Deep learning in voice analysis for diagnosing vocal cord pathologies: a systematic review.

OBJECTIVES: With smartphones and wearable devices becoming ubiquitous, they offer an opportunity for large-scale voice sampling. This systematic review explores the application of deep learning models for the automated analysis of voice samples to detect vocal cord pathologies. METHODS: We conducted a systematic literature review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. We searched MEDLINE and Embase databases for original publications on deep learning applications for diagnosing vocal cord pathologies between 2002 and 2022. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2). RESULTS: Out of the 14 studies that met the inclusion criteria, data from a total of 3037 patients were analyzed. All studies were retrospective. Deep learning applications targeted Reinke's edema, nodules, polyps, cysts, unilateral cord paralysis, and vocal fold cancer detection. Most pathologies had detection accuracy above 90%. Thirteen studies (93%) exhibited a high risk of bias and concerns about applicability. CONCLUSIONS: Technology holds promise for enhancing the screening and diagnosis of vocal cord pathologies. While current research is limited, the presented studies offer proof of concept for developing larger-scale solutions.

A Very Rare Complication of Vocal Fold Augmentation With Calcium Hydroxylapatite: Neck Abscess.

INTRODUCTION: Vocal fold injection augmentation is performed routinely for the treatment of glottic insufficiency especially due to unilateral vocal fold paralysis. There are numerous materials that are used for injection laryngoplasty, calcium hydroxylapatite being one of them. CASE REPORT: We present an interesting case of a 64-year-old male patient with metastatic acinic cell carcinoma of the right parotid gland, who underwent right vocal cord injection laryngoplasty with calcium hydroxylapatite for right vocal cord paralysis with glottal insufficiency and developed a neck abscess. DISCUSSION: This is the first report in the literature of neck abscess following vocal fold injection laryngoplasty using calcium hydroxylapatite. It seems that over injection of the vocal fold gave rise to extravasation of the injected material outside the laryngeal framework which later became a nidus for infection. CONCLUSIONS: We present the first case in the literature of neck abscess following vocal fold injection laryngoplasty using calcium hydroxylapatite. Clinicians should be aware of this rare but dangerous complication.

Non-contact optical in-vivo sensing of cilia motion by analyzing speckle patterns.

Cilia motion is an indicator of pathological-ciliary function, however current diagnosis relies on biopsies. In this paper, we propose an innovative approach for sensing cilia motility. We present an endoscopic configuration for measuring the motion frequency of cilia in the nasal cavity. The technique is based on temporal tracking of the reflected spatial distribution of defocused speckle patterns while illuminating the cilia with a laser. The setup splits the optical signal into two channels; One imaging channel is for the visualization of the physician and another is, defocusing channel, to capture the speckles. We present in-vivo measurements from healthy subjects undergoing endoscopic examination. We found an average motion frequency of around 7.3 Hz and 9.8 Hz in the antero-posterior nasal mucus (an area rich in cilia), which matches the normal cilia range of 7-16 Hz. Quantitative and precise measurements of cilia vibration will optimize the diagnosis and treatment of pathological-ciliary function. This method is simple, minimally invasive, inexpensive, and promising to distinguish between normal and ciliary dysfunction.

Two-dimensional Scheme for Arranging Voice Disorders.

Importance: Prevalent schemes that have been used for arranging voice pathologies have shaped theoretical and clinical views and the conceptualization of the pathologies and of the field as a whole. However, these available schemes contain inconsistencies and categorical overlaps. Objective: To develop and evaluate a new approach for arranging voice pathologies, using 2 continuous scales, organicity and tonicity, which were used to construct a 2-dimensional plane. Design, Setting, and Participants: This survey study was conducted among experts in the fields of laryngology and/or voice disorders from 10 countries. The survey was conducted using an online platform from March to May 2021. The data were analyzed in June 2021. Of the 45 experts who were initially approached, 39 (86.7%) completed the survey. Main Outcomes and Measures: The primary outcome measures were group ratings on 2 rating scales: organicity and tonicity. On the organicity scale, 0 represented nonorganic and 10 organic. On the tonicity scale, 0 represented hypotonic and 10 hypertonic. Results: Participants included 16 laryngologists and 23 speech-language pathologists, of whom 27 (69.2%) were women and 12 (30.8%) men with a mean age of 55 years. The Cronbach α was high for organicity and tonicity (0.98 and 0.97, respectively). Interrater agreement (rwg) was moderate to very strong (rwg≥0.50) for most pathologies. The correlation between the 2 scales was moderate and negative (r = -0.38; P = .03). The pathologies were scattered across the full range of both scales and the 4 quadrants of the 2-dimensional plane, suggesting the continuity and bidimensionality of the new arrangement scheme. In addition, a latent profile analysis suggested that the 4-cluster solution is valid and roughly corresponded to the 4 quadrants of the constructed plane. Conclusions and Relevance: The findings of this survey study suggest the potential use of a 2-dimensional plane that was based on 2 continuous scales as a new arrangement scheme for voice disorders. The results suggest that this approach provides a valid representation of the field based on 2 basic measures beyond the specific etiology of each laryngeal pathology or condition. This simple and comprehensive organization scheme has the potential to facilitate new insights on the nature of voice pathologies, considering the interpathology similarities and differences.

How face masks influence the sinonasal quality of life during the COVID-19 pandemic.

PURPOSE: To study different mask types' impact on a sinonasal quality of life. METHODS: For this observational cross-sectional study, a web-based survey was distributed via social media forums. We used the validated Hebrew version of the Sinonasal Outcome Test-22 followed by a questionnaire developed specifically for the present study, focusing on the time of the COVID-19 pandemic (Mask Sinonasal Outcome Test), and questions regarding general health issues. The participants' mask-wearing routine was also studied. RESULTS: Seventy percent of 351 participants had experienced a change in their breathing during the time of the pandemic. The median total Sinonasal Outcome Test-22 score was 13, and 10% of the participants reported a significantly impaired quality of life. According to multivariate analyses, the only subject-related variables significantly associated with the reduced sinonasal quality of life were female gender, younger age, a background of chronic rhinitis and sinusitis, and the mask-wearing average daily duration. The mask sinonasal outcome test convergent validity was confirmed. CONCLUSION: The majority of our survey's responders, predominantly female and younger participants, reported reduced sinonasal quality of life in the COVID-19 pandemic period. It can be attributed to mask-wearing, especially for a prolonged time, irrespective of the existing mask type. These findings should encourage medical companies to produce more "airway-minded" personal protection equipment.

Imaging of the age-related anatomical relationship between the innominate artery and the trachea.

PURPOSE: To measure the age-dependent changes of anatomical positions and relations between the trachea, cricoid cartilage (CC), and innominate artery (IA) in adults by computed tomography (CT). METHODS: A retrospective cohort reviewing images of 127 consecutive adult patients who underwent CT angiography (CTA) of the neck. The trachea-to-IA (T-IA) distance was measured as the minimal horizontal distance between them. The vertical distance between the CC and the IA was measured between the axial section, demonstrating the CC's inferior border to the axial section at the level of the T-IA measurement. RESULTS: Images of 125 patients (median age 53 years, range 18-89; 74 males) were reviewed. The mean T-IA distance was 2.3 ± 1.1 mm for males and 1.7 ± 0.9 mm for females (P = 0.002). The vertical C-IA distance was 44.2 ± 11.4 mm and 49.5 ± 12.5 mm for males and females, respectively (P = 0.01). Age correlated negatively with the vertical C-IA distance (P < 0.0001) and positively with the T-IA distance (P < 0.0001). The rate of IA variants was 23.2%, with no significant difference between the measurements of distances among patients with or without IA variants. CONCLUSIONS: This is the first description of the relationships between the trachea, CC, and IA distances in adults as depicted on CTA. The T-IA distance becomes larger while the T-CC distance becomes shorter with age.

Physical and Visual Characteristics of the Neck Predicting Gender Perception.

The association between neck characteristics (physical and visual) and the perception of gender is unclear. This association is critical, especially when the perception of the speakers' gender is of interest, such as in transgender patients. This study was the first to provide basic empirical data on this association among cisgender men and women. METHODS: The necks of 30 adult men and women were measured physically and then photographed and evaluated visually by a group of 10 judges. These judges also evaluated voice recordings of the same speakers. Another group of 124 judges rated the visual and auditory masculinity/femininity of the necks and the voices. RESULTS: While most physical measures of the neck were larger for men, neck-length did not significantly differ between genders. A stepwise multiple regression model revealed that the single physical measure that consistently differed between genders was neck-girth (P < 0.0001). The single visual-appearance measure that consistently differed between genders was thyroid-protrusion (P = 0.0003). Neck-girth was the only physical characteristic that significantly correlated with gender differences in voice. Furthermore, the size of the thyroid prominence (ie, Adam's apple) was not associated with gender differences in voice. CONCLUSIONS: Neck characteristics (both physical and visual) are significantly associated with the perception of gender. While larger necks are typically perceived as masculine, neck-length is neither associated with gender nor with the speaker's voice characteristics. These findings highlight the importance of examining various physical and visual characteristics of the neck, when considering a feminization confirmation procedure for transgender patients.

Awake Tracheostomy: Indications, Complications and Outcome.

BACKGROUND: Awake tracheostomy (AT) is aimed at securing the airway of patients with upper airway obstruction when other means are not feasible or have failed. Reports on AT in the literature are scarce. The goal of this study was to review our experience with the indications, complications and outcome of AT. METHODS: A retrospective chart review was conducted on all ATs performed between 2010 and 2016 in two university-affiliated, tertiary medical centers. Data on demographics, indications, techniques, urgency and postoperative complications were retrieved from the medical charts. RESULTS: The 37 of the 1023 recorded tracheostomies (3.62%) that were ATs comprised the study group (mean age of the patients 60.3 years, 32 [86.5%] males). The most common indication was head and neck (HN) malignancy (oncologic group, 70.3%), with the larynx (53.8%) being the most commonly involved site. Patients in the non-oncologic group (n = 11) were significantly younger (P = 0.048) and had a significantly higher prevalence of urgent surgery compared to the oncologic group (P = 0.0009). Major postoperative complications included tube dislodgement (n = 2) and pneumothorax (n = 1) that were managed successfully. One of the two patients with severe hypoxia and arrhythmia that necessitated cardiopulmonary resuscitation died. CONCLUSION: Whether the etiology of the AT was related to HN oncological disease or not was the most important clinical factor in our cohort. The non-oncologic group was significantly younger, suffered from more urgent events and tended to have more complications (nonsignificant). ATs had a 97.3% rate of immediate survival, a 5.4% risk of major irreversible complications and a 2.7% risk of mortality.

The Accuracy of Preoperative Rigid Stroboscopy in the Evaluation of Voice Disorders in Children.

OBJECTIVES: Stroboscopy is considered the most appropriate tool for evaluating the function of the vocal folds but may harbor significant limitations in children. Still, direct laryngoscopy (DL), under general anesthesia, is regarded the "gold standard" for establishing a diagnosis of vocal fold pathology. The aim of the study is to examine the accuracy of preoperative rigid stroboscopy in children with voice disorders. STUDY DESIGN: This is a retrospective study. METHODS: A retrospective study was conducted on a cohort of 39 children with dysphonia, aged 4 to 18 years, who underwent DL. Twenty-six children underwent rigid stroboscopy (RS) prior to surgery and 13 children underwent fiber-optic laryngoscopy. The preoperative diagnoses were matched with intraoperative (DL) findings. RESULTS: DL was found to contradict preoperative evaluations in 20 out of 39 children (51%) and in 26 out of 53 of the findings (49%). Overdiagnosis of cysts and underdiagnosis of sulci were noted in RS compared to DL. The overall rate of accuracy for RS was 64%. CONCLUSIONS: The accuracy of rigid stroboscopy in the evaluation of children with voice disorders was found to be similar with previous reports in adults.

Novel Anatomic Characteristics of the Laryngeal Framework: A Computed Tomography Evaluation.

OBJECTIVE: The thyroid cartilage (TC) in men has a more prominent thyroid notch and a narrower interlaminae angle (ILA) as compared with women. Anatomy textbooks classically stipulate that the ILA is 90° in men and 120° in women. Our observation, based on thyroid chondroplasty operations, of a much narrower angle led to the current investigation. STUDY DESIGN: Cohort imaging study. SETTING: Tertiary academic referral center. SUBJECTS AND METHODS: Computed tomography angiography neck images of adult patients were studied. The ILA was measured on 2 axial planes: at the level of the vocal processes (and the upper portion of thyroarytenoid muscles) and 5 mm superior and parallel to the former. The anterior projection of the TC and the vertical dimensions of the midline cricothyroid membrane (CTM) were also measured. RESULTS: A total of 126 patients were included in the study. The average ILAs were 63.5°±20.6° and 93.3°±16.6° for men and women, respectively (P < 10(-14)), and were significantly narrower at the upper level in comparison with the vocal process level (P < 10(-7) for men, P = .004 for women). The anterior projection of the TC in men was more prominent as compared with women (P = .0003) and significantly correlated with the ILA (P = .0159). The length of the midline CTM was 11.1±2.3 mm in men and 10.3±1.7 mm in women (P = .0355). CONCLUSIONS: The ILA is narrower than that reported in the classic anatomy textbooks. In male patients, the upper part of the TC becomes narrower and projects anteriorly like a "jug's spout." The mean vertical dimension of the midline CTM was 10 to 11 mm.

Computerized Analysis of Vocal Folds Vibration From Laryngeal Videostroboscopy.

OBJECTIVES: To develop an objective analysis of laryngeal videostroboscopy (VSS) movies in the space-time domain for quantitative determination of the true vocal folds (TVFs) vibratory pattern to allow for detection of local pathologies at early stages of development. METHODS: Contours of the TVF and false vocal folds (FVFs) were tracked on each frame of a VSS movie. A registration algorithm was used with respect to the centerline of the FVF to eliminate movements not related to TVF vibration. The registered contours of the TVF were analyzed in time and frequency domains. RESULTS: The TVF vibration demonstrated a sinusoidal pattern with the same fundamental frequency at every section along the folds of healthy subjects, as well as detection of an abnormal area with a different fundamental frequency in TVF with local pathologies. Analysis of the TVF vibration time delay of healthy subject revealed a posterior-to-anterior longitudinal wave that was not detected by visual observation. CONCLUSIONS: An objective analysis of laryngeal VSS movies was developed for quantitative determination of the TVF vibration. This analysis was able to detect and quantify TVF characteristics in normal subjects as well as in patients with pathologies beyond the ability of examinee's naked eyes.

Acute Invasive Fungal Rhinosinusitis in Children With Hematologic Malignancies: Outcome of Surgical Treatment.

The incidence of acute invasive fungal rhinosinusitis (AIFR) is rising due to more aggressive chemotherapy and longer survival of immunosuppressed patients. Early diagnosis and appropriate but nonmutilating surgical treatment are particularly problematic in the pediatric population. This study aimed to evaluate the outcome of surgery for pediatric AIFR. Medical records of children surgically treated for AIFR between 1998 and 2014 were reviewed. Diagnosis was based on both histopathological and microbiological confirmation. Surgery was performed with curative intent and repeated for any resectable extension. The children underwent endoscopy and magnetic resonance imaging every 2 and 6 months, respectively, during the first postoperative year. Thirteen patients (2-18 years old) met the EORTC/MSG criteria for proven invasive fungal sinusitis; fungal invasion was diagnosed by preoperative biopsy and confirmed in the surgical specimen. All patients underwent an average of two endoscopic procedures (range 1-3), and four of them also underwent an open surgery. The local control rate was at least 79%. There was no facial disfiguration during follow-up (average 41 months). Although AIFR is still associated with high mortality, aggressive medical and surgical treatment provides local control in most cases. Fair outcome should encourage a maximal joint effort of pediatric hemato-oncologists and otorhinolaryngologists in the management of AIFR.

Endoscopic laser medial arytenoidectomy for treatment of bilateral vocal fold paralysis.

Endoscopic laser medial arytenoidectomy for bilateral vocal fold paralysis has the advantage of preserving the structure and the position of the vocal fold, contrary to a transverse cordotomy or total arytenoidectomy. Our objective was to evaluate the functional results of this procedure. This is a prospective non-randomized study. Twenty patients were included: five patients had a tracheotomy preoperatively and 15 patients had dyspnea on exertion. Acoustic voice measurements, spirometric parameters and the voice handicap index 120 (VHI), were evaluated 1 week before surgery and 3 months after. All the five patients with tracheotomy were successfully decannulated. Acoustic records and VHI were available for eight patients. Jitter and shimmer were worse (p = 0.0078), whereas the VHI was not significantly different after surgery. Spirometric records, available for six patients, were not modified. Endoscopic laser medial arytenoidectomy allowed decannulation and subjective improvement of quality of life in patients with bilateral vocal fold paralysis.

Noninvasive detection of aneuploid cells in laryngeal epithelial precursor lesions.

BACKGROUND: Most cases of laryngeal cancer are preceded by precursor lesions which, if left untreated, can progress toward an invasive cancer. The objective of this study was to investigate the presence of chromosomal numerical aberrations in cells that were collected by noninvasive brush sampling from laryngeal lesions. METHODS: Laryngeal brush samples from 52 patients were analyzed simultaneously for morphology and fluorescence in situ hybridization (FISH) using centromeric probes for chromosome 17, chromosome 8, and a locus-specific instability (LSI) v-myc avian myelocytomatosis viral oncogene homolog (myc) proto-oncogene protein (C-MYC) probe for the MYC gene. The patients were divided according to histopathologic diagnosis. Group 1 included patients with squamous cell carcinoma, carcinoma in situ, and severe dysplasia; Group 2 included patients with moderate dysplasia, mild dysplasia, and hyperplasia; and Group 3 included patients with benign nondysplastic lesions. RESULTS: The proportion of cells with MYC and chromosome 8 gains demonstrated significant trends toward being the highest in Group 1 and the lowest in Group 3 (P = .001 and P = .003, respectively). No significant trend was observed for chromosome 17. Mann-Whitney Bonferroni-corrected analyses revealed that the most significant contribution was the difference between Groups 1 and 3 (P = .0195 for MYC gains and P = .036 for chromosome 8 gains). When using a cutoff point of 4% aneuploid cells (ACs), both MYC and chromosome 8 differed significantly between groups (P = .030 and P = .037, respectively). CONCLUSIONS: The current results suggested that FISH analysis of brush samples obtained noninvasively from suspicious laryngeal lesions can augment the clinical examination in predicting the nature of the lesions and can aid clinicians in monitoring and follow-up of high-risk patients. Cancer (Cancer Cytopathol) 2011. © 2011 American Cancer Society.

Outcome of tracheostomy in patients over 85 years old (oldest-old patients).

OBJECTIVE: To investigate morbidity, complication rate, and mortality in oldest-old patients who undergo tracheostomy. STUDY DESIGN: Historical cohort study. SUBJECT AND METHODS: The medical records for 64 patients (>85 years) who underwent standard or percutaneous tracheostomy between 2001 and 2005 in a tertiary care hospital were reviewed for in-hospital and out-of-hospital mortality, complications, and decannulation rate. RESULTS: Twenty-eight (43.8%) patients were discharged from the hospital and all remained tracheotomized at that time. Postoperative mortality had not been related to the procedure itself and the mortality rate reached 75 percent within the first three postoperative months and 93.8 percent within the first year post-tracheostomy. The post-tracheostomy course was complicated in three (4.7%) patients. There was no significant correlation between the length of hospital stay or survival and demographic parameters, pneumonia as the reason for mechanical ventilation, or performance of surgery before tracheostomy. CONCLUSION: Tracheostomy is a safe surgical procedure in the oldest-old patients. The high rate of the postoperative mortality is not related to the procedure itself. The possibility of permanent stoma should be considered and discussed with the patients and their families during the preoperative counseling.

Posterior glottic stenosis in adults.

BACKGROUND: Posterior glottic stenosis is a complication of prolonged intubation, manifesting as airway stenosis that may mimic bilateral vocal cord paralysis. It presents a variety of features that mandate specific surgical interventions. OBJECTIVES: To summarize our experience with PSG and its working diagnosis. METHODS: We conducted a retrospective review of a cohort of adult patients with PGS operated at the Sheba Medical Center between 1994 and 2006. RESULTS: Ten patients were diagnosed with PGS, 6 of whom also had stenosis at other sites of the larynx and trachea. Since 2000, all patients underwent laryngeal electromyographic studies and direct laryngoscopy prior to surgery. Surgical interventions included endoscopic laser procedures (in 2 patients), laryngofissure and scar incision (in 1), laryngofissure with buccal mucosa grafting (in 3) or with costal cartilage grafting (in 1) and laryngofissure with posterior cricoid split and stenting (in 1); one patient was not suitable for surgery. Postoperative follow-up included periodic fiberoptic endoscopies. Voice analysis was evaluated by the GRBAS grading. Seven patients were successfully decannulated within one to three procedures. Voice quality was defined as good in 7 patients, serviceable in 2 and aphonic in 1. CONCLUSIONS: Posterior glottic stenosis may be isolated or part of complex laryngotracheal pathologies. Electromyographic studies and direct laryngoscopy must be included in the diagnostic workup. Costal cartilage or buccal mucosa grafts are reliable, safe and successful with respect to graft incorporation and subglottic remodeling.

Evaluating the validity of the Voice Handicap Index-10 (VHI-10) among Hebrew speakers.

OBJECTIVE: To evaluate the validity of a translated version of the Voice Handicap Index-10 (VHI-10). STUDY DESIGN AND SETTING: In a parallel group design, 221 patients with different laryngeal pathologies and 172 people with no laryngeal pathology completed a Hebrew version of the VHI-10. Validity and reliability were assessed as well as group differences. RESULTS: Statistical analyses demonstrated high reliability values (Cronbach's Alpha r = 0.949). Responses were not affected by age (P = 0.373) or gender (P = 0.360). The control group received significantly lower scores than all pathological groups (P < 0.05). Within the pathological groups, the "neurogenic" and "mucosa irregularity" groups were rated higher than all other pathological groups (P < 0.05). CONCLUSION: The VHI-10 questionnaire maintains its validity and reliability across translation to Hebrew. Moreover, although the VHI-10 is essentially a unidimensional tool, it provides partial information on the 3 subjective dimensions of the full VHI.

Granular myringitis: Incidence and clinical characteristics.

OBJECTIVE: To examine the incidence and the clinical features of granular myringitis (GM). STUDY DESIGN: A 2-year prospective cohort study. SETTING: A primary otolaryngology clinic affiliated with a tertiary academic referral center. PATIENTS: All-aged patients diagnosed with GM who had no apparent middle ear disease or did not undergo ear surgery. INTERVENTION: Otoscopy and bacteriologic and histopathologic studies. MAIN OUTCOME MEASURES: Granular myringitis was noted in 0.41% of patient's population presenting different forms. RESULTS: Granular myringitis was detected in 26 patients. Recurrent infection occurred in seven (26.9%) and bilateral GM in five patients (19.2%). Perforation of the tympanic membrane (TM) was noted in eight patients (30.7%), six of which closed spontaneously. Otoscopic findings could be classified into three grades: focal de-epithelization (in 10), focal polypoid granulations (in 13), and diffuse polypoid formation over the entire TM (in 3). Histopathologic examination disclosed tiny fragments of granulation tissue infiltrated by nonspecific chronic and acute inflammatory reaction. CONCLUSION: Granular myringitis is encountered not infrequently in primary otolaryngology practice and presented different forms, recurrent episodes, and bilateral involvement. Topical application of antibiotics or caustic agents was successful in all cases. Perforation of the TM may develop and resolve spontaneously during the course of the disease.

Cricotracheal resection for airway reconstruction: The Sheba Medical Center experience.

BACKGROUND: Intubation and tracheostomy are the most common causes of benign acquired airway stenosis. Management varies according to different conceptions and techniques. OBJECTIVES: To review our experience with cricotracheal resection and to assess related pitfalls and complications. METHODS: We examined the records of all patients who underwent CTR in a tertiary referral medical center during the period January 1995 to April 2005. RESULTS: The study included 61 patients (16 women and 45 men) aged 15-81 years. In 17 patients previous interventions had failed, mostly dilatation and T-tube insertion. Complete obstruction was noted in 19 patients and stenosis > 70% in 26. Concomitant lesions included impaired vocal cord mobility (n=8) and tracheo-esophageal fistula (n=5). Cricotracheal anastomosis was performed in 42 patients, thyrotracheal in 12 and tracheotracheal in 7. A staged procedure was planned for quadriplegic patients and for three others with bilateral impaired vocal cord mobility. Restenosis occurred in six patients who were immediately revised with T-tube stenting. Decanulation was eventually achieved in 57 patients (93.4%). Complications occurred in 25 patients, the most common being subcutaneous emphysema (n=5). One patient died of acute myocardial infarction on the 14th postoperative day. CONCLUSIONS: CTR is a relatively safe procedure with a high success rate in primary and revised procedures. A staged procedure should be planned in specific situations, namely, quadriplegics and patients with bilateral impaired vocal cord mobility.