was written and approved for distribution by the American Academy of Otolaryngology-Head and Neck Surgery and the National Spasmodic Dysphonia Association. It was distributed to Otolaryngologists who perform laryngeal botulinum toxin injections via the e-mail lists of the National Spasmodic Dysphonia Association provider database, American Academy of Otolaryngology-Head and Neck Surgery Voice Committee and the American Laryngological Association Neurolaryngology Study Group. There were 81 survey participants who collectively reported performing >1700 laryngeal botulinum toxin injections for voice disorders monthly (Mean = 21.5 pts/month). Regarding botulinum toxin A (BtxA) vial use, 54% of participants reported using multiple doses per vial for different patients during a single clinic day, while 14% reported using pharmacy predrawn single use aliquots. A combination of usage practices was reported by 7% of participants. Using an individual vial per patient and discarding the unused remainder was reported by 26% of participants with an associated annual cost in wasted BtxA of $84,300 per physician. There is wide variation in injection practices regarding management of BtxA vials and adherence to an individual vial per patient policy is associated with significant waste of health care resources. Alternative approaches to BtxA vial use could positively impact health care resource utilization.

Correlation of Glottic Gap and Voice Impairment in Presbyphonia.

OBJECTIVE/HYPOTHESIS: The objective of this study was to investigate the glottic gap area as a significant marker for the severity of presbyphonia as it relates to patient-reported outcome measures (Voice Handicap Index-10 [VHI-10]) and stroboscopic findings. STUDY DESIGN: Retrospective case-control study conducted in an academic tertiary voice center. METHODS: Patients seen at a tertiary voice clinic who were diagnosed with presbyphonia without other organic laryngeal pathology from January 2014 to December 2017 were included. Clinical data and laryngeal videostroboscopy videos were collected. Still images at the point of vocal process approximation during adduction were captured, and the glottic gap area was measured using ImageJ. These were compared to a control cohort. Correlations were made using Wilcoxon rank sum test, Mann-Whitney U test, and Pearson correlation coefficients. RESULTS: Thirty-three patients were included. Inter-rater reliability of glottic area measurement was strong (intraclass correlation coefficient = 0.73, P < .001). Compared to controls, presbyphonia patients had a larger glottic gap area (P < .001) and greater open-phase quotient on laryngeal videostroboscopy (P < .001). Larger glottic gap area did not correlate with patient-reported vocal function as measured by VHI-10 (P = .79) and did not correlate with presence of secondary muscle tension dysphonia (P = .99). In the presbyphonia cohort, the glottic gap area did not correlate with age (P = .29). CONCLUSIONS: Glottic gap area at the point of vocal process approximation during phonation can be reliably measured. Patients with presbyphonia have a larger glottic gap area and greater open-phase quotient on stroboscopy, but these do not correlate with patient-reported voice impairment or the presence of secondary muscle tension dysphonia (MTD). These data suggest that dysphonia severity in presbyphonia is not fully explained by a glottic gap or secondary MTD alone. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1594-1598, 2021.

Differing Progression to Posterior Glottic Stenosis in Autoimmune and Idiopathic Subglottic Stenosis.

OBJECTIVES/HYPOTHESIS: We sought to characterize rates of progression to posterior glottic stenosis (PGS) from autoimmune or idiopathic subglottic stenosis. STUDY DESIGN: This was a retrospective review. METHODS: Patients from a tertiary-care laryngology practice over a 10-year period with autoimmune or idiopathic subglottic stenosis (SGS) were included. Patients with a history of prolonged intubation or other causes of iatrogenic stenosis were excluded. PGS was confirmed on videostrobolaryngoscopy recordings by a fellowship-trained laryngologist. PGS type (1-4) was also recorded. Demographic information was recorded, and if applicable, autoimmune disease type was specified. Time until PGS was recorded along with the number of interventions. Chi-squared analysis was used to compare PGS in autoimmune and idiopathic SGS. RESULTS: A total of 77 patients were identified with autoimmune (32 patients) or idiopathic (45 patients) subglottic stenosis. Autoimmune pathologies included systemic lupus erythematosus, granulomatosis with polyangiitis (GPA), rheumatoid arthritis, relapsing polychondritis, and sarcoidosis, with GPA the most common (14/32). Patients with autoimmune SGS had a higher rate of PGS (10 of 32) compared to idiopathic subglottic stenosis (1 of 45) for an odds ratio of 20 (95% CI: 2.4-166.4, P = .006). Patients with idiopathic SGS were more likely to be female (all 45 compared to 29/32 autoimmune, P = .07) and older (mean 53 (range 29-75) compared to 46 (20-82), P = .02). CONCLUSIONS: In this large patient cohort, autoimmune SGS patients were found to have a higher likelihood of developing PGS compared to their idiopathic counterparts, suggesting that counseling for this progression may be warranted. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1816-1820, 2021.

Impact of Fiberoptic Endoscopic Evaluation of Swallowing Outcomes and Dysphagia Management in Neurodegenerative Diseases.

OBJECTIVES/HYPOTHESIS: To determine the incidence of abnormal fiberoptic endoscopic evaluation of swallowing (FEES) findings in patients with progressive neurologic disorders and identify the most commonly implemented dysphagia management strategies. STUDY DESIGN: Retrospective Review. METHODS: A retrospective review was performed of patients with neurodegenerative disease who underwent FEES at a tertiary-care center between 2008 and 2019. Patient demographics, diagnosis, and Eating Assessment Tool-10 (EAT-10) scores were recorded. Rates of penetration, aspiration, and functional change in management (FCIM) to include dietary modifications, home exercises, swallow therapy, surgical intervention (injection augmentation or esophageal dilation), or alternative means of nutrition (i.e., percutaneous enteral gastrostomy [PEG] tube) were calculated. RESULTS: Two hundred nine FEES assessments were performed in 178 patients with a mean age of 64.8 years (standard deviation = ±14). The most common diagnoses were amyotrophic lateral sclerosis (32%) followed by Parkinson's disease or Parkinsonism (26%). FEES demonstrated penetration in 72.5% of patients and aspiration in 14.6%. Mean EAT-10 scores differed between patients with aspiration versus penetration versus normal FEES (24.7 vs. 14.9 vs. 13.9, respectively, P < .001). An FCIM was recommended in 88% of patients and most commonly included self-directed modifications (43%). Overall, 4.5% of patients underwent surgical intervention. A PEG tube was recommended for either supplemental or sole form of nutrition in 19% of the entire cohort. CONCLUSIONS: Most patients with neurodegenerative diseases presenting with dysphagia demonstrated abnormal FEES findings necessitating an FCIM, suggesting early dysphagia evaluation may be warranted in this cohort. These findings correlate with worsened EAT-10 scores in patients with aspiration or penetration on FEES. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:726-730, 2021.

Voice Change Following Testosterone Supplementation in Women: A Multi-Institutional Case Series.

OBJECTIVES: To describe voice changes as a result of the off-label use of androgen supplementation in women. METHODS: A multi-institutional retrospective consecutive case series identified women taking androgen supplementation who presented to voice clinics at two institutions with a chief complaint of voice change between 2014 and 2019. Age, occupation, hormone therapy, indication, Voice Handicap Index-10, fundamental frequency, semitone pitch range, testosterone blood level, treatment undertaken, and long-term outcome were collected. RESULTS: Nine women presented with voice change after initiation of androgen hormone supplementation. The mean age was 55 and three patients were performers. All patients underwent hormone therapy with testosterone supplementation, most commonly subcutaneous testosterone pellets. Six patients (67%) were being treated for menopause symptoms, one patient for decreased libido, one patient for breast cancer, and one patient who desired additional muscle gain. Time of symptom onset after hormone therapy initiation was highly variable, ranging from 0 to 48 months with a mean of 15 months. Mean Voice Handicap Index-10 was 21, mean fundamental frequency at comfortable speaking level was 155 Hz and mean semitone pitch range was 22 semitones. Two patients had markedly elevated serum total testosterone levels. Hormone therapy discontinuation and voice therapy were recommended in six (67%) patients each. Five patients returned for follow-up after treatment and noted some subjective benefit. CONCLUSIONS: Female patients treated with androgen supplementation may experience unintended voice changes, most prominently reduction in fundamental frequency. Although some benefit may be obtained from voice therapy and cessation of hormone therapy, voice changes may be permanent. Caution should be exercised when prescribing these medications to women.

Postoperative Complications in Obese Patients After Tracheostomy.

OBJECTIVE: To determine the prevalence of varying classes of obesity in patients undergoing tracheostomy and the associated complication rates as compared with nonobese patients. STUDY DESIGN: A retrospective chart review was performed from 2012 to 2018 on all patients who underwent open tracheostomy by the Department of Otolaryngology-Head and Neck Surgery. SETTING: All tracheostomies were performed at a single tertiary care center. METHODS: Patients were classified by body mass index (BMI) according to the World Health Organization classification system: underweight (<18.5), normal-overweight (18.5-29.9), class I (30-34.9), class II (35-39.9), and class III (>40). Charts were reviewed for patient demographic information, Charlson Comorbidity Index score, surgical indication, operative time, tracheostomy tube type, and postoperative complications. RESULTS: A total of 387 patients (mean ± SD BMI, 31.3 ± 14.2) were identified per the inclusion/exclusion criteria. Of patients with BMI >30 (n=153), 34.6% were categorized as obesity class I, 29.4% as class II, and 35.9% as class III. The most common indication for tracheostomy was malignancy in nonobese patients (41.5%) and respiratory failure for obese patients (58.2%). Operative time was significantly longer in obese patients, and most of these patients required an extended-length tracheostomy tube. Patients with a BMI >40 had higher rates of multiple postoperative complications or death (P = .009). Underweight patients also had a higher rate of complication than normal-overweight patients (P = .016). CONCLUSION: Class III and underweight patients had higher rates of postoperative complications, which should be taken into consideration during perioperative counseling.

Jet Ventilation in the Pregnant Patient with Airway Stenosis: Surgical Safety and Outcomes.

OBJECTIVE: To review pregnancy outcomes and the safety of jet ventilation use in the gravid patient undergoing surgical airway intervention. METHODS: A multi-institutional retrospective review of medical records was performed to identify women who underwent low-frequency jet ventilation during pregnancy for surgical treatment of airway stenosis. Postoperative complications were noted, and patients were interviewed regarding pregnancy outcomes. RESULTS: Six women were included in this series. No immediate complications relating to anesthesia or surgical intervention were noted in five of the six women. One patient with a well-known history of uncontrolled seizures experienced seizure activity postoperatively. One patient returned to the operating room at a later date for debridement of tracheal crusts. Five mothers delivered via cesarean section and one via spontaneous vaginal delivery. The mean gestation age was 37.3 weeks. One of the six infants delivered prematurely and three were delivered at low birth weight. Three of the six infants required elevated care immediately post-delivery but, at present, all are in good health. CONCLUSION: Low-frequency jet ventilation and surgical management of airway stenosis should be recognized as a safe treatment option in the gravid patient. Surgical intervention should not be delayed in patients with severe symptoms, particularly given the potential risk associated with prolonged corticosteroid use. LEVEL OF EVIDENCE: 4.

Multi-institutional Evaluation of Medialization Laryngoplasty in the Elderly.

OBJECTIVE: To evaluate voice outcomes of medialization laryngoplasty in the elderly population (65 years and older) and to identify swallow outcomes, complication rates, and predictors of voice outcomes. STUDY DESIGN: Case series with chart review. SETTING: Two tertiary academic medical centers. SUBJECTS AND METHODS: We retrospectively reviewed charts of 136 patients age 65 years and older undergoing medialization laryngoplasty between January 2008 and May 2016 at 2 tertiary academic institutions. Primary outcome was assessed using Voice Handicap Index 10 (VHI-10) score and Grade, Roughness, Breathiness, Asthenia, and Strain (GRBAS) score. Secondary outcomes were assessed using the Eating Assessment Tool 10 (EAT-10) when dysphagia was present, stroboscopic analysis of glottic closure, and complication rates. A logistic regression analysis assessed predictors of voice improvement after medialization laryngoplasty. RESULTS: Total GRBAS and VHI-10 scores showed a significant improvement postoperatively ( P < .05). A ≥20% improvement was seen in 81.6% of patients, and a ≥50% improvement was seen in 53.7%. No patient had major complications. Minor complications occurred in 5.9% of patients. Multivariable logistic regression identified preoperative injection augmentation as an independent predictor of less improvement in VHI-10 score ( P = .015). Voice therapy prior to medialization did not affect voice outcomes ( P = .640). CONCLUSION: Patient- and provider-perceived voice quality are significantly improved after medialization laryngoplasty in the elderly, and the procedure is associated with a low complication rate even in an elderly cohort. Improvement in patient-perceived voice outcomes after medialization laryngoplasty was diminished in patients with preoperative injection augmentation.

Voice Outcomes of Lipoinjection Versus Medialization Laryngoplasty for Nonparalytic Glottic Insufficiency.

OBJECTIVE: To compare voice outcomes of autogenous fat injection versus medialization laryngoplasty in patients with glottic insufficiency due to vocal fold paresis or atrophy. METHODS: A retrospective review was performed from 2009 to 2017 of all patients who underwent lipoinjection or medialization laryngoplasty (ML) for glottic insufficiency. Charts were reviewed for demographic information, preoperative diagnosis, surgical intervention, Voice Handicap Index-10 (VHI-10) and Glottal Function Index (GFI) scores, follow-up time (minimum 3 months), and concomitant voice therapy. RESULTS: Eighty-three patients were initially identified and limited to 28 based on the inclusion/exclusion criteria. Thirty-five procedures were performed with a total of 15 fat injections and 20 MLs. The mean age was 60.7 years in the lipoinjection group and 55.6 years in the ML group. There was no significant difference in pretreatment VHI-10 scores between the two groups. Using the lowest recorded voice scores during the follow-up period, both groups had a significant decrease (P < 0.05) compared to preoperative scores (VHI-10: fat decreased from 27.8 to 14.2, ML decreased from 30.5 to 9.1; GFI: fat decreased from 13.7 to 5.27, ML decreased from 13.6 to 4.6). When evaluating the entire follow-up period (median 19 months in fat group, 16.3 months in ML), only the ML group maintained a significant improvement in VHI-10 (median delta 14.5) and GFI (median delta 7) compared to preoperative scores. CONCLUSION: Although both autogenous fat injection and ML result in improved voice scores in the short term, the effect of fat injection appears to be limited, as evidenced by worsening VHI-10 and GFI scores over time. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1164-1168, 2019.

Subglottic stenosis: An evaluation of an elderly treatment-seeking population.

OBJECTIVES/HYPOTHESIS: To evaluate the demographics, etiology, intraoperative findings, and treatment outcomes of patients with subglottic stenosis (SGS), comparing those patients aged <65 years to an elderly population aged ≥65 years. STUDY DESIGN: Retrospective cohort study. METHODS: Nine-year retrospective review of patients with SGS. Forty-eight adults presented for evaluation and treatment of SGS between January 2008 and December 2016. At the time of presentation, 41 were aged <65 years and seven were aged ≥65 years. RESULTS: Comparing the aged <65 years group to the aged ≥65 years group, the etiology was idiopathic SGS in 50.0% versus 42.8%, intubation-related SGS in 22.5% versus 28.6%, and granulomatosis with polyangiitis in 27.5% versus 28.6%, respectively. No statistically significant difference was noted in the two groups when comparing the demographics, etiology, treatment, intraoperative findings, or intertreatment interval (ITI). CONCLUSIONS: We sought to analyze an older patient population with SGS and found no statistically significant differences compared to a younger population. ITI trended toward older patients requiring surgery more frequently but was not significant. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1155-1158, 2019.

Quantification of injection force mechanics during injection laryngoplasty.

OBJECTIVES: In-office or operative injection laryngoplasty requires needle stability for accurate material placement. To date, no reports compare injection forces based on needle gauge, bends, length, or material type or temperature. We hypothesize these factors alter injection forces and could impact clinical use. METHODS: Swine larynges were placed in a compression testing machine. Syringes were affixed to a stabilizing crossbeam. Straight needles (25G 1.5-inch; 27G 1.25-inch; or 9.8-inch malleable shaft 16G per oral with 24G tapered needle tip) were inserted into the swine vocal folds to simulate realistic tissue resistance pressure. Compressive loading was conducted at 40 mm/minute until steady-state force was achieved. Tests were completed with calcium hydroxylapatite (CaHa), carboxymethylcellulose, and hyaluronic acid at various temperatures and CaHa with various bends in the needles (n = 3 per group, comparisons performed by two-way analysis of variance (ANOVA), Tukey's post-hoc). RESULTS: Needle size, shape, and temperature altered injection force. Steady-state force was highest with the per-oral needle at a mean of 44.55N compared to 26.44N and 29.77N in the 25G and 27G percutaneous needles, respectively (P < 0.001). Stiffness rate (initial increasing force vs. distance to initiate injection) ranged from 19.75N/mm (per oral) to 22.06N/mm (25G) to 24.56N/mm (27G), (P = 0.875). Adding multiple bends to the per-oral needle increased stiffness rate to 24.99N/mm (P = 0.035), whereas the 25G needle stiffness rate remained unchanged (P = 0.941), with the stiffness rate decreasing in the 27G needle with increasing bends (P = 0.033). Increased temperature decreased injection forces across all materials. CONCLUSION: Needle caliber, length, and bends impact steady-state forces and stiffness rates during vocal fold injection. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1060-1066, 2019.

Shar Pei Larynx: Supraglottic and Postcricoid Mucosal Redundancy and Its Association With Medical Comorbidities.

OBJECTIVES:: The aim of this study is to describe a clinical entity the authors term "Shar Pei larynx," characterized by redundant supraglottic and postcricoid mucosa that the authors hypothesize coexists in patients with obstructive sleep apnea, laryngopharyngeal reflux, and obesity. By exploring this hypothesis, the authors hope to set the foundation for future research with the goal of identifying whether Shar Pei larynx is a marker for untreated sleep apnea or other diseases. STUDY DESIGN:: Retrospective chart review. SETTING:: Two tertiary care academic institutions. METHODS:: Data were collected from a 5-year period by querying for patients described to have "Shar Pei larynx" or "posterior supraglottic and/or postcricoid mucosal redundancy" on laryngoscopic findings. Relevant demographic and clinical characteristics were analyzed, with a focus on associations with obesity, sleep apnea, and laryngopharyngeal reflux. RESULTS:: Thirty-two patients were identified with physical findings consistent with Shar Pei larynx. Twenty-six patients (81.3%) were obese; 16 (50%) were morbidly obese. Twenty-two patients (68.8%) either had an existing diagnosis of obstructive sleep apnea or were diagnosed on polysomnography performed after initial evaluation. Sixteen patients (50%) had type 2 diabetes mellitus, and 87.5% of these patients were obese. Twenty-eight patients (87.5%) noted histories of reflux, with a median reflux symptom index of 27 of 45. Five patients underwent procedures to reduce mucosal redundancy related to Shar Pei larynx. CONCLUSIONS:: This pilot study confirms that the majority of patients diagnosed with Shar Pei larynx also had diagnoses of obesity, obstructive sleep apnea, and reflux disease. The demonstrated association is strong enough to warrant further study.

Treatment of chronic neurogenic cough with in-office superior laryngeal nerve block.

OBJECTIVES: Neurogenic cough is believed to result from a sensory neuropathy involving the internal branch of the superior laryngeal nerve (SLN). We present our outcomes for the treatment of neurogenic cough with localized blockade of the internal branch of the SLN. METHODS: A retrospective chart review of patients who underwent in-office percutaneous SLN block for treatment of neurogenic cough between 2015 and 2017 was conducted. Patient demographics, indications for injection, and response to treatment were recorded and analyzed. Cough severity index (CSI) scores before and after treatment were compared. RESULTS: Twenty-three patients underwent percutaneous blockade of the internal branch of the SLN in the clinic setting, and five patients were excluded for incomplete records. The indication was neurogenic cough as a diagnosis of exclusion. The injectable substance used was a 1:1 mixture of a long-acting particulate corticosteroid and a local anesthetic. Unilateral injections were performed in 13 patients, and five patients underwent bilateral injections. Of the unilateral injections, 10 were left-sided. Patients underwent an average of 2.4 SLN block procedures (range 1-7). Mean follow-up time postinjection was 85.4 days (7-450 days). Cough severity index scores decreased significantly from an average of 26.8 pretreatment to 14.6 posttreatment (P < 0.0001). CONCLUSION: The SLN block is an effective treatment for neurogenic cough, with average CSI scores significantly improved following injection. Further study is necessary to determine the characteristics of patients' responses to treatment, long-term outcomes, and efficacy of the procedure when compared to placebo and other accepted treatments for neurogenic cough. LEVEL OF EVIDENCE: 4. Laryngoscope, 1898-1903, 2018.

Pharyngeal Dystonia Mimicking Spasmodic Dysphonia.

OBJECTIVE: The aim of this study was to describe the presentation of pharyngeal dystonia (PD), which can occur as a focal or segmental dystonia with a primarily pharyngeal involvement for the discussion of treatment methods for controlling consequent symptoms. PD is specific to speech-related tasks. METHODS: A retrospective medical record review of four patients with PD was performed. RESULTS: All patients were initially misdiagnosed with adductor spasmodic dysphonia and failed standard treatment with botulinum toxin type A (BTX). On laryngoscopy, the patients were discovered to have segmental or focal dystonia primarily affecting the pharyngeal musculature contributing to their vocal manifestations. A novel treatment regimen was designed, which involved directing BTX injections into the muscles involved in spasmodic valving at the oropharyngeal level. After titrating to an optimal dose, all patients showed improvement in their voice and speech with only mild dysphagia. These patients have maintained favorable results with repeat injections at 6- to 12-week intervals. CONCLUSIONS: PD, or dystonia with predominant pharyngeal involvement, is a rare entity with vocal manifestations that are not well described. It can be easily mistaken for spasmodic dysphonia. PD is specific to speech-related tasks. A novel method of BTX injections into the involved muscles results in a significant improvement in voice without significant dysphagia.

Impact of Perioperative Voice Therapy on Outcomes in the Surgical Management of Vocal Fold Cysts.

INTRODUCTION: Vocal fold cysts are benign mid-membranous lesions of the true vocal fold, classified as mucus retention or epidermal inclusion cysts. Treatment is surgical excision with or without postoperative voice therapy. METHODS: A retrospective review was performed of the demographics, treatment approach, and outcomes of patients treated for vocal fold cysts between 2009 and 2014. Voice Handicap Index (VHI)-10 scores before and after treatment were compared using the Wilcoxon Rank-Sum test and the two-tailed Student's t test. Videostroboscopy examinations were reviewed for posttreatment changes in vibratory characteristics of the vocal folds. RESULTS: Twenty-five patients were identified, and one was excluded for incomplete records. Mean age was 41.9 years (66.7% female), and mean follow-up time was 5.58 months. Microflap excision was pursued by 21/24 (87.5%) patients, with 14 patients (58.3%) undergoing perioperative voice therapy. One cyst recurred. Two patients elected for observation, and their cysts persisted. VHI-10 decreased from 23.8 to 6.6 (P < 0.001) overall. There was a statistically significant reduction in VHI-10 in patients undergoing surgery with and without postoperative voice therapy (P < 0.004 and 0.001), but there was no significant difference between these two groups. Mucosal wave was classified as normal or improved in the majority. Cysts were characterized as mucus retention cysts in 19/21 (90%) and as epidermal inclusion cysts in 2/21 (10%). CONCLUSIONS: Vocal fold cysts impact mucosal wave and glottic closure. Surgical excision resulted in low rates of recurrence, and in improvement in the mucosal wave and VHI-10. Perioperative voice therapy did not offer a significant benefit. Mucus retention cysts were the majority, in contrast to other published studies.