Photoangiolysis with the 445-nm Blue Laser and the Potassium-Titanyl-Phosphate Laser: A Comparison.

OBJECTIVES: Photoangiolytic lasers have yielded significant innovation in laryngeal surgery in the last 25 years. After the discontinuation of the potassium titanyl phosphate (KTP) laser, a novel 445-nm blue laser was developed. The optimal balance between a laser's desired tissue effects and collateral tissue damage is a major determinant of laser selection in microlaryngeal surgery. The shell-less incubation system for the chick chorioallantoic membrane (CAM) simulates the microvasculature of the human vocal fold and is useful for testing effects of laser settings and in simulated surgery. The aim of this study is to compare the tissue effects of the KTP and blue lasers using the shell-less CAM model. METHODS: The shell-less incubation system contains: polymethylpentene film (used as a culture vessel), calcium lactate and distilled water supplementations. By using this system, the chick chorioallantoic membrane (CAM) can be fully exposed with a good field for surgery simulation. The effects of the 2 lasers (532 nm KTP and 445 nm blue) were quantified at clinically relevant energy settings and laser distances from target. Measures included imaging real-time vascular reactions in the CAM model, post-procedure histologic analysis of CAM tissue and temperature changes. RESULTS: Vessel coagulation and rupture rates were less common with the blue laser compared with the KTP laser. Histologic analysis demonstrated less tissue disruption with the blue laser. Temperature changes were less with the blue laser. CONCLUSION: In this CAM model with specific conditions, the blue laser reveals less tissue damage than the KTP laser. Suitable working distance and power setting of the laser are necessary for desired tissue effects.Level of Evidence: Level 3.

Xiang-Sheng-PoDi-Wan May Reduce the Risk of Pneumonia retain-->in Unilateral Vocal Fold Paralysis: A Nationwide Population-Based Cohort Study.

BACKGROUND: Pneumonia is a serious complication in patients with unilateral vocal fold paralysis (UVFP). Traditional Chinese medicine Xiang-Sheng-PoDi-Wan plays a role in promoting health and may reduce pneumonia rates in those with UVFP. The study aimed to evaluate Xiang-Sheng-PoDi-Wan treatment's effectiveness in preventing pneumonia hospitalization in patients with UVFP. METHODS: We analyzed a cohort of two million participants from 2000 to 2018 from the National Health Insurance Research Database of Taiwan. We identified patients with UVFP (International Classification of Diseases, Ninth Revision, Clinical Modification code 478.32) and documented outpatient, inpatient, and treatment records from the first diagnosis until hospitalization due to pneumonia, death, or the end of the study. We calculated the incidence of pneumonia and compared the risk of pneumonia in patients receiving Xiang-Sheng-PoDi-Wan treatment or conventional treatment and tracked the use of speech therapy. We used the Cox proportional regression model to estimate the hazard ratio with a 95% confidence interval. Our corrected covariants include age, gender, degree of urbanization, insured amount, and disease comorbidity. RESULT: The use of Xiang-Sheng-PoDi-Wan was associated with a lower risk of hospitalization for pneumonia in UVFP patients, with an adjusted hazard ratio (aHR) of 0.40 (0.21-0.77). The combination of Xiang-Sheng-PoDi-Wan and speech therapy could further reduce the risk of pneumonia hospitalization (aHR = 0.25 [0.02-0.82]). UVFP patients with comorbidities such as respiratory cancer 0.34 (0.12-0.98) or diabetes (aHR = 0.30 [0.09-0.96]) had higher rates of pneumonia hospitalization. CONCLUSION: The results suggest that Xiang-Sheng-PoDi-Wan may play a role in UVFP patients to reduce the long-term risk of pneumonia.

Comparative Treatment Outcomes for Idiopathic Subglottic Stenosis: 5-Year Update.

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

Long-Term Follow-up of 64 Patients With Idiopathic Subglottic Stenosis: Treatment Pathways, Outcomes, and Impact of Serial Intralesional Steroid Injections.

OBJECTIVE: To describe treatment pathways and long-term outcomes in 64 patients with idiopathic subglottic stenosis (iSGS), including the impact of serial intralesional steroid injection (SILSI) on degree of stenosis, need for subsequent operation, and patient-reported outcome measures. METHODS: Retrospective review of 64 female patients with iSGS undergoing varied management approaches, 57 of whom underwent SILSI as at least part of their care. Treatment pathways included SILSI only, endoscopic intervention followed by SILSI only, endoscopic interventions only, endoscopic intervention followed by SILSI followed by need for repeat endoscopic intervention, open surgery, and tracheotomy. Outcomes assessed included subjectively estimated percent airway stenosis, dyspnea index (DI), modified medical research council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), number of operative and office-based procedures performed, need for subsequent operative intervention, and inter-operative interval. RESULTS: Treatment pathways included SILSI alone (n = 6), endoscopic intervention(s) followed by SILSI only (n = 31), SILSI followed by additional endoscopic or office-based procedures (n = 16), open surgery (n = 3), and tracheostomy (n = 4). 57 of 64 patients underwent SILSI as at least part of their treatment. Inter-operative interval was increased after starting SILSI. Of patients undergoing SILSI, those with more procedures or shorter inter-operative interval prior to SILSI were more likely to return to the operating room. Estimated stenosis, DI, MMRC, and VHI-10 decreased with SILSI. Stenosis was not correlated with DI, MMRC, or VHI-10, though DI was correlated with both MMRC and VHI-10 score. CONCLUSION: Of 57 patients undergoing SILSI, 37 did not require further operative intervention. Improvements in inter-operative interval, dyspnea, and voice were observed across patients. Randomized trials to identify which patients may benefit most from SILSI are warranted.

Pre-tracheotomy for Potentially Emergent Airway Scenarios: Indications and Outcomes.

OBJECTIVES/HYPOTHESIS: Airway access in the setting of unsuccessful ventilation and intubation typically involves emergent cricothyrotomy or tracheotomy, procedures with associated significant risk. The potential for such emergent scenarios can often be predicted based on patient and disease factors. Planned tracheotomy can be performed in these cases but is not without its own risks. We previously described a technique of pre-tracheotomy or exposing the tracheal framework without entering the trachea, as an alternative to planned tracheostomy in such cases. In this way, a tracheotomy can be easily completed if needed, or the wound can be closed if it is not needed. This procedure has since been used in an array of indications. We describe the clinical situations where pre-tracheotomy was performed as well as subsequent patient outcomes. METHODS: Retrospective series of patients undergoing a pre-tracheotomy from 2015 to 2020. Records were reviewed for patient characteristics, indication, whether the procedure was converted to tracheotomy or closed at the bedside, and any post-procedural complications. RESULTS: Pre-tracheotomy was performed in 18 patients. Indications included failed extubation after head and neck reconstruction, subglottic stenosis, laryngeal masses, laryngeal edema, thyroid masses, and an oropharyngeal bleed requiring operative intervention. Tracheotomy was avoided in 10 patients with wound closed at the bedside; procedure was converted to tracheotomy in the remaining eight. There were no complications. Indications for conversion included failed extubation, intraoperative hemorrhage, significant stridor with dyspnea, and inability to ventilate. CONCLUSION: Pre-tracheotomy offers simplified airway access and provides a valuable option in scenarios where tracheotomy may, but not necessarily, be needed. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2802-E2809, 2021.

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

OBJECTIVES: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. METHODS: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. RESULTS: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. CONCLUSIONS: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

Proteomic and Genomic Methylation Signatures of Idiopathic Subglottic Stenosis.

OBJECTIVE: Idiopathic subglottic stenosis (iSGS) is a chronic inflammatory condition that causes dyspnea and affects middle-aged women of White race and non-Latino or Hispanic ethnicity. To better characterize its phenotype and pathogenesis, we assessed the proteomic and genomic methylation signatures of subglottic tissue collected from iSGS patients compared to controls. STUDY DESIGN: Molecular analysis of clinical biospecimens. METHODS: We collected subglottic tissue biopsies from 12 patients during direct laryngoscopy, immediately prior to surgical treatment of iSGS; as well as from 4 age-, sex-, and race/ethnicity-matched control patients undergoing other direct laryngoscopic procedures. We isolated protein and genomic DNA, acquired proteomic data using label-free quantitative mass spectrometry techniques, and acquired genome-wide methylation data using bisulfite conversion and a microarray platform. We compared molecular profiles across the iSGS and control groups, and with respect to clinical course in the iSGS group. Eight of the 12 iSGS patients underwent subsequent blood collection and plasma isolation for further assessment. RESULTS: Proteomic analysis revealed 42 differentially abundant proteins in the iSGS biopsies compared to controls, inferring enrichment of biological pathways associated with early wound healing, innate immunity, matrix remodeling, and metabolism. Proteome-based hierarchical clustering organized patients into two iSGS and one control subgroups. Methylation analysis revealed five hypermethylated genes in the iSGS biopsies compared to controls, including the biotin recycling enzyme biotinidase (BTD). Follow-up analysis showed elevated plasma BTD activity in iSGS patients compared to both controls and published normative data. CONCLUSION: iSGS exhibits distinct proteomic and genomic methylation signatures. These signatures expand current understanding of the iSGS phenotype, support the possibility of disease subgroups, and should inform the direction of future experimental studies. LEVEL OF EVIDENCE: Not applicable Laryngoscope, 131:E540-E546, 2021.

Pain Experience and Tolerance of Awake In-Office Upper Airway Procedures: Influencing Factors.

OBJECTIVES/HYPOTHESIS: Awake, unsedated in-office upper airway procedures are performed frequently and have high completion rates, yet less is known about the patients' pain experience and potentially influencing factors. It is also unclear if patients' pain experiences become worse with repeated procedures. We identified procedure- and patient-related factors that might influence procedural completion and pain scores. STUDY DESIGN: Retrospective chart review. METHODS: Pre-, intra-, and post-procedure pain scores were collected prospectively for awake unsedated upper airway procedures performed at a single institution over a 5-year period. Patient factors reviewed were demographics, body mass index, psychiatric and/or pain diagnosis, and related medications. Procedure factors reviewed were procedure type, route, side, and performance of the same procedure multiple times. Patients reported their pain level before, during, and after the procedure using a standard 0 to 10 scale. Maximum pain score change (PΔmax), or the difference between highest and lowest reported pain levels, was calculated. Descriptive and multivariate analyses were performed. RESULTS: Procedure completion was 98.7% for 609 first time patients and 99.0% in 60 patients undergoing 292 repeat procedures. PΔmax did not covary with age, gender, or BMI. PΔmax covaried with pain and psychiatric conditions and associated medications. PΔmax was highest for injection medialization and lowest for tracheoscopy. PΔmax decreased over time for those undergoing multiple identical procedures. CONCLUSIONS: Procedures were performed with a very high completion rate and low pain scores. Age, sex, and BMI did not affect pain experience. A combination of pain and psychiatric conditions did. Injection medialization had the highest PΔmax and tracheoscopy the lowest. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1580-E1588, 2021.

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research. Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease. Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook. Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications. Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk. Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

Office-Based Steroid Injections for Idiopathic Subglottic Stenosis: Patient-Reported Outcomes, Effect on Stenosis, and Side Effects.

OBJECTIVE: Office-based steroid injection has shown promise for idiopathic subglottic stenosis (iSGS). It is important to understand safety and patient-lived experience. We report patient experience related to airway restriction, voice, and side effects. METHODS: Sixteen patients (51 ± 14 years) with mild-moderate (20-50%) stenosis undergoing office-based transnasal steroid injections were included; fourteen had prior operations. Patients typically underwent three injections, 1 month apart, followed by transnasal tracheoscopy 1 month later to evaluate outcome; number of injections can vary based on disease severity and response. Outcomes were Dyspnea Index (DI), Modified Medical Research Council (MMRC) dyspnea scale, voice handicap index-10 (VHI-10), and degree of stenosis (estimated from procedural video). At each visit, patients were queried about post-injection airway restriction and side effects. Paired t-tests compared values at baseline versus follow-up tracheoscopy. RESULTS: DI decreased (t = 3.938, P = 0.0013), as did MMRC (t = 2.179, P = 0.0457). There was no change in VHI-10 (t = 1.354; P = 0.1957) scores. Airway stenosis decreased (t = 4.331; P = 0.0006); this was not correlated with change in DI (r = 0.267, P = 0.318). Side effects included airway restriction lasting <48 hours (n = 5), cough (n = 3), and nasal pain (n = 2). CONCLUSION: Steroid injections improved upper airway symptoms. Side effects were mild and transient. Improvement in DI did not correlate with percent stenosis.

Microlaryngeal Teaching Courses: A National Survey on Prevalence, Value, and Barriers to Implementation.

OBJECTIVE: To assess the prevalence of microlaryngeal teaching course in Accreditation Council for Graduate Medical Education (ACGME)-accredited otolaryngology residency programs in an effort to evaluate the nature, perceived value and barriers to implementation of microlaryngeal courses. METHOD: A 14-question survey to all ACGME-accredited otolaryngology programs in the United States. RESULT: Out of 119 ACGME-accredited otolaryngology programs identified on the ACGME Fellowship and Residency Electronic Interactive Database, responses were received from 67 programs (56%). Although 90% of respondents indicated that instruction courses in one discipline or another existed at their institution for their otolaryngology residents, only 33% indicated that their program offers a hands-on instruction course in microlaryngeal surgery. Of those programs that offered a microlaryngeal surgery course, 100% felt the residents appreciated the course; 95% of those programs that did not have a course felt their residents would appreciate a microlaryngeal course at their institution if they were able to offer one. Among programs without a microlaryngeal teaching course, the largest perceived barriers were cost and availability of appropriate equipment. CONCLUSION: Microlaryngeal courses for otolaryngology residency training are limited in availability in the United States, and there is variability in training across the country. All respondents in our survey indicated the value in these courses for microlaryngeal surgical skill training. There is a clear role for increasing availability of low-cost microlaryngeal stations and courses.

Sulcus Vocalis.

Sulcus vocalis, defined as a type of groove along the free edge of the vocal fold, disrupts the normal, pliable vocal fold cover, causing alterations in the intrinsic mucosal wave. The primary symptom is breathy, effortful dysphonia. Diagnosis may be challenging, and this classically has led to difficulties with identification and management. Treatment options, although often promising, have been notoriously unreliable. Current understanding, considerations for management, and future treatment options are explored.

High-resolution manometry and swallow outcomes after vocal fold injection medialization for unilateral vocal fold paralysis/paresis.

BACKGROUND: Injection medialization is performed to improve glottic closure, thereby airway protection. Overall objective to determine if unilateral injection medialization changes glottal area with concomitant adjustments in penetration/aspiration scale (PAS) scores and pharyngeal high-resolution manometry (HRM) parameters. METHODS: Enrolled 17 adults with unilateral vocal fold paralysis/paresis and aspiration/penetration. Fiberoptic endoscopic evaluation of swallowing and pharyngeal HRM completed at (1) baseline (within 1 week before injection), (2) postinjection (within 1 week post injection), and (3) 1-month postinjection. Comparisons between time points for PAS scores, glottal area, pharyngeal pressure, and timing. RESULTS: No significant differences in normalized glottal area. No significant differences in PAS scores, for any consistency. Significantly increased rate of mesopharynx pressure rise and maximum pressure at 1 month postinjection (P = .01 and .02, respectively) compared to baseline. Significant decrease in mesopharynx integral from baseline to 1 week postoperative (P = .03). CONCLUSION: Findings suggest unilateral vocal fold injection medialization had limited effect on swallow function.

Comparing Videostroboscopy and Direct Microlaryngoscopy: An Argument for Flexible Consent and Operative Plan.

INTRODUCTION: Office-based evaluation of glottic lesions has progressed significantly, but there can still be discrepancies compared with direct microlaryngoscopy (DML) in the operating room. We performed a prospective evaluation comparing diagnosis of epithelial and lamina propria glottic lesions on rigid telescopic strobovideolaryngoscopy (RTS) with DML. METHODS: Fifty subjects were enrolled and underwent RTS followed by DML. We compared presence and extent (unilateral or bilateral) of lamina propria and epithelial lesions. Primary (diagnoses motivating an operation) and secondary (diagnoses not requiring an operation) were considered. Changes in diagnosis and operative plan based on DML findings were evaluated. RESULTS: Sixty-eight lesions were identified on RTS, including 53 primary (15 epithelial, 38 lamina propria) and 15 secondary diagnoses. RTS was accurate in only 36% of subjects. Ten subjects had a different primary pathology identified on DML. A change in surgical management occurred in 16% of subjects. CONCLUSIONS: This is the first prospective study evaluating how both diagnosis and operative plan for epithelial and lamina propria glottic lesions differ based on RTS and DML. Despite significant advances in office-based diagnosis of glottic lesions, there are still notable limitations. Clinicians should consider these findings when counseling patients on interpretation and plan for findings based on RTS. Obtaining a flexible surgical consent and counseling patients on the potential for new diagnoses and interventions based on DML is warranted.

Idiopathic Supraglottic Stenosis Refractory to Multiple Interventions Improved With Serial Office-based Steroid Injections.

PURPOSE: The objective of this study was to describe a patient with idiopathic supraglottic stenosis who experienced persistent disease despite multiple office-based and operative interventions, whose disease is now better controlled with scheduled serial office-based steroid injections. METHODS: This is a case report and literature review. RESULTS: A 42-year-old female was referred for worsening supraglottic stenosis despite systemic steroids. She underwent awake tracheotomy. A thorough historical, histologic, and laboratory workup did not reveal an etiology to her stenosis. She later underwent endoscopic partial laryngectomy and was able to be decannulated. She underwent a second endoscopic partial laryngectomy two years later for worsening disease and then was managed over the next seven years with intermittent systemic steroids. Over the last year, she has undergone eight office-based steroid injections with improvement in her degree of stenosis and symptom burden. CONCLUSIONS: There are only four prior reported cases of idiopathic supraglottic stenosis, none of which has been managed with serial office-based steroid injections. This case report adds to the small body of literature on the management of this rare disease and proposes a new office-based treatment pathway that may help induce regression of stenosis.

Endoscopic Management of Idiopathic Subglottic Stenosis.

OBJECTIVE: To describe a homogeneous idiopathic subglottic stenosis (ISS) population undergoing endoscopic balloon dilation and evaluate factors affecting inter-dilation interval (IDI). METHODS: Retrospective review of 37 patients. Co-morbidity prevalence versus normal population was evaluated using chi-square tests. Correlations were evaluated using Pearson product moment tests. Independent samples t tests/rank sum tests assessed differences between groups of interest. RESULTS: All patients were female aged 45.9 ± 15.4 years at diagnosis. Four required a tracheotomy during management. Most prevalent co-morbidity was gastroesophageal reflux disease (GERD) (64.9%; P = .036). Body mass indices (BMI) at first and most recent dilation were 29.8 and 30.8 ( P = .564). Degree of stenosis before first dilation was 53 ± 14%. Patients underwent 3.8 ± 1.8 dilations (range, 1-11). Average IDI was 635 ± 615 days (range, 49-3130 days), including 556 ± 397 days for patients receiving concomitant steroid injection and 283 ± 36 for those who did not ( P = .079). Inter-dilation interval was not correlated with BMI ( r = 0.0486; P = .802) or number of co-morbidities ( r = -0.225, P = .223). CONCLUSIONS: Most patients with ISS can be managed endoscopically, and IDI may be increased with steroid injection. Gastroesophageal reflux disease is a common co-morbidity. Body mass index did not change over time despite potential effects on exercise tolerance; BMI did not affect IDI. Methods to determine optimal timing for next intervention are warranted.

Voice Outcomes following a Single Office-Based Steroid Injection for Vocal Fold Scar.

OBJECTIVE: Persistent dysphonia from vocal fold scar remains a clinical challenge, with current therapies providing inconsistent outcomes. We evaluated voice outcomes after a single office-based steroid injection. STUDY DESIGN: Case series with chart review. SETTING: Academic medical center. SUBJECTS AND METHODS: This study was based on pre- and postoperative analysis of patient-reported, perceptual, acoustic, aerodynamic, and videostroboscopic parameters. The sample comprised 25 patients undergoing office-based dexamethasone injection into the superficial lamina propria for mild/moderate vocal fold scar. Average follow-up was 13.7 ± 4.4 weeks; patients completed 3.5 ± 2.3 sessions of voice therapy between assessments. Complete data sets were not available for each parameter; sample size is noted with results. RESULTS: Voice handicap index (n = 24; P < .001) and glottal function index (n = 22; P < .001) decreased after injection. Total GRBAS score (grade, roughness, breathiness, asthenia, strain) decreased (n = 25; P < .001). Fundamental frequency range increased (n = 24; P = .024). Phonation threshold pressure decreased (n = 14; P = .017). Videostroboscopic parameters of vocal fold edge (P = .004), glottic closure (P = .003), and right mucosal wave (P = .016) improved after injection. CONCLUSIONS: Office-based steroid injection combined with voice therapy for mild/moderate vocal fold scar is associated with improved patient-reported and functional voice measures. These findings provide preliminary support for this approach. Importantly, the procedure is low risk and can be performed in the office, thus offering a simple treatment alternative to patients with a disorder that has traditionally been difficult to manage. Prospective studies evaluating the effects of multiple injections are warranted.

Practice variations in voice treatment selection following vocal fold mucosal resection.

OBJECTIVES/HYPOTHESIS: To characterize initial voice treatment selection following vocal fold mucosal resection in a Medicare population. STUDY DESIGN: Retrospective analysis of a large, nationally representative Medicare claims database. METHODS: Patients with > 12 months of continuous Medicare coverage who underwent a leukoplakia- or cancer-related vocal fold mucosal resection (index) procedure during calendar years 2004 to 2009 were studied. The primary outcome of interest was receipt of initial voice treatment (thyroplasty, vocal fold injection, or speech therapy) following the index procedure. We evaluated the cumulative incidence of each postindex treatment type, treating the other treatment types as competing risks, and further evaluated postindex treatment utilization using the proportional hazards model for the subdistribution of a competing risk. Patient age, sex, and Medicaid eligibility were used as predictors. RESULTS: A total of 2,041 patients underwent 2,427 index procedures during the study period. In 14% of cases, an initial voice treatment event was identified. Women were significantly less likely to receive surgical or behavioral treatment compared to men. From age 65 to 75 years, the likelihood of undergoing surgical treatment increased significantly with each 5-year age increase; after age 75 years, the likelihood of undergoing either surgical or behavioral treatment decreased significantly every 5 years. Patients with low socioeconomic status were significantly less likely to undergo speech therapy. CONCLUSION: The majority of Medicare patients do not undergo voice treatment following vocal fold mucosal resection. Further, the treatments analyzed here appear disproportionally utilized based on patient sex, age, and socioeconomic status. Additional research is needed to determine whether these observations reflect clinically explainable differences or disparities in care. LEVEL OF EVIDENCE: 2c. Laryngoscope, 126:2505-2512, 2016.

Evaluation of the Dysphonic Patient (in: Function Preservation in Laryngeal Cancer).

The evaluation of the dysphonic patient begins with a complete understanding of the laryngeal anatomy and physiology of voice production. A thorough history must be taken regarding the dysphonia qualities, alarming symptoms, and confounding factors. The complete head and neck examination culminates in a detailed visualization of the vocal folds using image-capturing laryngoscopy as well as stroboscopy or high-speed digital imaging to fully evaluate the viscoelastic properties of the vocal fold cover-body structure and function. Finally, the evaluation leads to the biopsy of any concerning lesions either under magnification in the operating room or topical anesthesia in the office.