Overlapping otolaryngologic surgery: Safety and efficacy.

BACKGROUND: Surgical procedures scheduled staggered between two operating rooms increase efficiency by eliminating turnover time. However, the practice might increase the surgeon's fatigue. Overlapping surgery has been assumed to be safe because no critical portions of procedures are performed simultaneously in two rooms, but there is little evidence in the literature to support that assumption for otolaryngologic surgery, and there is no evidence comparing non-overlapping and overlapping surgical outcomes for a single surgeon with all confounding factors controlled. METHODS: Retrospective cohort study that included a consecutive sample of adult subjects who underwent otolaryngologic laryngeal or otologic surgery between June 2013 and March 2016. All procedures were performed by the same surgical team and surgeon who had block time with 2-rooms every other week and 1-room on alternate weeks. The incidence of surgical complications was assessed in the perioperative period. Duration of surgery and time-in-room also were evaluated, as were surgical outcomes. RESULTS: A total of 496 surgeries were assigned to either overlapping-surgery (n = 346) or non-overlapping-surgery (n = 150) cohorts. Overlapping-surgery was a significant predictor for increased time-in-room on multivariate analysis but was not a significant predictor for surgery duration. Rate of complications, hospital readmission, emergency department visit, reoperation, mortality, and patient satisfaction did not differ significantly between cohorts. CONCLUSIONS: Overlapping surgery does not hinder patient safety or functional outcomes in patients undergoing otolaryngologic operations such as voice or ear surgery.

Havana syndrome: Overview for otolaryngologists.

Havana Syndrome is used to describe the array of deficits seen in diplomats stationed in Cuba from August 2016 to September 2017.1 Patients from this cohort were clinically studied, investigating their symptoms, audition and vestibular deficits, and imaging abnormalities seen on MRI.1-3 The primary studies were retrospective, looking at how these symptoms could be classified or fit into diagnostic criteria. The cohort had many similarities: a sound at the onset of symptoms, a mix of neurologic and otologic symptoms, and persistent symptoms that lasted for months.1-3 Theories of the cause of Havana Syndrome have led to no conclusive answer. Potential viral etiologies, mass psychogenic illness, and head trauma were examined as causes.1-5 Diseases with established diagnostic criteria were used to compare the patients' symptoms to try to find a disease that fits Havana Syndrome.3 Recent information from the Office of the Director of National Intelligence suggested the most likely cause to be mass psychogenic illness. With the cause of Havana Syndrome still unknown, a review of reported cases and reports helps otolaryngologists understand Havana Syndrome so they diagnose it only when appropriate and do not miss other conditions that may present with similar symptoms and that might respond well to targeted treatment.

Noninvasive Management of Voice Disorders: An Umbrella Review.

OBJECTIVES: The aim of this study was to assess published systematic reviews that discussed noninvasive management of voice disorders. An umbrella review was conducted to collect, organize, and summarize narratively all available pharmacologic and voice therapy interventions. STUDY DESIGN: Umbrella review of systematic reviews. METHODS: Pertinent systematic reviews were identified by searching Pubmed/Medline and Embase. A primary screen identified studies related to voice. The second round of screening focused on studies that involved noninvasive management of voice disorders such as pharmacologic or voice therapy interventions. Variables of interest included study design, number of studies included in the review, target population, method of intervention, and outcomes. RESULTS: Forty-three systematic reviews were eligible and included in the umbrella review. Ten studies focused on pharmacologic interventions, and 33 studies focused on voice therapy. Individual studies included in the systematic reviews ranged from 2-47, with a total of 601 studies overall. CONCLUSIONS: This study provides a detailed review of all available systematic reviews on noninvasive management of voice disorders. Explored medications included proton pump inhibitors, calcium channel blockers, tricyclic antidepressants, antibiotics, corticosteroids, and hormone replacement. Explored voice therapy techniques included hydration, vocal function exercises, laryngeal manual therapy, respiratory exercise, biofeedback, phonation, coping strategies, and others. This may be utilized to guide therapeutic decision-making and identify current gaps in the literature that may warrant future investigation.

Patients' Demographics and Risk Factors in Voice Disorders: An Umbrella Review of Systematic Reviews.

OBJECTIVES: This study aimed to provide a comprehensive overview of the systematic reviews that focus on the prevalence of voice disorders (VDs), associated risk factors, and the demographic characteristics of patients with dysphonia. An umbrella review was conducted to identify general research themes in voice literature that might guide future research initiatives and contribute to the classification of VDs as a worldwide health concern. STUDY DESIGN: Umbrella review of systematic reviews. METHODS: Pubmed/Medline and Embase were searched for eligible systematic reviews by two authors independently. Extracted data items included the study publication details, study design, characteristics of the target population, sample size, region/country, and incidence and/or prevalence of the VD(s) of interest. RESULTS: Forty systematic reviews were included. Sixteen reported a meta-analysis. Great heterogeneity in methods was found. A total of 277,035 patients across the included studies were included with a prevalence ranging from 0%-90%. The countries represented best were the United States and Brazil, with 13 studies each. Aging, occupational voice use, lifestyle choices, and specific comorbidities, such as obesity or hormonal disorders, seem to be associated with an increased prevalence of dysphonia. CONCLUSIONS: This review underscores the influence of VDs on distinct patient groups and the general population. A variety of modifiable or non-modifiable risk factors, having varied degrees of impact on voice qualities, have been identified. The overall effect of VDs is probably underestimated due to factors, such as sample size, patient selection, underreporting of symptoms, and asymptomatic cases. Employing systematic reviews with consistent methodologies and criteria for diagnosing VDs would enhance the ability to determine the prevalence of VDs and their impact.

Left Vocal Process Avulsion.

Vocal fold process avulsion results from trauma that detaches the vocal process and thyroarytenoid muscle from the body of the arytenoid cartilage. Vocal fold laxity often causes severe dysphonia. Findings can be subtle. A high index of suspicion often permits diagnosis and effective surgical repair.

Characterization of Laryngopharyngeal Reflux in the Elderly Population.

INTRODUCTION: Laryngopharyngeal reflux (LPR) often is not diagnosed due to its presentation without heartburn. The aim of this study was to analyze the signs and symptoms of elderly patients undergoing treatment for LPR using subjective as well as objective measures including strobovideolaryngoscopies, 24-hour pH studies, and manometry to highlight appropriate considerations for diagnosis and treatment. METHODS: This was a retrospective review of patients with laryngopharyngeal reflux who were seen from January 2010 to February 2021 in the practice of the senior author (Robert T. Sataloff) who had undergone 24-hour pH testing, and for whom all data were available. Patients aged 60 years and older were considered elderly and compared to patients younger than 40 and between the ages of 40 and 59. However, patients in their 60s, 70s, and 80s were evaluated and compared separately. Objective reflux findings, 24-hour pH studies, and manometry were compared between groups. RESULTS: Two hundred and eighty-eight patients being treated for LPR were included, 100 of whom were over the age of 60. While 94.1% of patients younger than 40 had a chief complaint of hoarseness, 71% percent of those aged 60 and older complained of hoarseness. Patients aged 60 and older were more likely to present with no voice complaint as their age increased (P = 0.001). Lower esophageal sphincter residual pressure was 12.15 ±â€¯6.28 in elderly patients compared to 4.90 ±â€¯3.38 in patients younger than 40 (P < 0.001). Upper esophageal sphincter (UES) basal pressure was decreased in elderly patients at 83.84 ±â€¯50.53 compared to 105.92 ±â€¯51.49 in patients younger than 60 or younger (P = 0.029). Older patients in their 70s and 80s also had lower UES basal pressures at 75.79 ±â€¯47.66 and 63.45 ±â€¯14.50 (P = 0.003). Additionally, while 71.4% of patients younger than 40 had normal esophageal motility (Chicago classification v4), only 40% of elderly patients had normal esophageal motility (P < 0.001). More severe ventricular obliteration also was present in elderly patients compared to non-elderly patients (P = 0.032), and thick endolaryngeal mucus was less likely to be present in elderly patients (P = 0.007). Reflux finding score differed between age groups with patients aged less than 40 scoring 14.78 ±â€¯2.5, 40-59 year olds scoring 15.83 ±â€¯2.13 and patients 60 and older scoring 15.48 ±â€¯2.43 (P = 0.018). CONCLUSION: Elderly patients diagnosed with LPR have different presentations of the disease compared with younger patients.

The Dubai Definition and Diagnostic Criteria of Laryngopharyngeal Reflux: The IFOS Consensus.

OBJECTIVE: The objective of this work was to gather an international consensus group to propose a global definition and diagnostic approach of laryngopharyngeal reflux (LPR) to guide primary care and specialist physicians in the management of LPR. METHODS: Forty-eight international experts (otolaryngologists, gastroenterologists, surgeons, and physiologists) were included in a modified Delphi process to revise 48 statements about definition, clinical presentation, and diagnostic approaches to LPR. Three voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 8/10. Votes were anonymous and the analyses of voting rounds were performed by an independent statistician. RESULTS: After the third round, 79.2% of statements (N = 38/48) were approved. LPR was defined as a disease of the upper aerodigestive tract resulting from the direct and/or indirect effects of gastroduodenal content reflux, inducing morphological and/or neurological changes in the upper aerodigestive tract. LPR is associated with recognized non-specific laryngeal and extra-laryngeal symptoms and signs that can be evaluated with validated patient-reported outcome questionnaires and clinical instruments. The hypopharyngeal-esophageal multichannel intraluminal impedance-pH testing can suggest the diagnosis of LPR when there is >1 acid, weakly acid or nonacid hypopharyngeal reflux event in 24 h. CONCLUSION: A global consensus definition for LPR is presented to improve detection and diagnosis of the disease for otolaryngologists, pulmonologists, gastroenterologists, surgeons, and primary care practitioners. The approved statements are offered to improve collaborative research by adopting common and validated diagnostic approaches to LPR. LEVEL OF EVIDENCE: 5 Laryngoscope, 134:1614-1624, 2024.

The impact of menopausal status on auditory brainstem responses.

OBJECTIVE: To determine the effect of decreased estrogen levels due to menopause on auditory brainstem response measurements (ABR). STUDY DESIGN: Retrospective chart review. SETTING: Academic. PATIENTS: Pre- and post-menopausal females (pre-M, post-M) and age-matched males. METHODS: ABR measurements of wave I, III, and V latencies, and interpeak latencies; amplitudes of waves I, III, V, and V/I ratio. OUTCOME MEASURE: Differences in ABR measurements between pre-M and post-M. RESULTS: 164 subjects (101 female and 64 male) were included. Post-M had significantly greater latencies (msec) than pre-M of wave V. Post-M had a significantly smaller wave I amplitude (uV) than pre-M. Post-M had a significantly higher wave V/I amplitude ratio than pre-M. Pre-M had significantly shorter latencies than young males for wave III, and wave V. Post-M had significantly shorter latencies than older males at wave III, and wave V. A two-way ANOVA revealed a significant interaction between the effects of age category and gender on V/I amplitude. CONCLUSION: Post-M group showed a significant drop in wave I amplitude compared with pre-M group, even in the absence of hearing loss, suggesting that the gender differences in hearing are related to estrogen signaling along the auditory pathway. If wave I amplitude changes between older and younger groups resulted from decreased peripheral hearing sensitivity, we would expect larger drops in amplitude in males since rates of presbycusis are higher. We observed much larger drops in wave I amplitude in females, which cannot be attributed to peripheral hearing loss. These results may assist in understanding gender differences in presbycusis and a possible protective effect of estrogen on the auditory system. Knowledge of gender differences in wave I may be important when ABR is used to assess possible synaptopathy.

Long-term Outcome of Autologous Lipoinjection Medialization Laryngoplasty versus Type I Thyroplasty.

Glottic insufficiency is incomplete or soft closure of the true vocal folds during phonation and is a common cause of dysphonia. Treatment includes voice therapy, type I thyroplasty, vocal fold injection augmentation (with materials such as autologous fat), arytenoid cartilage repositioning, or a combination of treatment modalities. The present study aimed to compare long-term outcomes of lipoinjection medialization with type I thyroplasty for patients with glottic insufficiency. METHODS: Adult voice center patients who had undergone surgical vocal fold medialization with autologous lipoinjection or with type I thyroplasty for glottic insufficiency were included in this retrospective study. The primary outcome measures were the need for further medialization surgery and improvement in the glottic gap. RESULTS: There were 172 subjects included in this study: 100 subjects underwent type I thyroplasty and 72 subjects underwent autologous lipoinjection medialization. Neither age nor gender differed significantly between thyroplasty and lipoinjection groups. The rate of further medialization surgery did not differ significantly between thyroplasty and lipoinjection groups, but further medialization surgery was performed longer after the initial operation in the thyroplasty group Baseline glottic gap did not differ significantly between thyroplasty and lipoinjection groups. When improvement from baseline was compared between thyroplasty and lipoinjection subjects, the improvement from baseline was similar for both groups at 6 months and at 12 months. Voice handicap index scores improved significantly after thyroplasty or after lipoinjection, and the improvement from baseline was similar in both cohorts. CONCLUSION: Both autologous lipoinjection medialization and type I thyroplasty provide effective medialization for patients with glottic insufficiency. Both techniques yield similar reoperation rates, and the benefit of surgery appears to last for at least 1 year for most patients.

Prevalence of Objective Voice Measurement Use in Laryngology Practices in the United States.

OBJECTIVES: The aim of this study was to assess the prevalence of use of objective voice measurements (OVM), instrumentation, and factors that may impact OVM outcomes, such as setting and implementation to clarify current practice. Doing so should clarify the impact of OVM research on patient care. METHODS: A 12-question, one-time anonymous survey using the Research Electronic Data Capture tool was distributed during January 2023 to laryngologists in the United States identified through membership in The Voice Foundation (TVF) or previous participation in a TVF symposium. RESULTS: A total of 101 responses to 418 emails yielded a response rate of 24.2%. Seventeen point eight percentage (N = 18) were in private practice, 63.4% (N = 64) were in academic settings, and 18.8% (N = 19) were classified as mixed private and academic. Common OVMs used were fundamental frequency 95.12% (N = 78), maximum phonation time 90.24% (N = 74), noise-to-harmonic ratio 71.95% (N = 59), jitter 71.95% (N = 59), and shimmer 70.73% (N = 58). Common equipment and software used Pentax Multi-Dimensional Voice Program 42.68% (N = 35), Pentax Computerized Speech Lab Model 4500B 37.80% (N = 31), and Pentax Visi-Pitch, Model 3950C 23.17% (N = 19), PRAAT 21.95% (N = 18), OperaVOX 4.88% (N = 4), VoceVista 3.66% (N = 3). Fifty one point two percentage (N = 42) stated that they used OVMs with the majority of their patients, most commonly for the assessment of treatment effectiveness (84.1%, N = 69), documentation (78.0%, N = 64), research (70.7%, N = 58), and/or diagnosis (61.0%, N = 50). Ninety point two percentage (N = 74) stated that OVMs were used during initial evaluation of patients. CONCLUSION: This study estimates of the prevalence of OVM use among laryngologists in the United States. There appears to be sufficient consistency among laryngology centers to permit comparison of results between centers, although additional research is needed. Future OVM research should compare measurements and equipment commonly used by laryngologists to define further the generalizability of results.

The Safety and Efficacy of the 445-nm Blue Laser for Operative Management of Benign Nonvascular Laryngeal Lesions.

The 445-nm blue laser combines the features of photocoagulative vascular lasers and cutting lasers in one device. The purpose of the present study was to evaluate the safety and efficacy of the 445-nm blue laser for the treatment of benign laryngeal pathologies, other than vascular lesions. Outcomes were compared to those when already-established therapies were used. METHODS: Adult voice center patients who underwent surgical intervention for vocal fold (VF) mass, VF scar, laryngeal stenosis, laryngeal web, or Reinke's edema were included in this retrospective study. Outcomes were compared to those achieved when traditional treatment modalities were used, including cold steel, CO2 laser, potassium-titanyl-phosphate (KTP) laser, and coblator. Strobovideolaryngoscopy footage was evaluated using a previously described model at four time points: postoperative visit #1: 1-14 days, postoperative visit #2: 30-60 days, postoperative visit #3: 61-365 days, postoperative visit #4: >365 days. RESULTS: Eighty cases using the blue laser and 153 controls (n = 78 cold steel, n = 51 KTP laser, n = 22 CO2 laser, n = 2 coblator) were included in this study. Procedures performed using blue laser included VF mass excision (n = 45), VF scar reduction (n = 16), laryngeal stenosis resection/repair (n = 25), laryngeal web excision (n = 7), and reduction of Reinke's edema (n = 1). On postoperative strobovideolaryngoscopy examination, the surgical objective score did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF edema did not differ significantly between the blue laser cohort and all controls at any postoperative visit. VF hemorrhage scores were significantly lower in the blue laser cohort compared to all controls at the first postoperative visit, but hemorrhage had resolved almost entirely by the second postoperative visit in all groups. Postoperative VF stiffness was worse in the blue laser group at the third postoperative visit compared to controls, but both groups had improved to similar levels by the fourth postoperative visit. The rate of lesion recurrence (24.29% versus 17.19%) did not differ significantly between the blue laser cohort and controls on multivariate analysis (Odds ratio [OR] = 1.081 [0.461-2.536]). The complication rate (12.50% versus 10.46%) did not differ significantly between the blue laser cohort and all controls on multivariate analysis (OR = 0.992 [0.375-2.624]). The blue laser was associated with a lower rate of revision surgery (30.00% versus 34.64%) on multivariate analysis (OR = 0.380 [0.168-0.859]). CONCLUSION: The 445-nm blue laser is safe and effective for the management of benign laryngeal lesions. It has efficacy and safety similar to those of traditional treatment modalities (including cold steel, CO2 laser, and KTP laser). Use of the blue laser may lead to lower rates of early postoperative hemorrhage and revision surgery. No adverse effects attributed directly to the use of the blue laser were observed in this study. Further research is encouraged to confirm or refute these findings.

Efficacy of the Grit Scale Score in Predicting Voice Therapy Adherence and Outcomes.

BACKGROUND: Voice therapy generally is considered first-line treatment for dysphonia and vocal fold paresis. It requires a commitment of time, effort and resources; currently, there is no good indicator to identify which patients are good candidates for voice therapy. The Grit scale, developed by psychologist Angela Duckworth, provides a method to quantify perseverance and commitment to long-term goals. OBJECTIVE: We hypothesized that the Grit scale score could correlate with patient adherence to voice therapy and outcomes, by which subjects with higher Grit scale scores demonstrate greater adherence and better outcomes. METHODS: Subjects were categorized into five groups, subjects who (1) were discharged from therapy after successful completion, (2) improved to normal, near-normal, or a level of voice function with which the patients were satisfied, and then stopped attending therapy (3) attended as at least the recommended number of sessions or greater than 8 sessions with some voice improvement (4) failed to improve to a voice function level satisfactory to the patient despite attending voice therapy, (5) failed to attend voice therapy as recommended. Subjects in groups 1-4 were considered adherent to voice therapy, whereas group 5 was considered not adherent. Category 1 was considered the most favorable outcome, whereas Category 5 was considered the least favorable outcome (1 > 2 > 3 > 4 > 5). RESULTS: Eighty-nine subjects are included in the study. The average age of subjects was 44.9 years old, and there was a nearly equal split between male and female subjects. The mean Grit score (48) of the adherent group (categories 1-4) was not significantly different from that of the non-adherent group (47, P = 0.190). Spearman's rho between Grit scale score and the categories (1 > 2 > 3 > 4 > 5) was 0.0674, P = 0.530. CONCLUSION: Neither the analysis by groups nor the Spearman correlation across all categories supported our hypothesis that higher Grit scale scores would be associated with better adherence and outcomes. The failure of the Grit scale score to predict adherence to voice therapy and outcomes emphasizes the need for further research to find a metric that will help predict and improve patient adherence with voice therapy and voice outcomes. Further research is needed to determine why it was unable to be predictive and to confirm or refute our findings.