Return to Vocal Performance Following Microlaryngoscopy in Singers.

INTRODUCTION: Although microlaryngoscopy has been recognized to be effective in addressing lesions in vocal performers, no detailed information regarding return to performance (RTP) following surgery exists. We describe our experience and offer proposals to establish standardized criteria for RTP among vocal performers. METHODS: Records for adult vocalists who underwent microlaryngoscopy for benign vocal fold (VF) lesions and had a clearly documented RTP date between 2006 and 2022 were reviewed. Patient demographics, diagnoses, interventions, and postsurgical care before and after RTP were described. The need for medical and procedural interventions and rate of reinjury were used to determine the success of RTP. RESULTS: Sixty-nine vocal performers (average age: 32.8 years, 41 [59.4%] female, 61 [88.4%] musical theater) underwent surgery for 37 (53.6%) pseudocysts, 25 (36.2%) polyps, 5 (7.2%) cysts, 1 (1.4%) varix, and 1 (1.4%) mucosal bridge. Fifty-seven (82.6%) underwent voice therapy. The average time to RTP was 65.0 ± 29.8 days. Prior to RTP, six (8.7%) experienced VF edema requiring oral steroids and one (1.4%) underwent a VF steroid injection. Within 6 months following RTP, eight (11.6%) received oral steroids for edema and three underwent procedural interventions (two steroid injections for edema/stiffness, one injection augmentation for paresis). One patient experienced pseudocyst recurrence. CONCLUSIONS: Return to vocal performance at an average of 2 months following microlaryngoscopy for benign lesions appears overwhelmingly successful, with low rates of need for additional intervention. There is a need for validated instruments to better measure performance fitness to refine and possibly accelerate RTP. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:329-334, 2024.

Correlations Between Anxiety and/or Depression Diagnoses and Dysphagia Severity.

OBJECTIVE: An increased prevalence of mood and anxiety disorders in patients with dysphagia has been noted previously, but whether dysphagia severity may be exacerbated by anxiety and depression has never been studied before. The purpose of this study is to identify the effect of pre-existing diagnosis of anxiety and/or depression (anxiety/depression) on the Eating Assessment Tool (EAT-10), a validated patient-reported outcome measure for dysphagia. We hypothesized that patients with dysphagia and normal instrumental evaluation have higher EAT-10 score in the presence of pre-existing anxiety and depression. METHODS: A retrospective chart review was conducted of patients seen at the multi-disciplinary dysphagia clinic of an urban academic institution. EAT-10 scores and pre-existing diagnoses of anxiety/depression were collected at the first visit with laryngologists. The two-sample t-test was used to compare mean EAT-10 scores between the anxiety/depression and no anxiety/depression groups, stratified by swallowing dysfunction etiology. RESULTS: The study included 290 consecutive patients seen starting in January 2018. In this cohort, 60 (21%) had pre-existing anxiety, 49 (17%) depression, and 36 (12%) both. Overall, 59 patients had normal swallowing based on instrumental swallowing testing (flexible endoscopic evaluation of swallowing, videofluoroscopic swallow study, esophagram, or esophagoscopy). Among those, mean EAT-10 score was significantly higher in patients with anxiety and/or depression (n = 30) (14.63, SD = 11.42) compared to those with no anxiety and/or depression (n = 29) (8.93, SD = 6.59) (p = 0.023). CONCLUSION: While anxiety/depression may aggravate dysphagia in patients with normal swallowing function, this correlation may not hold in those with objective swallowing dysfunction. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:2115-2120, 2024.

De Novo Granuloma of the Membranous Vocal Fold: A Marker of Occult Malignancy.

OBJECTIVE: De novo occurrence of granuloma (granulation tissue) on the membranous vocal fold is not readily explained by usual causes of granuloma at the vocal process. We describe a series of patients. STUDY DESIGN: Case series. SETTING: Single academic institution. METHODS: Cases were identified over a 16-year period. All patients exhibited granulation tissue on pathology. Demographic details, presentation, treatment, histology, and clinical outcomes were recorded. RESULTS: Five patients (mean age: 74.0 ± 6.1 years, 40.0% male, 40.0% former smokers) underwent a biopsy. Persistent or recurrent granulation led to a second biopsy in 4 patients an average of 1423.5 days later, revealing a new diagnosis of squamous cell carcinoma (SCC) in situ in one and mild dysplasia in another. Further persistence or recurrence led to a third biopsy or excision an average of 302.3 days later in 3 patients, demonstrating SCC in situ in 1. An average of 2.5 biopsies were required with a mean time to SCC in situ diagnosis of 919.5 days from presentation. Two patients continued to demonstrate persistent granulation tissue on histology. CONCLUSION: The membranous vocal fold is an atypical location for granuloma and portends a risk of occult malignancy. The occurrence of de novo granuloma at this site should prompt close long-term clinical surveillance with a low threshold for biopsy. Consideration should be given to tissue collection in the operating room to adequately sample the lesion's base. Concern should persist even after a negative biopsy, and serial observation with repeat biopsy as needed should be pursued.

Trust in Machine Learning Driven Clinical Decision Support Tools Among Otolaryngologists.

BACKGROUND: Machine learning driven clinical decision support tools (ML-CDST) are on the verge of being integrated into clinical settings, including in Otolaryngology-Head & Neck Surgery. In this study, we investigated whether such CDST may influence otolaryngologists' diagnostic judgement. METHODS: Otolaryngologists were recruited virtually across the United States for this experiment on human-AI interaction. Participants were shown 12 different video-stroboscopic exams from patients with previously diagnosed laryngopharyngeal reflux or vocal fold paresis and asked to determine the presence of disease. They were then exposed to a random diagnosis purportedly resulting from an ML-CDST and given the opportunity to revise their diagnosis. The ML-CDST output was presented with no explanation, a general explanation, or a specific explanation of its logic. The ML-CDST impact on diagnostic judgement was assessed with McNemar's test. RESULTS: Forty-five participants were recruited. When participants reported less confidence (268 observations), they were significantly (p = 0.001) more likely to change their diagnostic judgement after exposure to ML-CDST output compared to when they reported more confidence (238 observations). Participants were more likely to change their diagnostic judgement when presented with a specific explanation of the CDST logic (p = 0.048). CONCLUSIONS: Our study suggests that otolaryngologists are susceptible to accepting ML-CDST diagnostic recommendations, especially when less confident. Otolaryngologists' trust in ML-CDST output is increased when accompanied with a specific explanation of its logic. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:2799-2804, 2024.

Virtual Reality for Pain Management During High-Resolution Manometry: A Randomized Clinical Trial.

OBJECTIVE: High-resolution esophageal manometry (HRM) is the gold standard for the diagnosis of esophageal motility disorders. HRM is typically performed in the office with local anesthesia only, and many patients find it unpleasant and painful. The aim of this study was to examine the effects of the use of a virtual reality (VR) headset on pain and anxiety outcomes in patients with dysphagia undergoing HRM. METHODS: Patients with dysphagia were prospectively recruited and randomized to undergo HRM with and without VR distraction. Data collected included the State-Trait Anxiety Inventory-6 (STAI-6), the Short-Form McGill Pain Questionnaire, heart rate, and galvanic skin response (GSR) tracings. RESULTS: Forty subjects completed the study, including 20 subjects in the intervention arm and 20 in the control arm. There was evidence of a significant positive effect of VR on calmness (p = 0.0095) STAI-6 rating, as well as on physiologic measures of pain with significantly decreased GSR rise time (p = 0.0137) and average rate of change of conductance change (p = 0.0035). CONCLUSION: The use of VR during HRM catheter insertion increased calmness compared to control. Change of skin conductance was also reduced in the VR group, suggesting decreased physiologic pain. This study supports the consideration of the use of VR as a distraction tool to improve patient comfort during HRM. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:1118-1126, 2024.

Are Mobile Applications in Laryngology Designed for All Patients?

OBJECTIVES: Mobile applications (apps) are multiplying in laryngology, with little standardization of content, functionality, or accessibility. The purpose of this study is to evaluate the quality, functionality, health literacy, readability, accessibility, and inclusivity of laryngology mobile applications. METHODS: Of the 3230 apps identified from the Apple and Google Play stores, 28 patient-facing apps met inclusion criteria. Apps were evaluated using validated scales assessing quality and functionality: the Mobile App Rating Scale (MARS) and the Institute for Healthcare Informatics App Functionality Scale. The Clear Communication Index (CDC) Institute of Medicine Strategies for Creating Health Literate Mobile Applications, and Patient Education Materials Assessment Tool (PEMAT) were used to evaluate apps health literacy level. Readability was assessed using established readability formulas. Apps were evaluated for language, accessibility features, and representation of a diverse population. RESULTS: Twenty-six apps (92%) had adequate quality (MARS score > 3). The mean PEMAT score was 89% for actionability and 86% for understandability. On average, apps utilized 25/33 health literate strategies. Twenty-two apps (79%) did not pass the CDC index threshold of 90% for health literacy. Twenty-four app descriptions (86%) were above an 8th grade reading level. Only 4 apps (14%) showed diverse representation, 3 (11%) had non-English language functions, and 2 (7%) offered subtitles. Inter-rater reliability for MARS was adequate (CA-ICC = 0.715). CONCLUSION: While most apps scored well in quality and functionality, many laryngology apps did not meet standards for health literacy. Most apps were written at a reading level above the national average, lacked accessibility features, and did not represent diverse populations. Laryngoscope, 133:1540-1549, 2023.

Correlation Between Laryngoscopic Appearance and Histopathology in Vocal Fold Cysts.

OBJECTIVES/HYPOTHESIS: Cysts are benign vocal fold lesions typically divided into mucous retention or epidermoid subtypes. The conventional paradigm that the former are translucent and the latter opaque fails to encompass the heterogeneity of cyst appearance on laryngoscopy. This study aims to characterize the relationships between clinical cyst characteristics and histopathology. STUDY DESIGN: Retrospective cohort METHODS: Clinicodemographic data, videostroboscopy findings, and histopathology results were retrospectively reviewed for adults who underwent surgical excision of vocal fold cysts at our institution between 2006 and 2021. RESULTS: Diagnostic histopathologic material was available for 69 patients (age: 50.4 ± 15.1 years, 68.1% female). Clinically, most cysts were opaque (69.6%) and located at the vibratory margin (82.6%). 11.6% were infraglottic. Significant associations existed between cyst location and epithelial type, with infraglottic cysts and those at the superior surface more commonly exhibiting ductal (P = 0.003) and squamous (P = 0.002) epithelium, respectively. Cyst opacity did not correlate with histopathology (P = 0.415). Epidermoid cysts were more likely to exhibit clinical inflammation (P = 0.002).

Outcomes of Gender-Affirming Voice and Communication Modification Training for Non-binary Individuals: A Case Series.

OBJECTIVES: There is currently no research reporting solely on outcomes of voice and communication modification training (VCMT) in individuals who identify as non-binary and genderqueer (NBGQ) in the English literature. This study aimed to describe the objective and subjective impact of VCMT on the voice of NBGQ individuals undergoing a 12-week gender-affirming VCMT program. METHODS: A retrospective consecutive case series of NBGQ individuals enrolled in a VCMT program was performed. Demographics, Transgender Self-Evaluation Questionnaire (TSEQ), fundamental frequency (F0), and frequency range were collected before and after the program. RESULTS: Four NBGQ individuals enrolled between January 2019 and June 2021; the mean age was 27.0 years. While all four participants represented in this case series showed improvement in at least one of their initial goals, only one improved both their F0 and TSEQ scores; the other three participants had mixed results. CONCLUSION: NBGQ individuals experienced improvements in self-reported outcomes and changes in acoustic measures after completing VCMT in our case series. Individuals experienced significant improvement in subjective outcomes despite small changes in acoustic measures, and vice versa. More research is needed to better understand the voice and communication needs of NBGQ individuals, along with their outcomes with VCMT. LEVEL OF EVIDENCE: Level 4.

Mindfulness-Based Virtual Reality Intervention for Children and Young Adults with Inflammatory Bowel Disease: A Pilot Feasibility and Acceptability Study.

The aim of this pilot study was to assess: (1) the feasibility and acceptability of a Mindfulness-Based Virtual Reality (MBVR) intervention among children and young adults with Inflammatory Bowel Disease (IBD), and (2) the preliminary efficacy of MBVR on key psychological (anxiety) and physical (pain) outcomes. Participants were 62 children to young adults with IBD (M = 15.6 years; 69.4% Crohn's disease; 58% male) recruited from an outpatient pediatric IBD clinic. Participants completed a baseline assessment, underwent the 6-min MBVR intervention, completed a post-intervention assessment and study satisfaction survey, and provided qualitative feedback. Results suggest strong feasibility and acceptability. Participants reported high levels of satisfaction with MBVR including high levels of enjoyment (M = 4.38; range 1-5) and relaxation (M = 4.35; range 1-5). Qualitative data revealed several key themes including participants interest in using MBVR in IBD medical settings (e.g., hospitalizations, IBD procedures, IBD treatments), as well as in their daily lives to support stress and symptom management. Preliminary analyses demonstrated improvements in anxiety (t = 4.79, p = 0.001) and pain (t = 3.72, p < 0.001) following MBVR. These findings provide initial support for the feasibility and acceptability of MBVR among children and young adults with IBD. Results also suggest MBVR may improve key IBD outcomes (e.g., anxiety, pain) and highlight the importance of conducting a randomized controlled trial and more rigorous research to determine intervention efficacy.