Register transitions in an in vivo canine model as a function of intrinsic laryngeal muscle stimulation, fundamental frequency, and sound pressure level.

Phonatory instabilities and involuntary register transitions can occur during singing. However, little is known regarding the mechanisms which govern such transitions. To investigate this phenomenon, we systematically varied laryngeal muscle activation and airflow in an in vivo canine larynx model during phonation. We calculated voice range profiles showing average nerve activations for all combinations of fundamental frequency (F0) and sound pressure level (SPL). Further, we determined closed-quotient (CQ) and minimum-posterior-area (MPA) based on high-speed video recordings. While different combinations of muscle activation favored different combinations of F0 and SPL, in the investigated larynx there was a consistent region of instability at about 400 Hz which essentially precluded phonation. An explanation for this region may be a larynx specific coupling between sound source and subglottal tract or an effect based purely on larynx morphology. Register transitions crossed this region, with different combinations of cricothyroid and thyroarytenoid muscle (TA) activation stabilizing higher or lower neighboring frequencies. Observed patterns in CQ and MPA dependent on TA activation reproduced patterns found in singers in previous work. Lack of control of TA stimulation may result in phonation instabilities, and enhanced control of TA stimulation may help to avoid involuntary register transitions, especially in the singing voice.

A Novel Hybrid Procedure Combining Resection and Tracheoplasty for Complex Laryngotracheal Stenosis.

Adult airway stenosis is a common condition treated in the otolaryngology clinic. Patients with high-grade, long-segment stenosis often fail endoscopic management. We describe the successful use of a hybrid resection and laryngotracheoplasty procedure that maximizes airway luminal patency in adults with successful decannulation. Laryngoscope, 2024.

Heterogeneous Presentations and Serologies in Myasthenia Gravis Patients Presenting with Dysphagia.

INTRODUCTION: Myasthenia gravis (MG) is an autoimmune disease that affects the neuromuscular junction. MG patients may present de novo with primary otolaryngology complaints, including swallowing dysfunction. This study describes a range of unique presentations and rare diagnostic serologies, which have not previously been fully described. METHODS: A retrospective review was performed of all patients presenting with primary symptom of dysphagia and subsequently diagnosed with MG. Data collected included demographics, clinical presentation, swallow studies, serology, imaging, treatment, and response. RESULTS: Five patients met the inclusion criteria. Four endorsed dysphagia as primary complaint and one endorsed dysphagia and dysphonia. All patients underwent in-office swallow evaluations that showed vallecular or pyriform sinus residue. Three patients completed modified barium swallow studies that showed pharyngeal weakness and epiglottic dysfunction in all, and upper esophageal sphincter dysfunction in two. One patient with additional symptom of dyspnea was admitted and found to be in myasthenic crisis. Upon serologic evaluation, three patients were positive for acetylcholine receptor (AChR) antibodies only, one for muscle-specific-kinase (MuSK) antibodies only, and one for low density lipoprotein receptor-related protein 4 (LRP4) antibodies only. All patients received neurology evaluation and were treated with steroids, pyridostigmine, plasma exchange, or rituximab. In three patients with over 1 year follow-up, symptoms were significantly improved or resolved. CONCLUSION: MG is an important differential diagnosis in patients with unexplained pharyngeal dysphagia. While workup can include AChR antibody screening, in seronegative patients with persistent symptoms, additional testing for MuSK and LRP4 may lead to diagnosis and effective treatment. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.

Total tracheoesophageal puncture failure: A scoping review of patient characteristics and etiologies.

OBJECTIVES: Tracheoesophageal prosthesis (TEP) is a common method for post-laryngectomy speech rehabilitation. Despite its common use, some patients ultimately fail TEP rehabilitation. TEP dysfunction negatively affects quality of life due to poor voice quality and need for repeated interventions to restore TEP function. Occasionally, voice rehabilitation with TEP is completely unsuccessful. We performed a scoping review to characterize the main reasons for total TEP failure, in hopes of guiding selection of optimal TEP candidates. STUDY DESIGN: Scoping review using PubMed of all English language articles from 1990 to 2020 addressing causes of TEP failure. METHODS: This scoping review followed the population, intervention, comparison, outcome and study (PICOS) guidelines. Total TEP failure was defined as complete loss or abandonment of TEP voice or tract. A comprehensive search strategy using PubMed's MeSH subject headings and keywords was created. Causes and rates of failure were reviewed. RESULTS: Among 544 peer-reviewed journal articles reviewed for inclusion. Seventy articles met inclusion criteria, resulting in a total of 4928 TEP voice restoration patients for analysis. 15.2% of these patients had total TEP failure. The most common reasons for failure were dissatisfaction with voice (26.3%), leakage (17.9%), inadequate patient motivation (14.7%), comorbidities (14.2%), stoma problems (11.6%), and abandonment of TEP after dislodgement (10.6%). CONCLUSION: Common reasons for TEP failure included voice dissatisfaction, leakage, lack of patient motivation, patient comorbidities, and stoma problems. These factors should be considered when selecting candidates for TEP voice restoration.

Speech and Swallowing Outcomes of Surgically Managed Cervical Chordoma: A Case Series.

OBJECTIVES: Cervical chordoma is a rare, low-grade primary bone tumor occurring in the axial skeleton. Due to challenges in surgical exposure caused by anatomic location, patients may experience dysfunction in speech and swallowing. The objective of this study was to characterize speech and swallowing outcomes for patients undergoing surgical resection of cervical chordoma. Moreover, we detail in-depth two cases with similar initial presentations to compare prognostic factors and management strategies. METHODS: Eleven patients with histologically confirmed cervical chordoma treated between 1993 and 2020 were included in this retrospective case series. Outcomes measured included overall survival, disease-free survival, need for enteral feeds, as well as results of modified barium swallow study (MBSS) and fiberoptic laryngoscopy. RESULTS: The mean age at diagnosis was 55.9 years. The patient population was 81.8% male. Mean survival after diagnosis was 96 months. Four (36.4%) patients required post-operative MBSS and demonstrated aspiration. All four of these patients presented with tumors in the superior cervical spine and received surgeries utilizing anterior approaches. Of the four, 2 required enteral feeds long-term. Four (36.4%) patients endorsed dysphonia. One patient developed post-operative right vocal fold paresis. The remaining three patients experienced stable dysphonia pre- and post-operatively. Additionally, three (27%) patients required tracheostomy placement, two of which remained in place long-term. CONCLUSIONS: Dysphagia is a common side effect of cervical chordoma resection. It is associated with the use of an anterior approach during resection and with tumors located in the superior cervical spine. Patients with postoperative dysphagia should receive early multidisciplinary swallow rehabilitation. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:3706-3712, 2024.

Risk Analysis Index Frailty Score as a Predictor of Otolaryngology Surgical Outcomes.

OBJECTIVE: The Risk Analysis Index (RAI) score is a screening tool to assess patient frailty. It has been shown to be predictive of postoperative outcomes and mortality in orthopedic, urologic, and neurosurgical patient populations. We sought to evaluate the predictive ability of RAI score for surgical outcomes in an otolaryngology patient population. STUDY DESIGN: Retrospective study. SETTING: Academic tertiary medical center. METHODS: A retrospective study was conducted of adult patients undergoing otolaryngology surgery at a tertiary medical care center over 21 months. Patients were sent electronic RAI survey questionnaires via direct messaging, which was completed prior to surgery. Endpoint data were analyzed, including demographics, RAI score, and patient outcome data. Univariate analysis, ROC curves, and predictive modeling were utilized. RESULTS: A total of 517 patients responded to the RAI questionnaire, resulting in a 59.6% response rate. Mean RAI score was 21.38 ± 11.83. Higher RAI scores were associated with increased 30-day readmissions (P < .0015), postoperative complications (P < .001), hospital length of stay (P < .001), and discharge with home health (P < .001). Predictive models for RAI score and postoperative outcomes were created, and a cutoff score of RAI = 30 was established to identify frail patients. CONCLUSION: We evaluated if RAI scoring predicted postoperative complications in an otolaryngology patient population. Increased RAI score is significantly associated with poorer surgical outcomes, including increased hospital length of stay, 30-day readmissions, and postoperative complications. We propose a predictive model with suggested RAI cutoff scoring for use in the otolaryngology surgical population.

Prospective Outcomes After Serial Platelet-Rich Plasma (PRP) Injection in Vocal Fold Scar and Sulcus.

OBJECTIVE: Vocal fold scar and sulcus pose significant treatment challenges with no current optimal treatment. Platelet-rich plasma (PRP), an autologous concentration of growth factors, holds promise for regenerating the superficial lamina propria. This study aims to evaluate the potential benefits of serial PRP injections on mucosal wave restoration and vocal function. METHODS: In a prospective clinical trial across two institutions, patients with vocal fold scar underwent four serial PRP injections, one month apart. Blinded independent laryngologists and expert listeners used pretreatment and one-month post-fourth injection videostroboscopy and CAPE-V assessments to evaluate mucosal wave and voice quality changes, respectively. Additionally, patient reported outcome measures (PROMs) were evaluated. RESULTS: In the study, 15 patients received 55 PRP injections without adverse effects. Eight patients (53.3%) had mild, three patients (20%) had moderate, and four patients (26.7%) had severe scar. There was an average reduction of 8.7 points in post-treatment VHI-10 scores (p = 0.007). The raters observed an improvement in post-treatment voice in 73.4% of cases, and CAPE-V scores showed a reduction of 18.8 points on average (p = 0.036). The videostroboscopic VALI ratings showed an improvement in mucosal wave rating from 2.0 to 4.0. On average, the raters perceived the post-PRP exams to be better in 56.7% of cases. CONCLUSIONS: PRP has been validated as a safe autologous option for treatment of vocal fold scar. While results for mucosal wave and voice quality varied, there was a consistent improvement in PROMs. LEVEL OF EVIDENCE: Level 3: Prospective cohort study, with blinded analysis Laryngoscope, 2024.

Acid Peptic Disease among Patients with Acute Abdomen Visiting the Department of Emergency Medicine in a Tertiary Care Centre.

Introduction: Acid peptic disease is caused by excessive acid secretion or weakened mucosal defense. Symptoms include epigastric pain, bloating, and nausea. Factors like gastric acid, Helicobacter pylori infection, alcohol consumption, smoking, and stress contribute to peptic ulcers. Imbalances between offensive and defensive factors can lead to ulcers. Acid-related disorders impact the quality of life and mortality. Accurate diagnosis and prompt treatment are vital. This study aimed to find out the prevalence of acid peptic disease among patients with acute abdomen in the Department of Emergency Medicine in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted from 2 April 2022 and 2 April 2023 among the patients presented in the Department of Emergency Medicine in a tertiary care centre. Ethical approval was obtained from the Institutional Review Committee. All patients presenting with acute abdominal pain in the Emergency Department were included in the study. Patients not giving consent were excluded from the study. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Out of the 400 patients with acute abdomen, the prevalence of acid peptic disease was found to be 87 (21.75%) (17.71-25.79, 95% Confidence Interval). Conclusions: The prevalence of acid peptic disease among patients with acute abdomen was found to be lower than in other studies performed in similar settings. Keywords: acute abdomen; gastroenteritis; Helicobacter pylori; peptic ulcer.