Fenestration of the facial nerve by the stylomastoid artery.

BACKGROUND: Anatomic landmarks such as the tympanomastoid suture line, posterior belly of the digastric muscle, tragal pointer, and styloid process can assist the parotid surgeon in identifying and preserving the facial nerve. Vascular structures such as the posterior auricular artery and its branch, the stylomastoid artery, lay in close proximity to the facial nerve and have been proposed as landmarks for the identification of the facial nerve. In this case report, we describe an anatomic variation in which the stylomastoid artery has fenestrated the main trunk of the facial nerve, dividing it in two. METHODS: Two patients underwent parotidectomy (one for a pleomorphic adenoma, the second for a parotid cyst) through a standard anterograde approach with identification of the usual facial nerve landmarks. RESULTS: The appearance of the main trunk of the facial nerve was unusual in both patients due to its being fenestrated by the stylomastoid artery. The stylomastoid artery was divided, and the remainder of the facial nerve dissection was performed uneventfully with subsequent resection of the parotid mass in both patients. CONCLUSIONS: In rare instances, the stylomastoid artery can penetrate through the common trunk of the facial nerve. This is an important anatomic variant for the parotid surgeon to be aware of, as it can increase the difficulty of facial nerve dissection.

Increasing Prevalence of Voice Disorders in the USA: Updates in the COVID Era.

OBJECTIVE: To estimate the current prevalence of voice disorders among adults in the United States; to determine the association of individual factors with voice disorders. METHODS: The 2022 National Health Interview Survey (NHIS) was analyzed to identify adults reporting voice problems in the past 12 months. Demographics were assessed, as well as the duration, severity, and resolution of the voice problem. The relationship between voice problems, gender, lost workdays, and long COVID was investigated. A comparison to the 2012 NHIS was made to determine changes in voice disorder prevalence. RESULTS: 29.9 million Americans (95%CI[28.3-31.5]) annually report a voice problem, representing 12.2% of the population (95%CI[11.7-12.8%]). Overall, 26.8% and 13.2% reported the severity of their voice problem as moderate or severe, respectively. Only 5.1% (95%CI[4.3-6.0%]) of respondents sought treatment. Most voice problems were resolved within 1 week (53.0%,95%CI[50.9-55.1%]). Females were more likely than males to report a voice problem (14.4% vs. 10.0%,95%CI[13.7-15.1] and [9.3-10.7], respectively). The 17.6 million Americans with long COVID symptoms were more likely to have voice complaints than those without (21.1% vs. 11.6%,95%CI[18.9-23.5%] and [11.1-12.1%], respectively). Lost workdays were not significantly higher for those with voice disorders compared to those without (17.1 vs. 12.9 days,95%CI[12.0-22.1] and [11.0-14.8], respectively). CONCLUSIONS: Voice problems affect approximately 1 in 8 adults in the U.S. annually, demonstrating an alarming increased prevalence since 2012 using the same survey methodology. Relatively few individuals seek care for their voice problem, despite significant self-reported impact. Further study is required regarding the impact of COVID and changes in voice use patterns on voice disorders. LEVEL OF EVIDENCE: 3 Laryngoscope, 2024.

Histologic Evaluation of Silk-Hyaluronic Acid After Human Vocal Fold Injection.

OBJECTIVES: This case report aims to histologically examine human vocal fold tissue 9 months after silk-hyaluronic acid (silk-HA) injection. INTRODUCTION: Silk-HA is an engineered injectable implant made from natural protein biomaterial, silk, crosslinked with hyaluronic acid to provide long-lasting, dynamic office-based vocal fold injection augmentation to restore glottic competency. METHODS: We report the case of an adult female with left vocal fold immobility and bilateral atrophy that was treated with silk-HA injections with biopsy taken 9 months after injection for histological examination. CONCLUSION: Silk-HA injection in human true vocal fold demonstrates slow degradation of particles and intended cellular infiltration 9 months after injection.

A case of true vocal fold jaundice.

OBJECTIVES: While jaundice is frequently described in the sclera and skin, there are few reports of true vocal fold jaundice in patients with high bilirubin, and no reports by otolaryngologists in the literature. Here we describe a case of a patient with bilateral true vocal fold jaundice and discuss the potential pathogenesis and implications of this finding. METHODS: A 29-year-old man with history of Dubin-Johnson Syndrome presented with cough and difficulty breathing and was incidentally found to have persistent yellow discoloration of the true vocal folds bilaterally. RESULTS: Videolaryngoscopic exam demonstrated bilateral true vocal fold yellow discoloration with sparing of nearby laryngeal structures on initial presentation and follow-up exam. Direct and total bilirubin levels were found to be elevated. CONCLUSION: A patient with benign Dubin-Johnson Syndrome and elevated total and direct bilirubin was incidentally found to have bilateral vocal fold jaundice. Jaundice and the presence of bilirubin do not appear to cause harm to the function or health of the true vocal folds and may be related to the high concentration of elastin present in the true vocal folds.

Decision aid and preference assessment of topical anesthesia for otolaryngology procedures.

OBJECTIVES: To determine preference patterns for topical anesthesia in patients undergoing endoscopy pre-coronavirus (2019 coronavirus disease [COVID-19]) pandemic and analyze outcomes based on preference, using a decision aid format. METHODS: A decision aid was developed with expert and patient input. New patients presenting to subspecialty clinics over a 2-month pre-COVID-19 period completed a pre-procedure survey about their priorities, then were asked to choose between topical oxymetazoline/lidocaine spray or none. A post-procedure outcome survey followed. RESULTS: Of 151 patients, 90.1% patients elected to have topical anesthesia. Top patient priorities were "I want the scope to be easy for the doctor" and "I want to be as comfortable as possible." Patients who strongly wanted to avoid medication (P = .002) and bad taste (P = .003) were more likely to select no spray, whereas those who wanted to avoid pain received anesthetic (P = .011). According to the post-procedure assessment, 95.4% of patients were satisfied or strongly satisfied their choice, and this did not correlate with anesthetic vs none. CONCLUSIONS: Patient preferences are easily elicited and correlate with treatment choices. Most patients chose to have topical anesthetic and were willing to tolerate side effects; however, both patients with and without topical anesthetic were satisfied with their choices. This decision aid can be used to optimize shared decision making in the otolaryngology clinic. Given the aerosolizing potential of both spray and no spray conditions, this insight may be consequential when devising office protocols for post-COVID-19 practice. LEVEL OF EVIDENCE: II.

Coverage for Gender-Affirming Voice Surgery and Therapy for Transgender Individuals.

OBJECTIVES/HYPOTHESIS: To determine insurance coverage for gender-affirming surgery and voice therapy for individuals who seek to align their voice with their gender identity, and to analyze differences based on state-by-state transgender equality. STUDY DESIGN: Cross-sectional study. METHODS: Policies from the top three commercial insurers per state in 2019 were reviewed. Coverage status was determined by web-based search, telephone interviews, and email inquiries. A state-by-state equality score was calculated based on the number of laws and policies relating to the transgender community. Correlation between number of preauthorized procedures and state equality scores was assessed. RESULTS: Of the 150 insurance companies reviewed, only four (2.7%) held favorable policies, whereas 113 (75.8%) provided no coverage. Endoscopic surgery, open surgery, individual voice therapy, and group voice therapy interventions were equally excluded (n = 93, 62.4%). Coverage was not correlated with laws driving transgender equality (P = .782). CONCLUSIONS: Gender-affirming voice interventions are seldom covered by commercial insurance companies. Despite established medical necessity and years of experience in practice, gender-affirming interventions for voice have not yet been fully considered by third-party payors. Further investigation regarding cost-effectiveness and treatment efficacy is warranted to improve insurance coverage of voice-related gender-affirming care. LEVEL OF EVIDENCE: NA Laryngoscope, 131:E896-E902, 2021.

Risk Factors for Laryngectomy for Dysfunctional Larynx After Organ Preservation Protocols: A Case-Control Analysis.

OBJECTIVE: (1) To identify factors associated with severe dysfunctional larynx leading to total laryngectomy after curative treatment of head and neck squamous cell carcinoma and (2) to describe swallowing and voice outcomes. STUDY DESIGN: Retrospective single-institution case-control study. SETTING: Tertiary care referral center. METHODS: A 10-year chart review was performed for patients who had previously undergone radiation or chemoradiation for head and neck mucosal squamous cell carcinoma and planned to undergo total laryngectomy for dysfunctional larynx, as well as a control group of matched patients. Controls were patients who had undergone radiation or chemoradiation for mucosal squamous cell carcinoma but did not have severe dysfunction warranting laryngectomy; these were matched to cases by tumor subsite, T stage, and time from last treatment to video swallow study. Main outcomes assessed were postoperative diet, alaryngeal voice, pharyngeal dilations, and complications. RESULTS: Twenty-six patients were scheduled for laryngectomy for dysfunctional larynx, of which 23 underwent surgery. Originally treated tumor subsites included the larynx, oropharynx, hypopharynx, oral cavity, and a tumor of unknown origin. The median time from end of cancer treatment to laryngectomy was 11.5 years. All cases were feeding tube or tracheostomy dependent or both prior to laryngectomy. As compared with matched controls, cases were significantly less likely to have undergone IMRT (intensity-modified radiotherapy) and more likely to have pulmonary comorbidities. Eighty-nine percent of cases with follow-up achieved functional alaryngeal voice, and all were able to have oral intake. CONCLUSION: Non-IMRT approaches and pulmonary comorbidities are associated with laryngectomy for dysfunction after radiation or chemoradiation.

The health utility of mild and severe dysphonia.

OBJECTIVES/HYPOTHESIS: The impact of disease states can be measured using health state utilities, which are values that reflect economic preferences for health outcomes. Utilities for dysphonia have not been studied using direct methods. The objective of this project was to establish the baseline health utilities of mild and severe dysphonia from a societal perspective. STUDY DESIGN: Direct utility elicitation survey. METHODS: Four health states (monocular blindness, binocular blindness, mild dysphonia, and severe dysphonia) were evaluated by a convenience sample of adults recruited from the general public with three computer-aided estimation techniques (visual analog scale [VAS], standard gamble [SG], and time trade-off [TTO]). Standardized descriptions and voice recordings from multiple dysphonic patients were employed. Perfect health was defined as a utility of 1, with death 0. Analysis of variance with post hoc pairwise comparison was used to calculate significant differences between health states. RESULTS: Three hundred participants were surveyed, and 225 (75.0%) responses met quality thresholds. Severe dysphonia (VAS = 48.3, SG = 0.810, TTO = 0.798) was valued significantly worse than monocular blindness (VAS = 56.2, SG = 0.834, TTO = 0.839) on the VAS (P < .001) and equivalent on SG and TTO; it was preferred over binocular blindness (VAS = 25.7, SG = 0.631, TTO = 0.622; P < .001) with all methods. Mild dysphonia evaluated favorably with all methods to the other health states (VAS = 78.5, SG = 0.902, TTO = 0.908; P < .001). CONCLUSIONS: Voice disorders may have a measurable impact on utility, with severe dysphonia valued equivalently to monocular blindness. Mild dysphonia has a utility decrement from perfect health. These estimates are critical for quality-of-life assessment and could be used to assess cost-effectiveness of treatments for voice disorders. LEVEL OF EVIDENCE: NA Laryngoscope, 130:1256-1262, 2020.

Best practices for emergency surgical airway: A systematic review.

OBJECTIVE: In the case of an emergency surgical airway, current guidelines state that surgical cricothyrotomy is preferable to tracheotomy. However, complications associated with emergency cricothyrotomy may be more frequent and severe. We systematically reviewed the English literature on emergency surgical airway to elicit best practices. METHODS: PubMed, Embase, MEDLINE, and the Cochrane Library were searched from inception to January 2019 for studies reporting emergency cricothyrotomy and tracheotomy outcomes. All English-language retrospective analyses, systematic reviews, and meta-analyses were included. Case reports were excluded, as well as studies with pediatric, nonhuman, or nonliving subjects. RESULTS: We identified 783 articles, and 20 met inclusion criteria. Thirteen evaluated emergency cricothyrotomy and included 1,219 patients (mean age = 39.8 years); 4 evaluated emergency tracheotomy and included 342 patients (mean age = 46.0 years); 2 evaluated both procedures. The rate of complications with both cricothyrotomy and tracheotomy was comparable. The most frequent early complications were failure to obtain an airway (1.6%) and hemorrhage (5.6%) for cricothyrotomy and tracheotomy, respectively. Airway stenosis was the most common long-term complication, occurring at low rates in both procedures (0.22-7.0%). CONCLUSIONS: Complications associated with emergency cricothyrotomy may not occur as frequently as presumed. Tracheotomy is an effective means of securing the airway in an emergent setting, with similar risk for intraoperative and postoperative complications compared to cricothyrotomy. Ultimately, management should depend on clinician experience and patient characteristics. LEVEL OF EVIDENCE: IV.