Microbial Composition of the Laryngotracheal Region: A Systematic Review.

INTRODUCTION: Microbiome research has predominantly focused on the oral cavity and oropharynx's role in disease, while the upper airway, specifically the larynx and trachea, has been relatively overlooked. Examining the microbial communities in these regions can shed light on how dysbiosis influences diseases and their management. This review evaluates laryngotracheal microbial compositions in both healthy and diseased patients. METHODS: We conducted a systematic review in EMBASE, MEDLINE, and Cochrane Central databases, yielding 1383 studies in the initial search. Inclusion criteria involved participants aged over 18 years and the use of next-generation 16s ribosomal sequencing methods. RESULTS: We included 10 studies-seven focused on larynx sequencing and four on trachea sequencing (one investigated both sites). In a healthy larynx, diverse species such as Streptococcus, Cloacibacterium, Prevotella, and Helicobacter were found. Benign laryngeal diseases exhibited reduced microbial diversity, mainly dominated by Streptococcus. Subglottic stenosis patients showed diminished diversity in both idiopathic and iatrogenic scars. Laryngeal squamous cell carcinoma displayed increased diversity, primarily featuring Fusobacterium. Among non-respiratory-compromised surgery patients, the tracheal microbiome was more diverse in diabetics and those later developing lower respiratory infections. Pneumonia patients exhibited an abundance of Prevotella and Streptococcus, linked to an increased 28-day survival rate, while Streptococcus and Haemophilus abundance correlated with successful extubation. CONCLUSIONS: The laryngotracheal region hosts a unique microbial community influenced by both benign and malignant conditions. Many lesions remain unexplored, underscoring the need for future studies encompassing diverse laryngotracheal conditions. Clinical trials assessing microbiome modifications may unveil novel therapeutic avenues. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

High-Resolution Profiling of Human Vocal Fold Cellular Landscapes With Single-Nuclei RNA Sequencing.

INTRODUCTION: The function of the vocal folds (VFs) is determined by the phenotype, abundance, and distribution of differentiated cells within specific microenvironments. Identifying this histologic framework is crucial in understanding laryngeal disease. A paucity of studies investigating VF cellular heterogeneity has been undertaken. Here, we examined the cellular landscape of human VFs by utilizing single-nuclei RNA-sequencing. METHODS: Normal true VF tissue was excised from five patients undergoing pitch elevation surgery. Tissue was snap frozen in liquid nitrogen and subjected to cellular digestion and nuclear extraction. Nuclei were processed for single-nucleus sequencing using the 10X Genomics Chromium platform. Sequencing reads were assembled using cellranger and analyzed with the scanpy package in python. RESULTS: RNA sequencing revealed 18 global cell clusters. While many were of epithelial origin, expected cell types, such as fibroblasts, immune cells, muscle cells, and endothelial cells were present. Subcluster analysis defined unique epithelial, immune, and fibroblast subpopulations. CONCLUSION: This study evaluated the cellular heterogeneity of normal human VFs by utilizing single-nuclei RNA-sequencing. With further confirmation through additional spatial sequencing and microscopic imaging, a novel cellular map of the VFs may provide insight into new cellular targets for VF disease. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3193-3200, 2024.

The Use of Deep Learning Software in the Detection of Voice Disorders: A Systematic Review.

OBJECTIVE: To summarize the use of deep learning in the detection of voice disorders using acoustic and laryngoscopic input, compare specific neural networks in terms of accuracy, and assess their effectiveness compared to expert clinical visual examination. DATA SOURCES: Embase, MEDLINE, and Cochrane Central. REVIEW METHODS: Databases were screened through November 11, 2023 for relevant studies. The inclusion criteria required studies to utilize a specified deep learning method, use laryngoscopy or acoustic input, and measure accuracy of binary classification between healthy patients and those with voice disorders. RESULTS: Thirty-four studies met the inclusion criteria, with 18 focusing on voice analysis, 15 on imaging analysis, and 1 both. Across the 18 acoustic studies, 21 programs were used for identification of organic and functional voice disorders. These technologies included 10 convolutional neural networks (CNNs), 6 multilayer perceptrons (MLPs), and 5 other neural networks. The binary classification systems yielded a mean accuracy of 89.0% overall, including 93.7% for MLP programs and 84.5% for CNNs. Among the 15 imaging analysis studies, a total of 23 programs were utilized, resulting in a mean accuracy of 91.3%. Specifically, the twenty CNNs achieved a mean accuracy of 92.6% compared to 83.0% for the 3 MLPs. CONCLUSION: Deep learning models were shown to be highly accurate in the detection of voice pathology, with CNNs most effective for assessing laryngoscopy images and MLPs most effective for assessing acoustic input. While deep learning methods outperformed expert clinical exam in limited comparisons, further studies integrating external validation are necessary.

Complications and Functional Voice Limitations Following Gender-Affirming Laryngeal Surgery (GALS).

OBJECTIVE: Gender-affirming laryngeal surgery (GALS) procedures are effective, with high rates of patient satisfaction following endoscopic vocal fold shortening (glottoplasty) or chondrolaryngoplasty. Despite this, complications and functional limitations in voice use following GALS are not well described. The current study aims to visually characterize the clinical and laryngoscopic features of complications following GALS. METHODS: Patients who presented with complications or subjective dysphonia following glottoplasty or chondrolaryngoplasty across three tertiary care centers were included. Medical charts were reviewed for demographics, surgical history, the primary outcomes of short- and long-term surgical complications, and the secondary outcome of subjective difficulty in daily voice use unrelated to pitch or gender congruence. Postoperative videostroboscopy exams were reviewed for correlating features. RESULTS: Eighteen patients with complications after glottoplasty, chondrolaryngoplasty, or both were identified. Complications after chondrolaryngoplasty occurred in three patients and included skin tethering, late-stage infection with fistula, and voice change. Short-term complications following glottoplasty occurred in four patients and included persistent granulation at the neocommissure (n = 3) and suture dehiscence (n = 1). Persistent dysphonia or voice limitations greater than 6 months following glottoplasty were described by eight patients; associated stroboscopy findings included excessive web formation of greater than 50% (n = 4), incomplete web formation with opening anterior to the neocommissure (n = 2), and scarring of the remaining membranous vocal fold (n = 5). Dysphonia complaints were consistent with observed glottic insufficiency in seven of eight of these patients, with incomplete membranous vocal fold closure posterior to the neocommissure or anterior air escape. CONCLUSION: While chondrolaryngoplasty and glottoplasty have high success rates, complications related to healing, granulation, and web length are not uncommon. Long-term dysphonia appears to be related to postprocedural glottic insufficiency. These data should be used to counsel patients preoperatively about the risks and benefits of GALS.

Patient Satisfaction and Acoustic Changes in Trans Women after Gender Affirming Voice Training.

OBJECTIVES: Gains in pitch from gender affirming voice training (GVT) alone in trans women have historically been shown to decline after 1 year. Currently no standard exists for length and type of GVT that yields meaningful behavioral change and patient satisfaction with voice outcomes in trans women. This study aims to determine whether GVT alone leads to sustained pitch elevation and patient satisfaction in trans women. METHODS: Retrospective review from 2016 to 2020 of trans women patients who underwent GVT alone for voice change. Charts were reviewed for acoustic analysis of pitch including sustained vowel fundamental frequency, speaking fundamental frequency, and quality of life data from the Trans Woman Voice Questionnaire at pre-therapy, immediate post-therapy, and extended post-therapy time intervals. RESULTS: A total of 157 patients presented to our Voice Center, of which 34 participated in the full course of GVT. Patients underwent an average of six sessions of GVT (range 5-7) over an average of 13.14 weeks (range 6-16). Average time between completing GVT and presenting for extended follow-up was 11.37 months (range 6-31). Compared to initial presentation prior to therapy, at extended follow-up after completing GVT average change in F0/a/, SF0, and TWVQ were 64.6 Hz, 31.3 Hz, and 32.45. No significant change was noted between immediate post-therapy and extended post-therapy acoustic measures. TWVQ demonstrated continued improvement between immediate post-therapy and extended post-therapy. CONCLUSIONS: In self-selected patients who present for extended follow-up, GVT alone can result in sustained pitch elevation and voice-related quality life in trans women. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2340-2345, 2023.

1-Year Results of Combined Modified Wendler Glottoplasty with Voice Therapy in Transgender Women.

BACKGROUND: To date, 1-year evaluation of pitch elevation in patients undergoing modified Wendler glottoplasty (WG) in combination with VT has not been assessed. OBJECTIVES: To determine whether 1-year pitch elevation is sustained in patients who undergo modified WG in combination with VT for voice feminization. METHODS: A retrospective review of patients who underwent WG in combination with voice therapy (VT) was performed from 2016 to 2020. Charts were reviewed for sustained vowel fundamental frequency (F0/a/), speaking fundamental frequency (SF0), and Trans Woman Voice Questionnaire (TWVQ) at preoperative, initial postoperative (3-6 months after surgery), and 12-month postoperative visits. RESULTS: Change in average F0/a/, SF0 and TWVQ was 50.25 Hz, 32.96 Hz, and 32.6 at 12-months postoperatively compared to preoperative values. Initial and 12-month postoperative SF0 were significantly higher than preoperative SF0 (Mann-Whitney U test p = 0.0042, p = 0.0010). There was no difference in initial postoperative and 12-month postoperative SF0 (p = 0.50). TWVQ at 12 months was significantly lower than preoperative TWVQ (ANOVA p < 0.001, Tukey honestly significant difference HSD p < 0.05). CONCLUSIONS: Pitch elevation remains sustained at one year in patients undergoing modified WG in combination with VT. Modified Wendler glottoplasty combined with VT results in relatively long-term improvements in voice-related quality of life and is possibly a beneficial addition in the long-term management of patients who desire voice feminization. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:615-620, 2023.

Positive Predictive Value of Endoscopic Findings to Diagnose Vocal Fold Paresis.

OBJECTIVE: Laryngoscopy corresponding with laryngeal electromyography (LEMG) is essential in diagnosing vocal fold paresis. However, baseline asymmetry or other diseases oftentimes confound the exam, making diagnosis difficult. There is currently no agreed upon endoscopic criteria proven to reliably correlate with LEMG findings. We define a set of endoscopic findings termed "paresis triad" that, when present together, reliably correlate with LEMG. The paresis triad consists of (1) hypocontraction of the weak side of the larynx with increased ventricular show, (2) hypercontraction of the intact side with bulging of the false fold covering the ventricle, and (3) tilting of the interarytenoid cleft to the weak side. METHODS: We performed a retrospective review of patients with laryngeal asymmetry on laryngoscopy. Patients were divided into two groups: those with consistent paresis triad findings across all pitches and intensities, and those without. All patients underwent LEMG by a neurolaryngologist blinded to the laryngoscopic findings. The endoscopies were then rereviewed in a blinded manner by a second laryngologist to assess inter- and intrarater reliability for identification of the triad. RESULTS: Twelve patients met inclusion criteria (age 50 +/-15, 7F:5M). Nine had the paresis triad. Three had an inconsistent triad. All patients with the paresis triad had LEMG findings consistent with neurologic injury on the suspected side. All patients with inconsistent triad findings had normal LEMG. CONCLUSIONS: Our findings suggest the proposed laryngoscopic paresis triad may be useful objective criteria to diagnose paresis without the need for LEMG. Further prospective studies should examine a larger series of patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1712-1716, 2023.

Optimizing Botox regimens in patients with adductor spasmodic dysphonia and essential tremor of voice: A 31-year experience.

Objective: The purpose of this study was to quantitatively compare the effectiveness of unilateral and bilateral botulinum toxin A (BTX-A) injections for mitigating undesirable weak/breathy voice quality and dysphagia for patients with adductor spasmodic dysphonia and/or essential tremor of voice (ETV). Methods: Data were collected from the medical records of 319 patients, yielding three treatment cohorts: patients who received an equal dose bilateral injection regimen (BL=) throughout their course of treatment at VUMC, patients who switched to a unilateral injection regimen (UL), and patients who switched to an unequal dose bilateral injection regimen (BL≠). Changes in length of improvement, duration of weak/breathy voice, and dysphagia severity were compared. Results: The BL = treatment group reported the longest duration of improved voice. Shorter periods of improved voice were reported at baseline by patients who later switched to UL or BL ≠ injection regimens. Patients receiving UL injections reported significantly reduced weak/breathy voice and dysphagia. Patients receiving BL ≠ injections reported increased length of improved voice; however, dysphagia symptoms increased. Ninety-two percent of patients with ETV switched to a UL regimen, with 61% of patients transitioning within the first three injections. Conclusions: Patients with pronounced dysphagia and extended periods of weak/breathy voice may benefit from a UL injection approach to mitigate side effects from BTX-A without sacrificing improved voice outcomes. For patients seeking to extend their length of improved voice, a BL ≠ injection regimen may be effective provided the adverse side effects from BTX-A are minimal. Patients with ETV may benefit from a UL injection approach at the outset of their course of treatment with BTX-A. Level of evidence: III.

Effect of Wendler Glottoplasty on Acoustic Measures of Voice.

OBJECTIVES: Voice therapy has been the primary treatment for voice feminization in transfemale patients due to concerns that surgery worsens voice quality. We aim to determine the impact of Wendler glottoplasty on acoustic measures of voice. STUDY DESIGN: Retrospective case series. METHODS: Transgender female patients treated for vocal feminization with Wendler glottoplasty at a single tertiary care center were identified. Pre- and postoperative measures were taken with the Kay Elemetrics Real-Time Pitch, Analysis of Dysphonia in Speech and Voice, and Multidimensional Voice Program. RESULTS: Twenty-eight patients were included in this study. There were no statistically significant changes in fundamental frequency variation, peak amplitude variation, soft phonation index, noise-to-harmonics ratio, cepstral peak prominence, or cepstral spectral index of dysphonia at a significance level of P < .05. Average speaking fundamental frequency (SF0) increased from 143 Hz after voice therapy to 163 Hz after surgery (P = .0009). Lower range decreased in 61% and increased in 26% of patients. Upper range decreased in 52% and increased in 48% of patients. CONCLUSIONS: Wendler glottoplasty does not worsen voice quality based on acoustic measures. Although most patients experience an increase in average SF0, effects on vocal range are variable with approximately half of patients experiencing a reduction and half experiencing an increase in upper pitch limit. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:583-586, 2021.

Addition of Wendler Glottoplasty to Voice Therapy Improves Trans Female Voice Outcomes.

OBJECTIVES/HYPOTHESIS: VT is often considered the preferred treatment for vocal feminization in transgender patients. However, Wendler glottoplasty offers a surgical option for increasing fundamental frequency and perception of vocal femininity. We aimed to determine whether the addition of glottoplasty to VT results in greater fundamental frequency elevation and improvement in quality-of-life measures. STUDY DESIGN: Retrospective case series. METHODS: Forty-eight trans female patients were treated for vocal feminization. Twenty-seven patients underwent VT, and 21 patients underwent VT with additional glottoplasty (VTWG). Pre- and posttreatment acoustic measures, Trans Woman Voice Questionnaire (TWVQ), and Voice Handicap Index-10 (VHI-10) data were compared. RESULTS: Glottoplasty in combination with VT elevated average speaking fundamental frequency (SF0) to a greater extent than VT alone (P < .0001). The VTWG group achieved a 42-Hz increase in SF0, whereas the VT group achieved a 15-Hz increase in SF0. In both the VT and VTWG groups, the lower bound of physiologic range increased by 18 Hz (P = .0008 and P = .016, respectively). The addition of glottoplasty also resulted in greater improvement in voice-related quality of life. Improvement in TWVQ and VHI-10 was significantly greater in the VTWG group than the VT group (P = .007 and P = .029, respectively). TWVQ showed statistically significant improvement in the VTWG group only. CONCLUSIONS: VT results in SF0 elevation and improvement in VHI-10. The addition of glottoplasty to VT results in further improvements in SF0 and VHI-10 and statistically significant improvement in TWVQ. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:1588-1593, 2021.

Injection Laryngoplasty for Management of Neurological Vocal Fold Immobility.

Injection laryngoplasty as used in this chapter is synonymous with the term "injection augmentation." Injection augmentation is a technique designed to enhance glottic closure in patients with glottic insufficiency, or failure of glottic closure, by injecting material into the lateral aspect of the vocal fold to move the vibrating surface to the midline. This type of injection augments the vocal fold and improves glottic closure. Injection augmentation originated over 100 years ago. However, the current indications, techniques, and materials have changed significantly. Paralysis, defined as loss of function due to neu-rological injury, remains a common cause of glottic insufficiency. In cases of paralysis, nerve function to adduct the vocal folds for voice production and coughing is interrupted, bilaterally or unilaterally, and the glottis becomes insufficient. While unilateral vocal fold paralysis remains the most common indication for vocal fold injection augmentation, due to the development of newer injectable materials and less invasive injectable techniques, surgeons routinely perform injection augmentation for glottic insufficiency due to other causes such as vocal fold paresis, vocal fold atrophy, presbylarynx, vocal fold scar, and soft tissue loss. Additionally, there is an increasing performance of vocal fold injection in the awake patient. This allows for immediate feedback and reduced anesthetic risk. Outcomes assessment for injection augmentation remains varied by lack of consensus and large-scale studies to identify the factors most instrumental in documenting optimal results. We review the history of injection laryngoplasty, the indications for injection, choice of injectate, outcomes, complications, and future directions of injection laryngoplasty for augmentation.

A visual analog scale for patient-reported voice outcomes: The VAS voice.

OBJECTIVES: Although patient-reported outcome measures (PROMs) can be useful for assessing quality of life, they can be complex and cognitively burdensome. In this study, we prospectively evaluated a simple patient-reported voice assessment measure on a visual analog scale (VAS voice) and compared it with the Voice Handicap Index (VHI-10). STUDY DESIGN: Prospective survey. METHODS: An abbreviated voice measure was designed by a team of otolaryngologists, speech pathologists, and patients that consisted of four VAS questions related to (a) a global question of voice disturbance, (b) physical function of voice, (c) functional issues, and (d) emotional handicap. All English-speaking patients presenting to an academic laryngology clinic for a voice complaint were included. Internal consistency and validity were assessed with comparison to the VHI-10. RESULTS: A total of 209 patients were enrolled. Ninety-two percent of patients reported understanding the survey. The four-item VAS survey was highly correlated with VHI-10 score (Pearson correlation .81, P < .0001), and the Cronbach's alpha between all four VAS questions was .94. Age, gender, and diagnosis were not associated with either the global VAS or VHI-10 tool. CONCLUSION: Reducing the complexity of instruments assessing voice-related quality of life is feasible, and the VAS voice correlated with existing measures. Simplified assessments may offer advantages compared to more cumbersome PROMs. LEVEL OF EVIDENCE: 2c.

A randomized controlled trial of adjuvant mitomycin-c in endoscopic surgery for laryngotracheal stenosis.

OBJECTIVES/HYPOTHESIS: Topical mitomycin-C (MMC) application is a commonly accepted adjuvant therapy in the surgical treatment for laryngotracheal stenosis (LTS). However, the efficacy of MMC has not been examined in a prospective, randomized clinical trial in humans. We aimed to examine the efficacy of MMC in the treatment of LTS patients as compared to a placebo-controlled group. STUDY DESIGN: Prospective, randomized, double-blind, placebo-controlled clinical trial. METHODS: Fifteen patients with LTS were enrolled in a 24-month trial and randomized into one of two groups: 1) endoscopic surgical treatment with topical application of MMC or 2) endoscopic surgical treatment with topical application of saline. Postoperatively, patients were evaluated at standardized intervals with a symptom questionnaire and spirometry. Subsequent surgery was performed as needed based on relapse of stenosis on exam and patient-reported symptom severity. RESULTS: The average interval between surgical treatments was 17.9 months in the placebo group and 17.4 months in the MMC group (P = .95). There was no difference in magnitude of peak inspiratory flow (PIF) improvement between groups. The average magnitude of PIF change was 1.3 L/sec and 1.1 L/sec for the placebo and MMC groups, respectively (P = .64). Similarly, there was no difference in magnitude of symptom improvement or duration of symptom improvement between the two groups. CONCLUSIONS: This prospective, randomized. double-blind. placebo-controlled trial suggests that the use of MMC as a topical adjuvant therapy has no additional benefit in the endoscopic surgical management of LTS. Further study is needed. LEVEL OF EVIDENCE: 1b Laryngoscope, 130:706-711, 2020.

Measuring the impact of dysphonia on quality of life using health state preferences.

OBJECTIVES: Formal evaluation of health states related to dysphonia have not been rigorously evaluated in affected patients. The objective of this project was to evaluate the health states of mild, moderate, and severe dysphonia using formal health state preference evaluation, and to compare these outcomes with the degree of voice handicap. DESIGN: Prospective health state preference assessment. METHODS: A convenience sample of patients presenting with voice complaints were enrolled from an academic voice center. Demographic and voice handicap index (VHI-10) data were obtained, and an assessment of preference for five health states (monocular blindness, binocular blindness, mild dysphonia, moderate dysphonia, and severe dysphonia) was performed. Utility scores were calculated on a scale from 0 (death) to 1 (perfect health). Analysis was performed with ANOVA testing with post-hoc comparisons and correlation statistics. RESULTS: Of 209 assessments, 149 (75.6%) met quality criteria. Relative to monocular blindness (score 0.61 [CI 0.57-0.64]), moderate dysphonia (0.58 [0.54-0.62]) was rated equivalently, with severe dysphonia (0.33 [0.29-0.37]) ranking significantly worse and mild dysphonia (0.96 [0.95-0.98]) significantly better. Binocular blindness (0.18 [0.15-0.21]) was the worst-ranked health state. There was a weak inverse correlation of VHI-10 with dysphonia-related preference scores; with worsening reported voice handicap, scores decreased. CONCLUSION: This study demonstrated that dysphonia had a significant impact of quality of life, with moderate dysphonia ranking equivalently with monocular blindness. These numerical estimates may be used for ongoing research into the value and cost-effectiveness of medical, therapeutic, and surgical interventions for voice disorders. LEVEL OF EVIDENCE: 2c (outcomes research) Laryngoscope, 130:E177-E182, 2020.

Infection Rates After Microlaryngeal and Open Phonosurgery: The Role of Postoperative Antibiotics.

OBJECTIVE: Although it is known that the airway has bacterial contamination that seeds the surgical site during microlaryngeal surgery, literature on the use of postoperative antibiotics is lacking. We performed a retrospective analysis of open phonosurgical and phonomicrosurgical cases at a single institution to assess whether use of postoperative antibiotics impacts the incidence of surgical site infections (SSI). METHODS: In this retrospective cohort study, we reviewed 228 phonomicrosurgery and 53 open phonosurgery cases performed for benign diseases. Surgeries were performed by two laryngologists between February 2016 and August 2018. The surgeons differ in their postoperative antibiotic regimens: no antibiotics versus a 5- to 7-day postoperative course. Data collected include demographics, medical comorbidities, type of benign laryngeal disease, and surgical procedure. The primary outcome measure was postoperative infection, defined as the patient requiring a new prescription for antibiotics, an extended course of antibiotics, or any mention of infection at follow-up/emergency visits within the first month postoperatively. RESULTS: The overall rate of SSI was 3.1% and 0% for phonomicrosurgery and open phonosurgery cases, respectively. For phonomicrosurgery, there was no difference in the rate of SSI for patients who received or did not receive antibiotics perioperatively: 2.9% versus 3.2% (P = 0.99). Similarly, there was no difference in the infection rate for open phonosurgical cases. CONCLUSION: Infection rates after endoscopic and open phonosurgery are low. In this study, we found no evidence to suggest a protective effect associated with postoperative use of antibiotics. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1128-1131, 2020.

Transgender Voice and Communication.

Voice is a complex marker for gender and pivotal to the gender reassignment process. The goal of the transgender patient is to achieve a voice and communication style that is congruent with their gender identity. Voice and speech therapy are fundamental for successful transition. Phonosurgery, to adjust pitch, can be an important adjunct to relieve the patient from active pitch elevation of voice to free them to focus on the other adjustments needed and learned through behavioral training with speech and voice therapy. The authors review current management options for transgender patients with difficulties in voice and communication style.

Voice therapy associated with a decrease in the reflux symptoms index in patients with voice complaints.

OBJECTIVES/HYPOTHESIS: Patients with muscle tension dysphonia often demonstrate an elevation in Reflux Symptom Index (RSI) and 10-item Voice Handicap Index (VHI-10) scores, and may be erroneously diagnosed with laryngopharyngeal reflux disease. In this study we assessed the effects of voice therapy on RSI and VHI-10 scores in patients with voice complaints not responsive to antireflux medications. STUDY DESIGN: Retrospective cohort study. METHODS: A study of patients was conducted at a single tertiary-care center over 1 year (January 2012-January 2013). Patients were included if they had dysphonia not responsive to proton pump inhibition, did not have neurologic or neoplastic disease, and participated in at least three voice-therapy sessions in the absence of antireflux therapy. Primary analysis assessed change in RSI scores between the initial and follow-up visits with a laryngologist. RESULTS: A total of 18 patients were included (mean age = 49.9 ± 14.5 years, 89% female, 83% with a primary complaint of dysphonia). From initial to follow-up visit, the median RSI score (18.5 [interquartile range {IQR}, 9.5-22.8] vs. 10.5 [IQR, 4.5-14]; P = .02) and median VHI-10 score (25.5 [IQR, 11.3-30.0] vs. 13.5 [IQR, 9.5-20.8]; P = .03) significantly decreased. A significant inverse correlation was found between the number of voice therapy sessions/month and change in RSI score (r = -0.4; P = .05). CONCLUSIONS: In this study of patients with muscle tension dysphonia or vocal hyperfunction not responsive to antireflux therapy, RSI and VHI-10 scores improved following voice therapy. Results suggest that self-reported symptoms typically attributed to laryngopharyngeal reflux disease may actually be secondary to inefficient voice use patterns or anxiety about dysphonia that are responsive to voice therapy. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1169-1173, 2019.

Long-term outcomes in unilateral vocal fold paralysis patients.

OBJECTIVES/HYPOTHESIS: At presentation, unilateral vocal fold paralysis (UVFP) patients have different treatment options, including conservative management (CM), injection laryngoplasty (IL) with a temporary agent, or permanent medialization (PM). This study evaluates long-term outcomes for UVFP patients relative to intervention. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was performed of UVFP patients who presented to the University of California San Francisco Voice and Swallowing Center. Videolaryngostroboscopy examinations were reviewed. Maximum glottic closure was quantified with the normalized glottic gap area (NGGA). Perceptual voice analysis was performed using the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) at corresponding time points. RESULTS: Fifty-three patients met inclusion criteria. Six underwent CM only, 20 went on to require PM, 19 underwent IL only, and eight underwent IL and subsequent PM. NGGA at presentation was similar among groups; however, the CM group was noted to have more favorable CAPE-V scores for Breathiness (P = .007) and Loudness (P = .018). All groups had similar NGGA and CAPE-V scores at last follow-up. When compared to pooled data for patients who underwent PM, the IL group was noted to have similar NGGA and CAPE-V scores at presentation. Although improvements in both groups were noted following intervention, both groups appeared similar at last follow-up with the exception of Roughness, for which the IL group retained a slightly improved outcome (13.3 vs. 18.3, P = .03). CONCLUSIONS: At presentation, UVFP patients have similar NGGA. This finding suggests that treatment recommendations cannot be made on the size of the glottic gap alone. Furthermore, in many patients, IL results in long-term benefit with glottic closure and CAPE-V scores equivalent to that obtained with PM. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:430-436, 2018.

Perceptions of the laryngology Match: A survey of program directors and recent trainees.

OBJECTIVES/HYPOTHESIS: Evaluate program director and recent trainee perceptions of the advantages and disadvantages of the laryngology Match. STUDY DESIGN: Web-based survey study. METHODS: A Web-based survey study was distributed to program directors and recent laryngology trainees to evaluate perceptions of the laryngology Match. A 15-item questionnaire with free-form, Likert, and multiple selection answers was emailed to 115 recent/current trainees and 22 laryngology directors. RESULTS: Fifty-nine percent (13/22) of the program directors and 47% (54/115) of the recent trainees responded to the survey. There were significant increases in the number of programs applied to, interview offers received, and interviews attended by laryngology trainees who applied after adoption of the Match compared to those who applied prior to the Match. Seventy-one percent (22/31) of applicants after 2012 participated in the Match; those who did not accepted positions outside of the Match. Ninety-five percent (21/22) who applied through the Match successfully matched. Two-thirds of recent trainees and three-quarters of directors believe the Match process primarily benefits the applicant. The number of candidates interviewed per program approximately doubled from three to six after institution of the Match. CONCLUSIONS: Overall, both program directors and recent or current laryngology trainees have a positive perception of the laryngology match process. The Match process increased the number of applicants and interviews per year, which both directors and trainees believe increases an applicant's chance at successfully matching. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:2818-2822, 2017.