Understanding Performers' Perspectives on Access to Care and Support for Voice Injuries: A Survey Study.

INTRODUCTION: Previous studies show that performers face higher risk of voice injury and experience greater impairment compared to nonperformers. Understanding the factors influencing support for performers is important for improving outcomes. METHODS: An anonymous online survey was distributed to a target audience of performers with past voice injury, inquiring about their understanding of voice injury "red flags," access to voice care support resources, treatment adherence, and comfort discussing injury with others. Responses were analyzed considering various clinicodemographic factors and aspects related to care and treatment. RESULTS: The survey was completed by 151 performers with self-reported history of voice injury, representing multiple performance genres. Participants commonly sought help from a general otolaryngologist (52; 34.44%), laryngologist (41; 27.15%), or voice teacher (40; 26.49%) and treatments included voice therapy, rest, medication, and surgery, with a majority reporting high treatment adherence (129; 87.16%), a statistically significant factor in resolving symptoms. Those with partial or nonadherence cited financial/insurance barriers, scheduling/availability conflicts, or treatment dissatisfaction. Participants reported high awareness of voice injury "red flags" (mean 86.80; SD 18.87%), and moderate access to voice care tools/resources (mean 74.76; SD 29.1) and a voice team (mean 71.23; SD 36.52), but low support from management/production teams (mean 50.69; SD 37.23). Several expressed a desire for better education about preventive care (mean 70.06; SD 37.78). Comfort levels in discussing voice injuries varied across social contexts, but those working with voice teachers were more comfortable discussing their voice problems with colleagues and peers. CONCLUSION: This study explores performers' perspectives on accessing care for voice injuries and emphasizes the importance of increased preventive education to address the ongoing stigma surrounding voice injuries and to foster a supportive environment for performers seeking help. Additionally, the study highlights the role of voice professionals in both providing and advocating for support systems for performers with voice injury.

De Novo Granuloma of the Membranous Vocal Fold: A Marker of Occult Malignancy.

OBJECTIVE: De novo occurrence of granuloma (granulation tissue) on the membranous vocal fold is not readily explained by usual causes of granuloma at the vocal process. We describe a series of patients. STUDY DESIGN: Case series. SETTING: Single academic institution. METHODS: Cases were identified over a 16-year period. All patients exhibited granulation tissue on pathology. Demographic details, presentation, treatment, histology, and clinical outcomes were recorded. RESULTS: Five patients (mean age: 74.0 ± 6.1 years, 40.0% male, 40.0% former smokers) underwent a biopsy. Persistent or recurrent granulation led to a second biopsy in 4 patients an average of 1423.5 days later, revealing a new diagnosis of squamous cell carcinoma (SCC) in situ in one and mild dysplasia in another. Further persistence or recurrence led to a third biopsy or excision an average of 302.3 days later in 3 patients, demonstrating SCC in situ in 1. An average of 2.5 biopsies were required with a mean time to SCC in situ diagnosis of 919.5 days from presentation. Two patients continued to demonstrate persistent granulation tissue on histology. CONCLUSION: The membranous vocal fold is an atypical location for granuloma and portends a risk of occult malignancy. The occurrence of de novo granuloma at this site should prompt close long-term clinical surveillance with a low threshold for biopsy. Consideration should be given to tissue collection in the operating room to adequately sample the lesion's base. Concern should persist even after a negative biopsy, and serial observation with repeat biopsy as needed should be pursued.

Return to Vocal Performance Following Microlaryngoscopy in Singers.

INTRODUCTION: Although microlaryngoscopy has been recognized to be effective in addressing lesions in vocal performers, no detailed information regarding return to performance (RTP) following surgery exists. We describe our experience and offer proposals to establish standardized criteria for RTP among vocal performers. METHODS: Records for adult vocalists who underwent microlaryngoscopy for benign vocal fold (VF) lesions and had a clearly documented RTP date between 2006 and 2022 were reviewed. Patient demographics, diagnoses, interventions, and postsurgical care before and after RTP were described. The need for medical and procedural interventions and rate of reinjury were used to determine the success of RTP. RESULTS: Sixty-nine vocal performers (average age: 32.8 years, 41 [59.4%] female, 61 [88.4%] musical theater) underwent surgery for 37 (53.6%) pseudocysts, 25 (36.2%) polyps, 5 (7.2%) cysts, 1 (1.4%) varix, and 1 (1.4%) mucosal bridge. Fifty-seven (82.6%) underwent voice therapy. The average time to RTP was 65.0 ± 29.8 days. Prior to RTP, six (8.7%) experienced VF edema requiring oral steroids and one (1.4%) underwent a VF steroid injection. Within 6 months following RTP, eight (11.6%) received oral steroids for edema and three underwent procedural interventions (two steroid injections for edema/stiffness, one injection augmentation for paresis). One patient experienced pseudocyst recurrence. CONCLUSIONS: Return to vocal performance at an average of 2 months following microlaryngoscopy for benign lesions appears overwhelmingly successful, with low rates of need for additional intervention. There is a need for validated instruments to better measure performance fitness to refine and possibly accelerate RTP. LEVEL OF EVIDENCE: 4 Laryngoscope, 134:329-334, 2024.

Validation of a 3D-Printed Percutaneous Injection Laryngoplasty Simulator: A Randomized Controlled Trial.

OBJECTIVE: Simulation may be a valuable tool in training laryngology office procedures on unsedated patients. However, no studies have examined whether existing awake procedure simulators improve trainee performance in laryngology. Our objective was to evaluate the transfer validity of a previously published 3D-printed laryngeal simulator in improving percutaneous injection laryngoplasty (PIL) competency compared with conventional educational materials with a single-blinded randomized controlled trial. METHODS: Otolaryngology residents with fewer than 10 PIL procedures in their case logs were recruited. A pretraining survey was administered to participants to evaluate baseline procedure-specific knowledge and confidence. The participants underwent block randomization by postgraduate year to receive conventional educational materials either with or without additional training with a 3D-printed laryngeal simulator. Participants performed PIL on an anatomically distinct laryngeal model via trans-thyrohyoid and trans-cricothyroid approaches. Endoscopic and external performance recordings were de-identified and evaluated by two blinded laryngologists using an objective structured assessment of technical skill scale and PIL-specific checklist. RESULTS: Twenty residents completed testing. Baseline characteristics demonstrate no significant differences in confidence level or PIL experience between groups. Senior residents receiving simulator training had significantly better respect for tissue during the trans-thyrohyoid approach compared with control (p < 0.0005). There were no significant differences in performance for junior residents. CONCLUSIONS: In this first transfer validity study of a simulator for office awake procedure in laryngology, we found that a previously described low-cost, high-fidelity 3D-printed PIL simulator improved performance of PIL amongst senior otolaryngology residents, suggesting this accessible model may be a valuable educational adjunct for advanced trainees to practice PIL. LEVEL OF EVIDENCE: NA Laryngoscope, 134:318-323, 2024.

Correlation Between Laryngoscopic Appearance and Histopathology in Vocal Fold Cysts.

OBJECTIVES/HYPOTHESIS: Cysts are benign vocal fold lesions typically divided into mucous retention or epidermoid subtypes. The conventional paradigm that the former are translucent and the latter opaque fails to encompass the heterogeneity of cyst appearance on laryngoscopy. This study aims to characterize the relationships between clinical cyst characteristics and histopathology. STUDY DESIGN: Retrospective cohort METHODS: Clinicodemographic data, videostroboscopy findings, and histopathology results were retrospectively reviewed for adults who underwent surgical excision of vocal fold cysts at our institution between 2006 and 2021. RESULTS: Diagnostic histopathologic material was available for 69 patients (age: 50.4 ± 15.1 years, 68.1% female). Clinically, most cysts were opaque (69.6%) and located at the vibratory margin (82.6%). 11.6% were infraglottic. Significant associations existed between cyst location and epithelial type, with infraglottic cysts and those at the superior surface more commonly exhibiting ductal (P = 0.003) and squamous (P = 0.002) epithelium, respectively. Cyst opacity did not correlate with histopathology (P = 0.415). Epidermoid cysts were more likely to exhibit clinical inflammation (P = 0.002).

Performers With History of Voice Injury: A Survey Study of Treatment Outcomes and Vocal Function.

INTRODUCTION: Past studies show that performers are more susceptible to voice injury, have higher incidence of injury, and experience greater vocal impairment than non-performers. Despite literature demonstrating otherwise, there remains fear and stigma that voice injury is a career-ending circumstance. Much of this is due to a lack of information about post-treatment vocal function. METHODS: An anonymous online survey was distributed via email, flyer, and social media to a target audience of performers with a history of voice injury. It inquired about occupation, vocal symptoms, professionals consulted, and treatment adherence. Outcome measures included ability to perform, resolution of symptoms, and attitudes about their voices after voice injury. Findings were analyzed descriptively with statistical analysis to determine factors that may be related to favorable outcomes. RESULTS: The survey was completed by 151 performers representing a range of genres, including musical theatre, classical, and popular genres. The most reported vocal symptoms were decreased range, singing voice quality changes, increased singing effort, and vocal fatigue. Most initially sought care from an otolaryngologist, laryngologist, or voice teacher. Diagnoses and recommendations varied, but those who adhered to treatment were more likely to report resolution of voice symptoms (P = 0.025). Those with symptoms for 2-4 weeks reported greater vocal confidence than those with a longer symptom duration (P = 0.0251). Performers working with a voice teacher were more likely to find treatment helpful (P = 0.0174). Those with neurogenic voice conditions reported less vocal reliability than participants with other pathologies (P = 0.0155). CONCLUSION: The majority of participants continued to perform, reported resolved or improved voice symptoms after treatment, and reported positive attitudes about their voices, regardless of their injury or current presence or absence of pathology on exam. Findings of this study highlight a need for continued outreach to voice teachers, education programs, and production teams about vocal function after voice injury.

Taking steps to protect cancer nurses from exposure to hazardous drugs.

Freelance medical writer Christine Clark (chris@salt.u-net.com) reports on an online meeting held in March 2023 as part of a series on the risks of exposure to hazardous drugs for nurses working in oncology.

Saving time when preparing intravenous antibiotics.

Preparation of intravenous antibiotic doses takes up a significant amount of nurse time and exposes nurses to the risk of needlestick injury. The use of the Ecoflac® Connect needle-free connector could streamline preparation, reducing the time taken as well as eliminating needlestick injury risk. Because Ecoflac Connect is a closed system, it also minimises the risk of microbial contamination. This study showed that it took 83 experienced nurses 73.6 (SD 25.0) seconds to prepare an amoxicillin injection using the Ecoflac Connect needle-free connector compared with 110.0 (SD 34.6) seconds using the standard needle and syringe method, saving 36 seconds per dose on average, reducing the time taken by one-third. Based on recent government figures, the saving in nurse time would equate to 200-300 full-time nurses in England, equivalent to £6.15 million-£9.23 million a year. Additional savings would accrue from the prevention of needlestick injuries. Where wards are understaffed, this time saving could be critical, increasing time for care.

Comparison of Nasal Obstruction Symptom Evaluation Score Outcomes After Autologous Cartilage Grafts and Latera Nasal Implants.

OBJECTIVE: To compare quantitative Nasal Obstruction Symptom Evaluation (NOSE) scores for ACG and Latera implants for nasal valve repair. METHODS: Retrospective chart review of patients who underwent ACG or Latera placement between January 2016 through May 2019 by a single surgeon. Patients who had completed NOSE surveys pre- and post-operatively were identified and eligible for inclusion. Data regarding baseline demographic characteristics, adjunctive surgical procedures, NOSE scores at 1, 3, and 6-month post-operative visits, complications, and total operative time were collected. Unpaired t-tests and linear mixed models were performed to analyze differences between study groups. RESULTS: There were 24 and 39 patients who underwent ACG and Latera, respectively, who met eligibility criteria. There were no differences in demographic characteristics or pre-operative baseline NOSE scores (ACG: 65.1 and Latera: 64.4; P = .92) between groups. Mean operative times were not significantly different between groups (ACG: 113 minutes and Latera: 102 minutes; P = .76). Within each group, NOSE scores were significantly improved at each post-operative visit compared to pre-operative baselines. Between groups, mean NOSE scores were lower at each post-operative visit for ACG compared to Latera (1-month ACG: 21.7 and Latera: 45.9, P = .002 ; 3-month ACG: 14.5 and Latera: 39.9, P = .034; 6-month ACG: 8.4 and Latera: 44.2, P = .003). CONCLUSIONS: Both ACG and Latera offer significant improvements in patient-reported nasal obstruction severity; however, ACG may yield more favorable subjective symptom scores.

The need to protect cancer nurses from exposure to hazardous drugs.

Freelance medical writer Christine Clark (chris@salt.u-net.com) reports on an online meeting held in May 2022 as part of a series on the risks of exposure to hazardous drugs for nurses working in oncology.

Helping to protect cancer nurses from exposure to hazardous drugs.

Freelance medical writer Christine Clark (chris@salt.u-net.com) reports on an online meeting held in April 2021 on protecting nursing staff working in oncology from exposure to hazardous drugs.

How can we protect cancer nurses from exposure to hazardous drugs?

Freelance medical writer Christine Clark (chris@salt.u-net.com) reports on an online meeting held in November 2020 on protecting nursing working in oncology from exposure to hazardous drugs.

The Postcricoid Cushion: An Unusual and Surgically Treatable Cause of Infant Aspiration.

OBJECTIVES: To highlight the importance of recognizing the postcricoid cushion as a surgically treatable cause of newborn aspiration in select cases unresponsive to conservative measures. METHODS: A retrospective review was performed on a single case of neonatal aspiration at a tertiary care pediatric hospital. RESULTS: Resolution of aspiration was achieved in an otherwise healthy six-week old term infant following ablation of a postcricoid cushion using microlaryngeal instrumentation and coblation. Prior airway and swallowing evaluations, along with a trial of reflux therapy and pacing of feeds, preceded the surgical excision, successfully avoiding gastrostomy tube placement. CONCLUSIONS: Otolaryngology consults for neonatal dysphagia and aspiration are challenging. The postcricoid cushion is considered an anatomic variant that can engorge with crying. When large, it can prevent feeds from entering the esophagus and lead to pooling and aspiration. The postcricoid cushion is evident on flexible fiberoptic laryngoscopy, but without a vigilant eye may be easily overlooked. This single case report suggests that surgical ablation may be effective management in select cases after ruling out concomitant aerodigestive pathology and neurodevelopmental causes of aspiration and only after conservative therapy has failed. A video demonstrating the surgical ablation is included.

Aspirin use predicts prolonged survival in patients with oropharyngeal cancer: Nationwide Veterans Affairs database study.

BACKGROUND: Single-institution studies suggest that aspirin reduces the risk of death in head and neck cancer. The aim of this study was to investigate the effect of aspirin use on overall survival (OS) in veterans with oropharyngeal cancer (OPC). METHODS: A total of 23 083 veterans with OPC were identified between 2005 and 2018 from the Veterans Health Administration Corporate Data Warehouse. Records were queried for clinical-demographic data, aspirin prescriptions, and outcomes. Three-year OS was estimated. A Cox model was used to estimate hazard ratios (HR) for aspirin use. RESULTS: Among the 23 083 identified veterans, 17 206 veterans met inclusion criteria. 21.8% used aspirin. Three-year OS was prolonged for aspirin users (66%) compared to nonaspirin users (54%; P < .001). Adjusted HR for death for nonaspirin users was 1.75 (95% confidence interval (CI) [1.60-1.91]). The average treatment effect of aspirin on survival using inverse probability weighting was 10% (95% CI [0.08-0.11]). CONCLUSION: Aspirin use following OPC diagnosis was independently associated with improved 3-year OS among veterans nationwide.

The Role of Age and Gender on Perception of Women After Cosmetic Rhinoplasty.

BACKGROUND: Rhinoplasty is known to increase attractiveness; however, the influence of observer age and gender are largely undetermined. METHODS: This retrospective cross-sectional study included 20 women who underwent cosmetic rhinoplasty between January 1st, 2012, and December 31st, 2019. A total of 4 surveys were constructed with 10 sets of photographs each (5 preoperative and 5 postoperative). Surveys were designed such that photographs of the same patient were not placed in the same survey to avoid recall bias. Each of these surveys were then sent to at least 30 lay people via a web-based survey tool. Anonymous blinded respondents used a 7-point Likert scale to rate their perception of each patient's aggressiveness, likeability, sociability, trustworthiness, attractiveness, femininity, intelligence and confidence. A multivariate linear mixed effect model was applied to analyze the overall patient trait data as well as to assess age and gender differences. RESULTS: This survey study included photographs of 20 women (mean age, 28.2 years) before and after cosmetic rhinoplasty. A total of 174 respondents (mean age range, 25-34 years [41%]; 108 [62%] were female) completed the survey. Overall, postoperative photographs were perceived as significantly more sociable (0.13; 95% CI, 0.01-0.25), attractive (0.21; 95% CI, 0.09-0.34), feminine (0.18; 95% CI, 0.05-0.30), and confident (0.15; 95% CI, 0.02-0.27). When analyzed by sex, men rated women as less aggressive (-0.42, 95% CI, -0.65,-0.17) and more likeable (+0.45, 95% CI, 0.21-0.69), sociable (+0.38, 95% CI, 0.14-0.62), trustworthy (+0.37, 95% CI, 0.13-0.61), attractive (+0.60, 95% CI, 0.35-0.84), feminine (+0.23, 95% CI, 0.07-0.41) and intelligent (+0.29, 95% CI, 0.04-0.53). In contrast, female respondents indicated an increase in perceived attractiveness (+0.16, 95% CI, 0.06-0.22) and femininity (+0.18, 95% CI, 0.03-0.32) for women after rhinoplasty. Raters aged 25-34 indicated improvements across all traits analyzed. Almost all age ranges rated post-operative photographs as more attractive (18-24: +0.32, 95% CI, 0.19-0.46; 25-34: +0.52, 95% CI, 0.33-0.72; 35-44: +0.29, 95% CI, 0.12-0.51; 45-54: +0.50, 95% CI, 0.11-0.89) while individuals over age 55 only indicated increased trustworthiness (+0.51, 95% CI, 0.03-0.99). CONCLUSIONS: These findings suggest that cosmetic rhinoplasty improves perceptions of personality and physical traits of women with males and individuals aged 25-34 indicating the greatest benefit. LEVEL OF EVIDENCE: Level IV.

Digital Appearance Manipulation Increases Consideration of Cosmetic Surgery: A Prospective Cohort Study.

Background: Social media has gained significant popularity over the last decade. We now have the opportunity to digitally enhance our physical appearance using a variety of applications in the palm of our hands. One app, in particular, Facetune2, allows one to smooth skin, alter the size and shape of our nose, and even enhance our jaw line. Objectives: (1) To assess whether using a digital appearance manipulation (DAM) application directly causes increased acceptance of cosmetic surgery and (2) to measure the impact photograph editing has on an individual's self-esteem, self-rated attractiveness, and self-rated personality traits. Design Type: Prospective cohort study. Methods: A total of 20 subjects were recruited to participate in this study between July 25 and September 24, 2019, using University e-mail list invitations. Subjects first completed a basic intake questionnaire that included demographic information as well as baseline acceptance of cosmetic surgery, Rosenberg self-esteem, and self-perception scores. Subjects then had two sets of headshots taken (neutral and smile) and provided an introduction on the use of the Facetune2 app. Subjects received a digital copy of their photographs and were asked to download the free mobile app. After 1 week of appearance manipulation, subjects submitted their best edited photographs and completed the same three questionnaires. Wilcoxon signed rank test analysis was then used to assess for changes before and after DAM. Results: Overall, study participants indicated increased consideration of cosmetic surgery on the acceptance of cosmetic surgery scale after DAM (+3.45, p = 0.04). When divided by gender, females further signified increased consideration of cosmetic surgery to keep looking young (+1.4, p = 0.04). Males indicated increased social motivation for cosmetic surgery after DAM (+1.5, p = 0.04). Both males (+1.0, p = 0.04) and females (+0.8, p = 0.03) indicated that they "could end up having some kind of cosmetic surgery" in the future. Comparison of the personality perception and Rosenberg self-esteem scores for all study participants before and after DAM showed no significant changes. Conclusions: The results of this study suggest that DAM can directly lead to increased consideration of cosmetic surgery for both males and females without affecting self-esteem.

Blood use and transfusion needs at a large health care system in Washington state during the SARS-CoV-2 pandemic.

BACKGROUND: This report evaluates hospital blood use trends during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, and identifies factors associated with the need for transfusion and risk of death in patients with coronavirus 2019 (COVID-19). METHODS: Overall hospital blood use and medical records of adult patients with COVID-19 were extracted for two institutions. Multivariate logistic regression models were conducted to estimate associations between the outcomes transfusion and mortality and patient factors. RESULTS: Daily blood use decreased compared to pre-COVID-19 levels; the effect was more significant for platelets (29% and 34%) compared to red blood cells (25% and 20%) at the two institutions, respectively. Surgical and oncologic services had a decrease in average daily use of platelets of 52% and 30%, and red blood cells of 39% and 25%, respectively. A total of 128 patients with COVID-19 were hospitalized, and 13 (10%) received at least one transfusion due to anemia secondary to chronic illness (n = 7), recent surgery (n = 3), and extracorporeal membrane oxygenation (n = 3). Lower baseline platelet count and admission to the intensive care unit were associated with increased risk of transfusion. The blood group distribution in patients with COVID-19 was 37% group O, 40% group A, 18% group B, and 5% group AB. Non-type O was not associated with increased risk of mortality. CONCLUSION: The response to the SARS-CoV-2 pandemic included changes in routine hospital operations that allowed for the provision of a sufficient level of care for patients with and without COVID-19. Although blood type may play a role in COVID-19 susceptibility, it did not seem to be associated with patient mortality.

Management of Adult Inpatient Otolaryngologic Consultations During the COVID-19 Pandemic: A Proposed Tier-Based Triage System.

The coronavirus disease 2019 (COVID-19) pandemic has placed tremendous strain on health care systems, leading to unprecedented challenges and obstacles in the delivery of patient care. Otolaryngologists are frequently called on for inpatient consultations for an array of pathologies, ranging from chronic benign conditions to acutely life-threatening processes. Professional otolaryngologic societies across the world have proposed limiting patient care to time-sensitive and urgent matters; however, limited literature is available to describe how this transient change in philosophy may translate to clinical practice. Here we present a structured algorithm that allows for rapid triage of otolaryngologic consults during the ongoing pandemic, in efforts to minimize infectious spread and protect clinicians while preserving high-quality patient care. Considerations for managing these consults are presented, with a commentary on practical and ethical considerations.

Perioperative Considerations in Endoscopic Skull Base Surgery.

PURPOSE OF THE REVIEW: Present an overview of perioperative considerations specific to endoscopic skull base surgery necessary to maximize successful outcomes. RECENT FINDINGS: The majority of perioperative considerations for endoscopic skull base surgery lack strong supporting evidence and frequently have varied use or implementation amongst institutions. A notable exception comes from a recent randomized controlled trial demonstrating the benefit of lumbar drainage in high-risk cerebrospinal fluid leaks. SUMMARY: Skull base surgeons must consider a multitude of perioperative factors. While many components of perioperative management are extrapolated from related fields such as endoscopic sinus surgery or open cranial base surgery, additional high-quality studies are needed to delineate best practices specific to endoscopic skull base surgery.

Surgical Considerations for an Awake Tracheotomy During the COVID-19 Pandemic.

Background: The current global COVID-19 pandemic is caused by the novel coronavirus Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2). Given that SARS-CoV-2 is highly transmissible, surgical societies have recommended that procedures with a high risk of aerosolization be avoided or delayed. However, some high-risk procedures, such as those related to head and neck malignancies, cannot always be delayed. Care must be taken during aerosol-generating procedures to minimize viral transmission as much as possible. Preoperative testing for COVID-19, limited operating room personnel, adequate personal protective equipment, and surgical technique are factors to consider for high-risk procedures. Methods: This article presents the case of an awake tracheotomy performed for a transglottic mass causing airway obstruction. Results: With detailed planning and specific techniques, the amount of aerosolization was reduced, and the procedure was performed as safely as possible. Conclusion: This case provides a template for future aerosol-generating procedures during respiratory pandemics.