Stimulated Vocal Fold Immobility After Vagal Nerve Stimulator Placement: A Case Series.

INTRODUCTION: Vagal nerve stimulator (VNS) implantation is a vital therapy for epilepsy refractory to other treatments; however, it is associated with a very high rate of voice changes. Relatively few of these patients are evaluated for vocal fold motion impairments. In this series, we evaluate 5 such patients with a novel phenotype of forced abduction with VNS stimulation. METHODS: Retrospective case series. RESULTS: Five patients with a VNS implant who underwent operative direct or in-office rigid laryngoscopy and had vocal fold motion impairment associated with VNS activation are included. All 5 patients had vocal fold mobility with VNS off and a fixed with activation. All patients exhibited vocal fold abduction with VNS activation. Patient 2 has since undergone laryngeal reinnervation, which helped her intermittent dysphonia but left a small glottic gap. A type 1 thyroplasty corrected this gap and improved her voice further. Patient 3 has undergone laryngeal reinnervation for which early results show improvement in perceptual and patient reported outcomes. Patients 4 and 5 have both undergone laryngeal reinnervation with improvement in voice. CONCLUSION: Previous reported cases of stimulated immobility associated with VNS use describe only adduction of the vocal fold. This series expands the previous work showing the VNS activation can also cause stimulated immobility in an abducted position, for which reinnervation and other medialization procedures offer promising treatment.

Comparing cadaveric and 3D-printed laryngeal models in transcutaneous injection laryngoplasty.

Background: There is increasing focus on the development of high-quality simulation models for medical education. Cadaveric models, although considered more realistic, may be difficult to obtain and costly. The advent of three-dimensional (3D) printing has offered a low-cost, reliable, and reproducible alternative. This study sought to compare the utility of 3D-printed to cadaveric models for training in transcutaneous injection laryngoplasty (TIL). Methods: A simulation course with a cross-over design was employed. Video laryngoscopes were utilized for both the 3D and cadaveric models to assess the accuracy of injection into the vocal fold. Pre-procedure and post-procedure surveys were administered to evaluate understanding and comfort level on a Likert scale of 1-10. Each model was also rated on a 1-5 Likert scale for self-efficacy, fidelity, and educational value. Results: Pre- and post-survey data were completed by 15 otolaryngology residents and medical students. Mean pre-seminar understanding and comfort level were 3.7 and 2.2, respectively, compared to 6.9 and 5.9 (p < .05) following use of the 3D model and 6.4 and 4.7 (p < .05) following use of the cadaver model. When comparing 3D and cadaveric models, no significant differences were observed regarding self-efficacy, fidelity, and educational value. Conclusion: There was a similar mean increase in understanding and comfort following use of the 3D and cadaveric models. 3D-printing can provide an excellent adjunct to, and eventually a potential replacement for hands-on cadaveric training in medical education, particularly for TIL. Level of Evidence: Level III.

Alterations in Emotional Expression Through Speech in Patients With Unilateral Vocal Fold Paralysis: A Preliminary Study.

Unilateral vocal fold paralysis (UVFP) has a known impact on patients' quality of life. One of the potentially affected domains that has not been studied yet is emotional prosody. To produce and transmit an efficient emotional prosody, several vocal parameters are modulated by the speaker, principally the fundamental frequency, the speech rate, and the voice intensity. We retrieved 300 sentences produced by 10 patients suffering from UVFP, equally in neutral, anger, and sadness. A jury of six health care voice experts was asked to hear these sentences and choose an emotion for each vocalization, between neutral, anger, and sadness. The jury mainly considered the heard sentences as being in a neutral emotion. Vocal parameters analysis of the anger and sadness sentences that were mistaken as neutral showed the absence of significant difference in their fundamental frequencies and speech rates. By being unable to modulate their vocal parameters as needed to produce emotional prosody, specifically the fundamental frequency and speech rate, patients with UVFP suffer from limitations in their capacity to produce the emotional prosody wanted, making the emotions they feel hardly transmitted to their entourage, which can explain the social barriers these patients complain of.

Effectiveness of Voice Therapy on Voice Quality and Function in Individuals with Unilateral Vocal Fold Paralysis: Systematic Review and Meta-Analysis.

BACKGROUND: Unilateral vocal fold paralysis (UVFP), characterized by immobility of one vocal fold, results from injuries of recurrent laryngeal nerves. Voice therapy is a conservative intervention aiming to address these symptoms, but standard protocols are lacking. In this study, we provided an updated review of voice therapy for UVFP over the past 3 years and analyzed the effect of voice therapy from the perspective of voice assessment recommended by the guidelines of the European Laryngological Society and the Union of the European Phoniatricians in 2023. METHODS: Following preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement, we searched the databases, including PubMed, Embase, Web of Science, the Cochrane Library, and SCOPUS, from their earliest records to December 1, 2023. Quality assessment utilized Cochrane Risk of Bias and Risk Of Bias In Non-randomized Studies of Interventions tools. Data extraction encompassed study design, participant characteristics, therapy protocols, and outcome measures, including subjective and objective assessments. We performed heterogeneity analysis by calculating the I2 statistic and meta-analysis by calculating the standardized difference of means and weighted mean differences. RESULTS: Our systematic review and meta-analysis included 12 studies encompassing 459 patients. The review revealed a predominance of female participants across studies. Therapy protocols primarily included breathing control, laryngeal manipulation, and resonance training, often supplemented by home exercises. Outcome measures demonstrated significant improvements in subjective parameter: Voice Handicap Index ((standard mean difference) SMD = -1.51, P < 0.001), acoustic parameters: fundamental frequency (SMD = -0.38, P = 0.003), jitter (SMD = -0.97, P < 0.001), shimmer (SMD = -0.94, P < 0.001), and noise-to-harmonic ratio (SMD = -0.89, P < 0.001), and aerodynamic parameters: maximum phonation time (SMD = 1.29, P < 0.001), with early intervention yielding enhanced rate of complete glottal closure. DISCUSSION: Two randomized controlled trials (RCTs) involved patients aware of their allocation to the treatment group, and the remaining 10 studies were retrospective, leading to bias from deviations in the intended intervention. Subjective and aerodynamic parameter inconsistency was observed, but after excluding studies with the onset of UVFP greater than 12 months, the heterogeneity of VHI scores decreased. The funnel plot was grossly symmetrical in the publication bias test. Significant improvements were noted in subjective, acoustic, and aerodynamic outcomes after intervention. Besides, there were commonalities in protocols, such as breathing control, laryngeal manipulation, and resonance training, often supplemented by home exercises. SYSTEMATIC REVIEW REGISTRATION: This protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on March 28, 2024, registration number: CRD42024529750.

Comparison of the Effectiveness of Injection Laryngoplasty Using Autologous Platelet-Rich Plasma or Autologous Fat With Platelet-Rich Fibrin for the Treatment of Patients With Unilateral Vocal Fold Paralysis.

OBJECTIVES: Unilateral vocal fold paralysis (UVFP) can be idiopathic or a result of surgery, cancer, or neurological disease. The most common presentation is dysphonia, which causes problems with communication, and can lead to anxiety and depression. Injection laryngoplasty (IL) is a current means of treatment, but there have been few studies to determine the optimal material to use. Therefore, we aimed to compare the use of autologous platelet-rich plasma and autologous fat with platelet-rich fibrin for IL under local anesthesia and general anesthesia, respectively. STUDY DESIGN: A prospective randomized controlled study was conducted at the Otolaryngology-Head and Neck Surgery Department, Ramathibodi Hospital, Faculty of Medicine, Mahidol University. METHODS: Thirty-four patients with UVFP were recruited. All met the inclusion criteria and were randomized to two groups, to be treated using autologous platelet-rich plasma under local anesthesia or autologous fat with platelet-rich fibrin under general anesthesia. The primary outcome was the mean difference in the Voice Handicap Index (VHI) between the groups at 1- and 6-months post. The secondary outcomes were the mean differences in voice acoustic parameters [maximum phonation time (MPT), jitter, shimmer, and harmonic-to-noise ratio (HNR)] between the groups at these time points. RESULTS: At the measured time points, there were no significant differences in the mean VHIs (P = 0.462), MPT (P = 0.79), jitter (P = 0.234), shimmer (P = 0.863), or HNR (P = 0.096) between the groups. Few people who underwent the procedure under local anesthesia developed laryngospasm, while some of those in the fat with platelet-rich fibrin developed postoperative abdominal contusion or hematoma which resolved spontaneously. CONCLUSIONS: We have found no difference in the effectiveness of IL using autologous platelet-rich plasma under local anesthesia or autologous fat with platelet-rich fibrin performed under general anesthesia in patients with UVFP. No serious or life-threatening complications were found in both groups.

A Novel Option for Revision Medialization: Repeat Reinnervation.

Nonselective laryngeal reinnervation (NSLR) shows comparable voice results to thyroplasty after one year without permanent implants. In the rare case of a second ipsilateral vocal fold paralysis after NSLR, we present the first recorded revision NSLR. Case report. A 51 year old woman with a history of right NSLR in 2017 for vocal fold paralysis after an anterior cervical diskectomy and fusion (ACDF) presented for re-evaluation prior to a revision of her ACDF. Ipsilateral revision was recommended to reduce the risk of bilateral vocal fold paralysis. Post-operatively, she was noted to have vocal fold immobility. Her maximum phonation time at that time was 9 s. Her voice was moderately breathy and moderately asthenic. Fundamental frequency (F0) was 211 Hz. Jitter was 2.868%, and shimmer 14.429%. Noise to harmonic ratio was 0.366. Cepstral peak prominence was 2.689. After being offered thyroplasty or revision reinnervation, she opted for revision reinnervation due to a strong preference for her reinnervated voice. She underwent a revision cross-neck NSLR with a commercial nerve graft in September 2022. One year later, her MPT was found to be 7.6 s, with mild breathiness and asthenia. F0 was 190 Hz. Jitter decreased to 2.42%, shimmer to 6.478%, and NHR to 0.165. Cepstral peak prominence increased to 4.427. VHI decreased from 35 pre-operatively to 7 post-operatively. We present the first case of a revision NSLR. Notable improvement has been found in objective voice measures and patient-reported outcomes post-operatively, demonstrating feasibility in similar patients. Laryngoscope, 2024.

Vocal Fold Paralysis Following Benign Thyroid Nodule Laser Thermal Ablation.

Laser thermal ablation (LTA) is an increasingly common procedure to treat benign and malignant thyroid nodules, allowing patients to avoid thyroidectomy. There are few reported postprocedural complications of LTA among patients with benign thyroid nodules. While vocal fold paralysis is a well-known potential complication after thyroidectomy, we present the first case report of vocal fold paralysis following LTA. A female in her 80s presented to an outside endocrinologist with symptoms of hyperthyroidism and benign thyroid nodules. The patient underwent a fine needle aspiration biopsy, radioiodine uptake scan, radioactive thyroid ablation, and LTA at an outside institution. The patient first noticed hoarseness 2days after LTA, and she presented to our office with a weak, breathy voice more than 4months postprocedure. Videostroboscopic examination revealed immobility of the left vocal fold with incomplete glottic closure. After awake injection laryngoplasty in the office, the patient experienced voice improvement. In conclusion, LTA is a relatively new treatment modality with limited literature on adverse outcomes. As minimally invasive techniques such as LTA are becoming more common, it is essential to remain fully aware of risks to recognize and mitigate complications like vocal fold paralysis.

Percutaneous Vocal Fold Lateralization in children - a case series of a Brazilian tertiary pediatric hospital (pediatric vocal fold lateralization cases in a Brazilian hospital).

OBJECTIVES: Percutaneous Vocal Fold Lateralization (PVFL) consists of external fixation with non-absorbable percutaneous suture of the vocal fold in a lateral position, under direct glottic visualization. The objective of this study is to determine the effectiveness of PVFL in a university pediatric hospital, as well as to describe the potential risks and complications of the surgery. METHODS: Retrospective cohort study, with data collected from electronic medical records. The study was approved by the Research Ethics Committee of the institution. Surgeries were performed with the modified Lichentenberg technique and data, and outcomes were analyzed. RESULTS: Six patients with Bilateral Vocal Fold Paralysis who underwent Percutaneous Vocal Fold Lateralization were evaluated. Three patients were male. The age at diagnosis ranged from 2 to 132 days (mean 10.5 days). The reason for investigating the upper airway was the presence of increased work of breathing and stridor. Five patients had a favorable clinical evolution, with spontaneous ventilation in room air and absence of stridor or ventilatory effort, without the need for tracheostomy. Surgical results in this series corroborate the findings of other similar cohorts, which showed Percutaneous Vocal Fold Lateralization as a safe and effective procedure in avoiding tracheostomy or allowing decannulation in children with Bilateral Vocal Fold Paralysis. CONCLUSIONS: PVFL seems to be a safe and effective procedure, but it has morbidity, due to immediate, and probably late, non-serious complications. Studies with a larger number of patients, with longer follow-up and using a controlled and randomized clinical design are needed to establish the role of PVFL in the treatment of BVFP in newborns and infants. LEVELS OF EVIDENCE: Level 4 (step 4).

Transcutaneous Laryngeal Ultrasound for Assessing Hyaluronic Acid Status in Patients Undergoing Injection Laryngoplasty.

OBJECTIVE: Injection laryngoplasty (IL) with hyaluronic acid (HA) is an effective treatment for patients with glottic insufficiency. The duration of HA maintenance in the vocal fold remains unknown. In this study, transcutaneous laryngeal ultrasound (TLUS) was used to evaluate the absorption and migration of HA after IL. Subsequent management might be provided based on the TLUS finding. METHODS: Patients diagnosed with unilateral vocal fold paralysis (UVFP) or vocal fold atrophy were recruited. All patients underwent IL with HA in an office-based setting along with TLUS to monitor the status of HA. The schedule of TLUS included assessments before and after IL until non-visualization. RESULTS: The study population comprised 38 women and 17 men. Of the patients, 54.1% underwent IL for UVFP, whereas 45.9% underwent IL for vocal fold atrophy. Multivariate Cox regression analysis for factors affecting HA absorption revealed that the cause of injection was the most important independent predictor (hazard ratio [HR], 2.15; 95% confidence interval [CI], 1.03-4.46; p = 0.040). The duration of HA maintenance was significantly longer in patients with UVFP than in those with vocal fold atrophy (8.77 vs. 4.70 months, HR, 2.33; 95% CI, 5.47-8.18; p = 0.002). CONCLUSION: TLUS is an objective assessment method for patients undergoing IL with HA. Subsequent tailor-made management could be offered based on the TLUS findings during follow-up. For patients at high risk of upper respiratory tract infection or who are intolerant to flexible nasopharyngoscopy, TLUS can be used as an alternative tool to evaluate the condition of the glottis after IL with HA. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.

Scaffold-Forming Collagen and Motor-Endplate Expressing Muscle Cells for Porcine Laryngoplasty.

OBJECTIVE: Vocal fold paralysis impairs quality of life, and no curative injectable therapy exists. We evaluated injection of a novel in situ polymerizing (scaffold-forming) collagen in the presence and absence of muscle-derived motor-endplate expressing cells (MEEs) to promote medialization and recurrent laryngeal nerve (RLN) regeneration in a porcine model of unilateral vocal fold paralysis. METHODS: Twelve Yucatan minipigs underwent right RLN transection. Autologous muscle progenitor cells were isolated from muscle biopsies, differentiated, and induced to MEEs. Three weeks after RLN injury, animals received injections of collagen, collagen containing MEEs, or saline into the paralyzed right vocal fold. Stimulated laryngeal electromyography and acoustic vocalization were used for function assessments. Larynges were harvested and underwent histologic, gene expression, and further quantitative analyses. RESULTS: Injections were well-tolerated, with the collagen scaffold showing immunotolerance and collagen-encapsulated MEEs remaining viable. Collagen-treated paralyzed vocal folds showed increased laryngeal adductor muscle volumes relative to that of the uninjured side, with those receiving MEEs and collagen showing the highest volumes. Muscles injected with MEEs and collagen demonstrated increased expression of select neurotrophic (BDNF and NTN1), motor-endplate (DOK7, CHRNA1, and MUSK), and myogenic (MYOG and MYOD) related genes relative to saline controls. CONCLUSION: In a porcine model of unilateral vocal fold paralysis, injection of in situ polymerizing collagen in the absence and presence of MEEs enhanced laryngeal adductor muscle volume, modulated expression of neurotrophic and myogenic factors, and avoided adverse material-mediated immune responses. Further study is needed to determine long-term functional outcomes with this novel therapeutic approach. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Radiofrequency Versus CO2 Laser in Posterior Cordotomy for Managing Bilateral Abductor Vocal Fold Immobility.

PURPOSE: This study aimed to assess the outcomes of posterior cordotomy in cases with bilateral abductor vocal fold immobility (BAVFI), either by radiofrequency or CO2 laser. METHODS: This prospective comparative randomized study included 80 patients with BAVFI of different etiologies. They were divided randomly into two groups. Group A included 44 patients for whom radiofrequency was used for posterior cordotomy, while the other group (group B) included 36 patients managed by CO2 laser-assisted posterior cordotomy. RESULTS: The postoperative respiratory chink improved significantly in both groups, with a significant improvement in the dyspnea, especially in group B. The postoperative voice handicapped VHI-10 scores showed significant deterioration in both groups. CONCLUSIONS: CO2 laser and radiofrequency-assisted posterior cordotomy were effective and safe for managing cases with BAVFI. Moreover, the CO2 laser has the upper hand regarding breathing and exercise tolerance outcomes, significantly impacting the quality of life.

Virtual Reality-Enhanced Assessment of the Anterior Glottic Angle Using Cadaveric Models: A Proof-of-Concept Study.

OBJECTIVES: Vocal fold paralysis (VFP) is a complex disorder that affects voice, speech, swallowing, and overall quality of life. Current evaluation methods for determining the position of paralyzed vocal folds lack the objectivity required for personalized interventions and research on innovative treatments for VFP. This study was designed to validate the accuracy and reproducibility of a virtual reality (VR)-based platform to measure the anterior glottic angle (AGA), a critical component in determining the position of a paralyzed vocal fold. STUDY DESIGN: Retrospective. METHODS: A retrospective analysis of computed tomography (CT) scans of 39 adult patients was conducted to measure the AGA shortly after death. Two measurement methods were used: 2-dimensional (2D)-CT for direct measurements on 2D images and a 3-dimensional (3D)-VR method utilizing a dedicated platform to create a 3D VR model of the larynx. The AGA measurements conducted by two senior otolaryngologists using the 3D-VR method were compared to the 2D-CT measurements made by one of these same otolaryngologists. RESULTS: The mean AGA measured by the 3D-VR method was found to be 32.936 ± 6.486° (n = 39), and the measurements were highly correlated (r = 0.9670, P < 0.0001). By contrast, the 2D-CT method without VR yielded a significantly lower mean angle of 23.754° (n = 35) with a higher standard deviation of 10.365°. The 3D-VR method demonstrated excellent reliability for AGA measurements (intraclass correlation coefficient of 0.954). CONCLUSION: The findings underscore the potential value of using a VR-based platform to improve reproducibility and reduce the variability in measurements of AGA in cases of VFP.

Unusual Presentation of Double-seronegative Myasthenia Gravis with Positive Anti-LRP4 Antibody: Diagnostic Utility of a Videofluoroscopic Swallowing Study.

An 86-year-old woman was admitted to our hospital with cryptogenic progressive dyspnea and dysphagia following a tracheostomy procedure 4 months prior to presentation. She exhibited fluctuating diplopia, bilateral vocal fold paralysis, normal nerve test results, negative findings for serum anti-acetylcholine receptor and anti-muscle-specific kinase antibodies, and positive findings for anti-LDL-receptor related protein 4 (LRP4). A videofluoroscopic swallowing study (VFSS) with edrophonium revealed an improvement in bulbar paralysis. Consequently, the patient was diagnosed with double-seronegative myasthenia gravis (DSN-MG) and began immunomodulatory therapy. This case emphasizes the diagnostic challenges of bulbar-type DSN-MG and underscores the value of a VFSS with edrophonium for diagnosing this condition.

Fenestration Approach for Arytenoid Adduction in Unilateral Vocal Fold Paralysis.

OBJECTIVE: Several surgical techniques have been reported for the treatment of unilateral vocal fold paralysis (UVFP). Although the fenestration approach has recently been applied for arytenoid adduction (AA) in some cases, long-term large-cohort studies on its usefulness are lacking. Therefore, this study aimed to evaluate the long-term voice outcomes of this technique in patients with UVFP. STUDY DESIGN: Retrospective study. METHODS: A total of 168 patients with UVFP underwent laryngoplasty comprising AA performed through fenestration of the thyroid ala combined with a type I thyroplasty (TPI). The maximum phonation time (MPT) and mean airflow rate (MFR) were measured before and after surgery, and voice analysis included an estimation of shimmer and jitter. Anterior and posterior surgical windows were created in the lower thyroid ala and were used for typical TPI and AA, respectively. The window locations were determined based on three-dimensional computed tomography data. AA was performed by pulling the muscular process of the arytenoid cartilage toward the lateral cricoarytenoid muscle through the posterior window without releasing the cricothyroid joint. All surgeries were performed under local anesthesia, and medialization was endoscopically confirmed. RESULTS: Postoperative MPT >10 seconds was achieved in 156 of the 168 patients. Postoperatively, MFR improved to <250 mL/s in all but two patients, and MPT, MFR, jitter, and shimmer significantly improved in all patients. Furthermore, perceptual evaluation using the Grade, Roughness, Breathiness, Asthenia, and Strain scale revealed significant improvement in all patients. CONCLUSIONS: The fenestration approach preserves the cricothyroid joint and does not open the cricoarytenoid joint; therefore, the laryngeal cartilage is stabilized, and no distortion of the laryngeal framework occurs. Our results showed that combined AA and TPI via the fenestration approach provided stable long-term postoperative voice improvement in patients with UVFP. LEVEL OF EVIDENCE: Level 3.

Imaging Modalities for Identifying Causes of Vocal Fold Paralysis: A Systematic Review and Meta-Analysis.

BACKGROUND: Vocal fold paralysis (VFP), involving one or both vocal folds, often indicates underlying pathologies. Identifying VFP causes is vital for excluding malignancies and focusing on treating the cause. While various imaging methods are used to investigate VFP causes, their detection abilities remain unclear. This study aims to assess the detection prevalence of different imaging techniques in determining the causes of VFP. METHODS: In September 2023 a comprehensive search was conducted per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines across multiple databases, including Web of Science, PubMed, Scopus, Cochrane CENTRAL, and EMBASE. Following the search, the retrieved studies were screened based on the predefined eligibility criteria. Data extraction from the included studies was carried out independently by two authors. Outcomes were analyzed using pooled proportions and 95% confidence intervals. RESULTS: Our meta-analysis encompassed 14 studies with 1492 VFP patients included. Malignant causes for VFP identification were most prevalent in F-fluorodeoxyglucose Positron Emission Tomography (PET)/Computed Tomography (CT) (41.5%) followed by Magnetic resonance imaging (MRI) (40%), with CT being the lowest (17.1%). Conversely, benign causes had the highest prevalence in F-fluorodeoxyglucose PET/CT (10.8%), followed by MRI (6.7%) and CT (4%). In the VFP cause identification, MRI had the highest detection prevalence (58.1%), followed by CT (30.1%), and Ultra Sound (US) had the lowest (26.8%). In chest lesion detection, CT had the highest prevalence (17.6%), followed by Chest X-ray (CXR) (6.5%). Head lesions were detected with CT at a prevalence of 15%, while neck lesion detection showed CT prevalence at 38.9% and US at 20.6%. CONCLUSION: Our study revealed varying prevalence rates for the identification of malignant and benign causes across different imaging modalities. MRI demonstrated the highest overall detection prevalence for VFP causes, while CT was most commonly used and had the highest prevalence for specific lesions detection in various regions. These findings provide valuable insights into the diagnostic utility of different imaging techniques in the evaluation of VFP.

Analysis of Google Searches in Laryngology: Where Do People Look and Are the Answers They Find Credible?

OBJECTIVES: Patients recently diagnosed with a new medical condition frequently search the internet to learn about their diagnosis. We aimed to identify specific questions people ask regarding common laryngological diagnoses by evaluating "People Also Ask" (PAA) questions generated by Google, search volume of these diagnoses, and to determine if the sources accessed were credible. STUDY DESIGN: Descriptive study. METHODS: The terms "subglottic stenosis" (SS), "Zenker's diverticulum" (ZD), "vocal fold paralysis" (VFP), and related terms were entered into Google. PAA questions and associated websites were then extracted using Ahrefs software. Questions were categorized into specific topics. Websites were categorized by type and then assessed using the Journal of the American Medical Association (JAMA) benchmark criteria. A search engine optimization tool was used to determine search volume for individual topics. RESULTS: One hundred and forty-four PAA questions (SS n = 52, ZD n = 49, and VFP n = 43) and their associated websites were extracted. Inquiries were most related to disease etiology (34%), management (27.1%), and signs/symptoms (16.7%). Sources most commonly linked to PAA questions were academic (37.6%), government (25.6%), and commercial (16.2%) websites, while medical practice (7.69%), single surgeon (3.42%), and social media (9.40%) websites were less frequently referenced. JAMA scores were highest for government websites (mean 3.35, standard deviation = 0.54) and lowest for academic websites (mean 0.77, standard deviation = 0.14). CONCLUSIONS: The most asked questions regarding SS, ZD, and VFP are related to etiology and management. Academic medical institution websites are most frequently viewed to answer these questions. Therefore, academic laryngological professionals should ensure the information on their websites is current and accurate.

Investigation of the Position and Angle of the Vocal Fold Projected onto the Thyroid Cartilage.

OBJECTIVE: To perform laryngeal framework surgery for unilateral vocal fold paralysis and obtain favorable voice improvement, it is necessary to accurately determine the vocal fold and arytenoid cartilage positions. Thus, the position and angle of the paralyzed vocal folds and arytenoid cartilage projected onto the affected thyroid plate were measured using computed tomography (CT) before and after surgery. METHODS: Forty-six male patients with thyroid cartilage ossification observed on preoperative CT and vocal fold paralysis were included. Using Adobe Illustrator®, the thyroid plate on the affected side was reconstructed from the continuous images of the sagittal section of the CT examination during participant's quiet breathing (reconstructed affected thyroid plate [RATP]). RESULTS: The anterior commissure mean position was slightly cranial to the midpoint of the thyroid cartilage midline. The paralyzed vocal fold angle was not parallel to the baseline. The average unaffected vocal fold angle during vocalization projected onto the affected thyroid plate was 13.83°, which differed significantly from the average paralyzed vocal fold angle before surgery (19.05°). However, no significant difference was observed in comparison with the average angle of the paralyzed vocal fold after arytenoid adduction. The average distance from the inferior notch of the affected side thyroid cartilage to the affected arytenoid cartilage was 16.7 mm. CONCLUSION: By understanding the positional relationship between the thyroid cartilage plate and internal structure from preoperative CT images, more effective surgery can be performed according to individual differences. LEVEL OF EVIDENCE: IV Laryngoscope, 134:4088-4094, 2024.

Outcomes of laryngeal framework surgeries for unilateral vocal cord paralysis in the elderly patients.

OBJECTIVE: Laryngeal framework surgery is a widely accepted treatment for unilateral vocal fold paralysis with good functional outcomes. Recently, with the aging of the population, opportunities to perform this procedure in elderly patients have increased; however, the safety and efficacy of this procedure in elderly patients has not been established. Therefore, this study aimed to investigate the safety and functional outcomes of laryngeal framework surgery in elderly patients. METHODS: Between January 2008 and December 2017, 97 patients with unilateral vocal fold paralysis underwent laryngeal framework surgery, and 71 among them completed pre- and post-operative voice function evaluations. The clinical course of these 71 patients were retrospectively reviewed. RESULTS: Out of 71 patients, 35 were assigned to the younger group (< 65 years) and 36 to the elderly group (≥ 65 years). Complications included post-operative edema and submucosal hematoma that were safely managed in all cases, and no differences were identified between the groups. Significant improvements were observed in maximum phonation time (MPT), mean flow rate, alternating current/direct current ratio, pitch perturbation quotient, amplitude perturbation quotient, and noise-to-harmonic ratio in both groups, and multivariate analysis of variance revealed greater improvement in the younger group in MPT. CONCLUSION: Laryngeal framework surgeries for unilateral vocal fold paralysis are safe and effective, regardless of age. Better improvement was observed in the younger group in the MPT suggesting that the effects of laryngeal framework surgeries is more likely to be present in the younger group than in the elderly.

Transcriptome Analysis of Left Versus Right Intrinsic Laryngeal Muscles Associated with Innervation.

OBJECTIVES/HYPOTHESIS: Recurrent laryngeal nerve injury diagnosed as idiopathic or due to short-term surgery-related intubation exhibits a higher incidence of left-sided paralysis. While this is often attributed to nerve length, it is hypothesized there are asymmetric differences in the expression of genes related to neuromuscular function that may impact reinnervation and contribute to this laterality phenomenon. To test this hypothesis, this study analyzes the transcriptome profiles of the intrinsic laryngeal muscles (ILMs), comparing gene expression in the left versus right, with particular attention to genetic pathways associated with neuromuscular function. STUDY DESIGN: Laboratory experiment. METHODS: RNA was extracted from the left and right sides of the rat posterior cricoarytenoid (PCA), lateral thyroarytenoid (LTA), and medial thyroarytenoid (MTA), respectively. After high-throughput RNA-Sequencing, 88 samples were organized into 12 datasets according to their age (P15/adult), sex (male/female), and muscle type (PCA/LTA/MTA). A comprehensive bioinformatics analysis was conducted to compare the left-right ILMs across different conditions. RESULTS: A total of 774 differentially expressed genes were identified across the 12 experimental groups, revealing age, sex, and muscle-specific differences between the left versus right ILMs. Enrichment analysis of Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathways implicated several genes with a left-right laryngeal muscle asymmetry. These genes are associated with neuronal and muscular physiology, immune/inflammatory response, and hormone control. CONCLUSION: Bioinformatics analysis confirmed divergent transcriptome profiles between the left-right ILMs. This preliminary study identifies putative gene targets that will characterize ILM laterality. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:3741-3753, 2024.

Evaluating the Potential of AI Chatbots in Treatment Decision-making for Acquired Bilateral Vocal Fold Paralysis in Adults.

OBJECTIVES: The development of artificial intelligence-powered language models, such as Chatbot Generative Pre-trained Transformer (ChatGPT) or Large Language Model Meta AI (Llama), is emerging in medicine. Patients and practitioners have full access to chatbots that may provide medical information. The aim of this study was to explore the performance and accuracy of ChatGPT and Llama in treatment decision-making for bilateral vocal fold paralysis (BVFP). METHODS: Data of 20 clinical cases, treated between 2018 and 2023, were retrospectively collected from four tertiary laryngology centers in Europe. The cases were defined as the most common or most challenging scenarios regarding BVFP treatment. The treatment proposals were discussed in their local multidisciplinary teams (MDT). Each case was presented to ChatGPT-4.0 and Llama Chat-2.0, and potential treatment strategies were requested. The Artificial Intelligence Performance Instrument (AIPI) treatment subscore was used to compare both Chatbots' performances to MDT treatment proposal. RESULTS: Most common etiology of BVFP was thyroid surgery. A form of partial arytenoidectomy with or without posterior transverse cordotomy was the MDT proposal for most cases. The accuracy of both Chatbots was very low regarding their treatment proposals, with a maximum AIPI treatment score in 5% of the cases. In most cases even harmful assertions were made, including the suggestion of vocal fold medialisation to treat patients with stridor and dyspnea. ChatGPT-4.0 performed significantly better in suggesting the correct treatment as part of the treatment proposal (50%) compared to Llama Chat-2.0 (15%). CONCLUSION: ChatGPT and Llama are judged as inaccurate in proposing correct treatment for BVFP. ChatGPT significantly outperformed Llama. Treatment decision-making for a complex condition such as BVFP is clearly beyond the Chatbot's knowledge expertise. This study highlights the complexity and heterogeneity of BVFP treatment, and the need for further guidelines dedicated to the management of BVFP.