Acoustics and aerodynamic effects following glottal and infraglottal medialization in an excised larynx model.

OBJECTIVE: This study aimed to investigate the impact of the implant's vertical location during Type 1 Thyroplasty (T1T) on acoustics and glottal aerodynamics using excised canine larynx model, providing insights into the optimal technique for treating unilateral vocal fold paralysis (UVFP). METHODS: Measurements were conducted in six excised canine larynges using Silastic implants. Two implant locations, glottal and infraglottal, were tested for each larynx at low and high subglottal pressure levels. Acoustic and intraglottal flow velocity field measurements were taken to assess vocal efficiency (VE), cepstral peak prominence (CPP), and the development of intraglottal vortices. RESULTS: The results indicated that the implant's vertical location significantly influenced vocal efficiency (p = 0.045), with the infraglottal implant generally yielding higher VE values. The effect on CPP was not statistically significant (p = 0.234). Intraglottal velocity field measurements demonstrated larger glottal divergence angles and stronger vortices with the infraglottal implant. CONCLUSION: The findings suggest that medializing the paralyzed fold at the infraglottal level rather than the glottal level can lead to improved vocal efficiency. The observed larger divergence angles and stronger intraglottal vortices with infraglottal medialization may enhance voice outcomes in UVFP patients. These findings have important implications for optimizing T1T procedures and improving voice quality in individuals with UVFP. Further research is warranted to validate these results in clinical settings.

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.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review.

OBJECTIVE: To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD). METHODS: Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report. RESULTS: A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03). CONCLUSION: KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2110-2115, 2023.

Surgery and Adjuvant Therapy Improve Derkay Scores in Adult and Pediatric Respiratory Papillomatosis.

OBJECTIVES/HYPOTHESIS: Comparing Derkay anatomical score at time of procedure, disease characteristics, and mean treatment interval among adult and pediatric patients with recurrent respiratory papillomatosis (RRP). STUDY DESIGN: Restrospective study. METHODS: Retrospective review of juvenile-onset (JO) and adult-onset (AO) RRP patients treated longitudinally at pediatric and adult institutions from 1999 to 2019. Patients were included if they had a tissue diagnosis of papilloma and had at least a 12-month follow-up. RESULTS: One hundred and twelve patients met inclusion criteria (68 JO-RRP and 44 AO-RRP). All patients were stratified into either potassium titanyl phosphate (KTP) (n = 42), CO2 (n = 21), or microdebrider (n = 49) treatment groups. The Derkay score improved between first and last procedure in the KTP group (mean difference, 3.5; P < .001), CO2 group (mean difference, 4.4; P < .001), and microdebrider group (mean difference, 4.1; P < .001), but overall improvement did not differ across groups (P = .73). Baseline mean to last mean Derkay score improved for nine patients during bevacizumab treatments (mean difference, 3.0; P = .01) but did not improve for these same patients during an interval prior to receiving bevacizumab treatments. Baseline mean to last mean Derkay score improved for 19 patients during cidofovir treatments (mean difference, 3.84; P < .001) but did not improve for these same patients during the interval prior to receiving cidofovir treatments. The AO-RRP population had more patients with dysplasia (50%) compared to JO-RRP population (10%) (P < .001). CONCLUSION: Various surgical modalities appear to be equally effective treatments for RRP. Adult and pediatric patients have decreased recurrent disease burden when receiving bevacizumab or cidofovir. AO-RRP patients have more concomitant dysplasia. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:2420-2426, 2022.

Surgical Treatment of Acquired Velopharyngeal Insufficiency in Adults With Dysphagia and Dysphonia.

OBJECTIVES: Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions. METHODS: A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort. RESULTS: VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision. CONCLUSION: This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions.

Montgomery's Aperture: An External Anatomic Landmark for Surgical Identification of the Anterior Commissure.

OBJECTIVES: This study evaluates the consistency of palpable identification of an external landmark for the anterior commissure (AC), termed Montgomery's aperture (MA), in cadaveric and surgical settings. METHODS: Part 1: In human cadaveric larynges, palpation of the external laryngeal framework was used to identify MA by three blinded otolaryngologists. The vertical height (VH) of the thyroid cartilage and distance from MA to the inferior border of the thyroid cartilage were measured, larynges were bisected, and the AC was identified and measured. Surface anatomy was demonstrated visually using 3D imaging. Part 2: Retrospectively collected case series used palpation of MA in thyroplasty type 1 (TT1) and compared the result to ½ VH. RESULTS: Part 1: MA was identified in seven cadavers by three surgeons. In four of seven MA was palpated at the location of AC. The average difference between the AC and MA was -0.95 ± 0.96 mm. The average difference between AC and ½VH was 0.08 ± 0.72 mm. Part 2: In 49 patients (57% females) who underwent TT1, MA correlated within ½VH in 67% of cases. MA was inferior to ½VH in 27% of cases, on average 1.08 mm ± 0.51 mm below ½VH. MA was not palpable in 6% (3 of 49) of patients. CONCLUSION: We define the MA as the external indentation or flattening of the thyroid cartilage located within 1 millimeter inferior or at ½ VH of the thyroid cartilage. MA is a reliable, reproducible, palpable landmark for the anterior commissure. It serves as an important landmark that can be used in laryngoplastic surgery in which accurate prediction of the glottis is important.

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.

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.

Open Versus Endoscopic Surgery of Zenker's Diverticula: A Systematic Review and Meta-analysis.

Most Zenker's diverticula (ZD) cohort studies are single-institution retrospective observational studies of recurrence rates. There is a gap in the literature regarding patient-reported outcomes after ZD surgery. This study was conducted to compare if open transcervical diverticulectomy (OD) is better than endoscopic laser diverticulectomy (ELD) or endoscopic stapler-assisted diverticulectomy (ESD). The study design is of systematic review and meta-analysis. The following databases were searched: SCOPUS, EMBASE, PubMed, and Word of Science through December 2017. The quality of the studies was evaluated using 22-item STROBE checklist with 3 independent physician reviewers. The Inter-rater reliability was calculated both as a percent and utilizing Cohen's Kappa. For the meta-analysis, Cohen's d for an effect size was calculated for all studies comparing dysphagia results before and after surgery. A total of 865 patients were treated across 11 selected publications, of which 106 patients were treated OD, 310 ELD, and 449 with an ESD approach. Patient-reported dysphagia outcomes were reported as Cohen's d (confidence interval): OD, ELD, and ESD were 1.31 (0.88, 1.74), 1.91 (1.62, 2.20), and 2.45 (2.04, 2.86), respectively. The pooled effect of all studies for dysphagia was 2.22 (1.85, 2.59) and regurgitation 2.20 (1.80, 2.59). We did not prove that OD has superior outcomes compared to ESD and ELD. Any method of surgical intervention yields a large effect (i.e., improvement in dysphagia and regurgitation) comparing patient-reported symptoms before and after surgery. Future research, currently underway, includes a prospective, multi-institutional study comparing standardized outcomes between treatments of ZD including symptom resolution, complications, and recurrences using validated measures to define long-term outcomes.Level of Evidence 3.

Cervical slide tracheoplasty in adults with laryngotracheal stenosis.

OBJECTIVES: 1) Evaluate success rates for adults undergoing cervical slide tracheoplasty. 2) Examine complication rates of slide tracheoplasty in adults. METHODS: A retrospective cohort of adults > 21 years of age undergoing cervical slide tracheoplasty for tracheal stenosis between October 2011 and August 2017 was reviewed. Comorbidities, stenosis grade, etiology of stenosis, primary versus revision surgery, complications, and number of adjunct endoscopic procedures required postoperatively were evaluated. RESULTS: Nineteen patients (63% female) underwent cervical slide tracheoplasty during the study period (median age 30 years, range 21-70). The most common etiology of stenosis was iatrogenic (68%), followed by congenital etiologies (26%). Fifty-eight percent of patients had undergone a previous open airway procedure. Thirty-nine percent were tracheostomy-dependent prior to surgery, and the remainder had severe exercise intolerance. Sixty-three percent were successfully extubated on the operating room table at the end of the procedure. Six (32%) patients experienced surgical complications, including one anastomotic dehiscence, three neck abscesses requiring incision and drainage (I&D), and replacement of adjunctive airway device in two patients. Seventy percent of the patients required ≥ 1 endoscopic dilation in the first 12 months following surgery, with a median of one (range 1-8) procedure. At most recent follow-up (median 8 months, range 4-64 months), 18 of 19 (95%) of patients had minimal airway symptoms without need for tracheostomy. The one patient who was not decannulated expired of a presumed cardiac event prior to decannulation. CONCLUSION: Cervical slide tracheoplasty is an excellent reconstructive option for adult patients with tracheal stenosis, including those with history of previous airway reconstruction. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:818-822, 2019.

Office-based esophageal dilation in head and neck cancer: Safety, feasibility, and cost analysis.

OBJECTIVE: To review experience, safety, and cost of office-based esophageal dilation in patients with history of head and neck cancer (HNCA). METHODS: The medical records of patients undergoing esophageal dilation in the office were retrospectively reviewed between August 2015 and May 2017. Patients were given nasal topical anesthesia. Next, a transnasal esophagoscopy (TNE) was performed. If the patient tolerated TNE, we proceeded with esophageal dilation using Seldinger technique with the CRE™ Boston Scientific (Boston Scientific Corp., Marlborough, MA) balloon system. Patients were discharged directly from the outpatient clinic. RESULTS: Forty-seven dilations were performed in 22 patients with an average of 2.1 dilations/patient (range 1-10, standard deviation [SD] ± 2.2). Seventeen patients (77%) were male. The average age was 67 years (range 35-78 years, SD ± 8.5). The most common primary site of cancer was oral cavity/oropharynx (n = 10), followed by larynx (n = 6). All patients (100%) had history of radiation treatment. Four patients were postlaryngectomy. The indication for esophageal dilation was esophageal stricture and progressive dysphagia. All dilations occurred in the proximal esophagus. There were no major complications. Three focal, superficial lacerations occurred. Two patients experienced mild, self-limited epistaxis. One dilation was poorly tolerated due to discomfort. One patient required pain medication postprocedure. Office-based esophageal dilation generated $15,000 less in health system charges compared to traditional operating room dilation on average per episode of care. CONCLUSION: In patients with history of HNCA and radiation, office-based TNE with esophageal dilation appears safe, well-tolerated, and cost-effective. In a small cohort, the technique has low complication rate and is feasible in an otolaryngology outpatient office setting. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:2261-2267, 2018.

Vertical Phase Difference and Glottal Efficiency in Musical Theater and Opera Singers.

OBJECTIVE: The objectives of this study were to (1) determine the relationship between vertical phase difference (VPD) and glottal efficiency (GE) in singers and (2) to compare VPD and GE between musical theater and opera singing styles. METHODS: Five opera and three musical theater singers (Mean age = 25.3, 100% male) performed a series of vocal tasks at two pitches (low pitch C#3, 133 ± 5 Hz; high pitch C#4, 277 ± 5 Hz) for three levels of loudness (soft, baseline, and loud), while undergoing flexible distal chip videostroboscopy. Aerodynamic and acoustic information for each vocal task was recorded using the Phonatory Aerodynamic System. VPD was qualitatively measured via visual-perceptual judgments of repeated comparison tests, where a blinded rater was asked to select the video in which the subject demonstrated the greatest VPD. Aerodynamic data were analyzed for differences in GE. RESULTS: Qualitative visual-perceptual analysis indicated that increased magnitude of VPD was correlated with tasks involving increased loudness or higher pitch. GE was similarly correlated with increased loudness or higher pitch. GE was minimally correlated with subglottal pressure at high pitch. CONCLUSION: This prospective study reveals novel human subject evidence that VPD may correlate with GE. Future studies will further explore the implications of VPD with respect to GE, subglottal pressure, and laryngeal mechanics.

Gender and age in benign vocal fold lesions.

OBJECTIVE/HYPOTHESIS: Certain lesions appear to occur predominantly in one gender or in younger or older patients. We examined a large sample from a treatment-seeking population to describe gender and age associations of an array of benign vocal fold lesions. STUDY DESIGN: Retrospective review. METHODS: The medical records and evaluations of all adult patients presenting for care over a 5-year period were examined for demographic characteristics and lesion type. A total of 641 lesions in 602 patients were grouped into 13 broad categories, and prevalence was compared between male and female patients and three age groups. RESULTS: Pseudocysts and bilateral midfold lesions occurred principally in young (18-39 years old) females (P < 0.0001). Reinke's edema was found in older (> 39 years old) women (P < 0.012). Polyps, contact lesions, leukoplakia (all P < 0.0001), and sulcus (P < 0.0002) were found predominantly in men. CONCLUSION: Certain benign mucosal lesions are strongly associated with age and especially with gender. These differences may be explained by intrinsic differences in laryngeal anatomy and phonatory physiology in these groups, including differences in phonatory frequency and air pressure, and in the ability of the membranous vocal fold to withstand phonotrauma. Such inherent differences have implications for treatment expectations and approaches.

What can vortices tell us about vocal fold vibration and voice production.

PURPOSE OF REVIEW: Much clinical research on laryngeal airflow has assumed that airflow is unidirectional. This review will summarize what additional knowledge can be obtained about vocal fold vibration and voice production by studying rotational motion, or vortices, in laryngeal airflow. RECENT FINDINGS: Recent work suggests two types of vortices that may strongly contribute to voice quality. The first kind forms just above the vocal folds during glottal closing, and is formed by flow separation in the glottis; these flow separation vortices significantly contribute to rapid closing of the glottis, and hence, to producing loudness and high frequency harmonics in the acoustic spectrum. The second is a group of highly three-dimensional and coherent supraglottal vortices, which can produce sound by interaction with structures in the vocal tract. Present work is also described that suggests that certain laryngeal pathologies, such as asymmetric vocal fold tension, will significantly modify both types of vortices, with adverse impact on sound production: decreased rate of glottal closure, increased broadband noise, and a decreased signal to noise ratio. SUMMARY: Recent research supports the hypothesis that glottal airflow contains certain vortical structures that significantly contribute to voice quality.