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.

Diagnosing and Managing Velopharyngeal Insufficiency in Patients With Cleft Palate After Primary Palatoplasty.

Velopharyngeal insufficiency (VPI) after palatoplasty is caused by improper anatomy preventing velopharyngeal closure and manifests as a hypernasal resonance, audible nasal emissions, weak pressure consonants, compensatory articulation, reduced speech loudness, and nostril or facial grimacing. A multidisciplinary team using multimodal instruments (speech analysis, nasoendoscopy, videofluoroscopy, nasometry, and magnetic resonance imaging) to evaluate velopharyngeal function should manage these patients. Careful monitoring of velopharyngeal function by a speech pathologist remains paramount for early identification of VPI and the perceptual assessment should follow a standardized protocol. The greatest methodology problem in CLP studies has been the use of highly variable speech samples making comparison of published results impossible. It is hoped that ongoing international collaborative efforts to standardize procedures for collection and analysis of perceptual data will help this issue. Speech therapy is the mainstay treatment for velopharyngeal mislearning and compensatory articulation, but it cannot improve hypernasality, nasal emissions, or weak pressure consonants, and surgery is the definitive treatment for VPI. Although many surgical methods are available, there is no conclusive data to guide procedure choice. The goal of this review article is to present a review of established diagnostic and management techniques of VPI.

Consensus for voice quality assessment in clinical practice: guidelines of the European Laryngological Society and Union of the European Phoniatricians.

INTRODUCTION: To update the European guidelines for the assessment of voice quality (VQ) in clinical practice. METHODS: Nineteen laryngologists-phoniatricians of the European Laryngological Society (ELS) and the Union of the European Phoniatricians (UEP) participated to a modified Delphi process to propose statements about subjective and objective VQ assessments. Two anonymized voting rounds determined a consensus statement to be acceptable when 80% of experts agreed with a rating of at least 3/4. The statements with ≥ 3/4 score by 60-80% of experts were improved and resubmitted to voting until they were validated or rejected. RESULTS: Of the 90 initial statements, 51 were validated after two voting rounds. A multidimensional set of minimal VQ evaluations was proposed and included: baseline VQ anamnesis (e.g., allergy, medical and surgical history, medication, addiction, singing practice, job, and posture), videolaryngostroboscopy (mucosal wave symmetry, amplitude, morphology, and movements), patient-reported VQ assessment (30- or 10-voice handicap index), perception (Grade, Roughness, Breathiness, Asthenia, and Strain), aerodynamics (maximum phonation time), acoustics (Mean F0, Jitter, Shimmer, and noise-to-harmonic ratio), and clinical instruments associated with voice comorbidities (reflux symptom score, reflux sign assessment, eating-assessment tool-10, and dysphagia handicap index). For perception, aerodynamics and acoustics, experts provided guidelines for the methods of measurement. Some additional VQ evaluations are proposed for voice professionals or patients with some laryngeal diseases. CONCLUSION: The ELS-UEP consensus for VQ assessment provides clinical statements for the baseline and pre- to post-treatment evaluations of VQ and to improve collaborative research by adopting common and validated VQ evaluation approach.

High-Speed Image Analysis Comparing Loading of Vocal Folds During Coughing and Phonation: A Case Study.

PURPOSE: Coughing is related to voice problems, since it involves firm glottal closure, fast glottal opening, and high subglottic pressure and flow rate. In this study, the glottal area variation and movements of laryngeal structures during coughing and phonation are compared. METHODS: High-speed laryngoscopy recordings were made of a normophonic male participant with a healthy larynx producing a neutral vowel and coughing. Oral air pressure was registered in a mouthpiece, through which an endoscope was inserted into the pharynx. Electroglottography, acoustic, and pressure signals were recorded simultaneously. The glottal width variation at the membranous and cartilaginous parts of the glottis was derived from the high-speed images, and the strong vibration of the false vocal folds was also registered. RESULTS: In coughing, compared to ordinary vowel phonation in nearly the same sound pressure level (93-94 dB6cm), the glottal width was 25% larger at the middle of the vocal folds, the maximum glottal opening velocity was 39% higher, and the maximum glottal width declination rate during glottal closing was up to three times higher. The maximum acceleration was 40% higher, and the maximum deceleration was 47% higher. Fundamental frequency f0 was the highest (ca. 400 Hz) at the beginning of the first phase of a typical coughing process. During the last part of the coughing process, f0 decreased from ca. 250 Hz to ca. 85 Hz at the phonation offset. CONCLUSIONS: The remarkable increase in maximum glottal width declination rate implies much higher vocal fold loading in coughing compared to phonation.

Virtual visits at the Helsinki Head and Neck Center during the COVID-19 pandemic: patient safety incidents and the experiences of patients and staff.

BACKGROUND: During the COVID-19 pandemic, health care had to find new ways to care for patients while reducing infection transmission. The role of telemedicine role has grown exponentially. METHODS: A questionnaire on experiences and satisfaction was sent to the staff of the Head and Neck Center of Helsinki University Hospital and to otorhinolaryngology patients treated remotely between March and June 2020. Additionally, patient safety incident reports were examined for incidents involving virtual visits. RESULTS: Staff (response rate 30.6%, (n = 116)) opinions seemed to be quite polarized. In general, staff felt virtual visits were useful for select groups of patients and certain situations, and beneficial in addition to face-to-face visits, not instead of them. Patients (response rate 11.7%, (n = 77)) gave positive feedback on virtual visits, with savings in time (average 89 min), distance travelled (average 31.4 km) and travel expenses (average 13.84€). CONCLUSIONS: While telemedicine was implemented during the COVID-19 pandemic to ensure patient treatment, its usefulness after the pandemic must be examined. Evaluation of treatment pathways is critical to ensure that quality of care is upheld while new treatment protocols are introduced. Telemedicine offers the opportunity to save environmental, temporal, and monetary resources. Nonetheless, the appropriate use of telemedicine is essential, and clinicians must be offered the option to examine and treat patients face-to-face.

Outcomes of Primary Furlow Double-Opposing Z-plasty for the Treatment of Symptomatic Submucous Cleft Palate.

BACKGROUND: Submucous cleft palate (SMCP) requires surgical repair if symptomatic. The Furlow double-opposing Z-plasty is the preferred method in Helsinki cleft center. AIMS: To assess the efficacy and complications of Furlow Z-plasty in the treatment of symptomatic SMCP. METHODS: This retrospective study reviewed documentation of 40 consecutive patients with symptomatic SMCP who underwent primary Furlow Z-plasty by 2 high-volume cleft surgeons at a single center between 2008 and 2017. Patients underwent perceptual and instrumental evaluation of velopharyngeal function (VPF) by speech pathologists preoperatively and postoperatively. RESULTS: The median age at Furlow Z-plasty was 4.8 years (SD 2.6, range 3.1-13.6). The overall success rate, including postoperative competent or borderline competent VPF, was 83%, and 10% required secondary surgery for residual velopharyngeal insufficiency. The success rate was 85% in nonsyndromic, and 67% in syndromic patients with no significant difference ( P =0.279). Complications arose in only 2 (5%) patients. No children were found to have obstructive sleep apnea postoperatively. CONCLUSION: Furlow primary Z-plasty is a safe and effective operation for symptomatic SMCP with a success rate of 83% with only 5% rate of complications.

Working conditions during the COVID-19 pandemic in primary and tertiary healthcare: a comparative cross-sectional study.

OBJECTIVES: The COVID-19 pandemic has globally affected healthcare workers' (HCWs) health and wellbeing. Most studies on COVID-19 have focused on tertiary healthcare. The aim of this study was to increase the knowledge on the effects of the pandemic on working conditions in tertiary and primary healthcare. MATERIAL AND METHODS: The comparative cross-sectional study consisted of an online questionnaire sent to HCWs of the City of Helsinki (primary healthcare) and Helsinki University Hospital (tertiary healthcare). Altogether 1580 HCWs with direct patient contact participated in the study: 895 from tertiary and 685 from primary healthcare. Statistical analysis used SPSS 25 from IBM. The tests used were the χ2 test, Fisher's exact test, and binary logistic regression analysis. RESULTS: Primary HCWs were less likely to treat COVID-19 patients (OR = 0.45, 95% CI: 0.37-0.56). However, both groups reported a similar number of COVID-19 infections, primary HCWs 4.9% and tertiary HCWs 5.0%, and workrelated quarantine was significantly more prevalent (OR = 1.96, 95% CI: 1.38-2.79) among primary HCWs. In addition, work-related wellbeing was poorer among primary HCWs than tertiary HCWs in terms of feeling more stressed at work (OR = 3.20, 95% CI: 2.55-4.02), not recovering from work (OR = 0.49, 95% CI: 0.39-0.62), reported mental wellbeing below normal levels (OR: 1.59, 95% CI: 1.26-2.00), and increased working hours (OR = 1.63, 95% CI: 1.25-2.12). CONCLUSIONS: The study demonstrates how the pandemic has affected the wellbeing and working conditions of not only tertiary but also less studied primary HCWs. The authors' findings suggest that the challenges identified during the COVID-19 pandemic in the health and wellbeing of healthcare workers are even greater in primary care than in tertiary care. Int J Occup Med Environ Health. 2023;36(1):139-50.

Adjustment of Health-Care Service Delivery Among Phoniatricians and ENT Specialists During the COVID-19 Pandemic, A UEP Survey.

BACKGROUND: Applying measures that prioritize staff safety, while protecting patient safety and care, represents a challenge during the current pandemic. Many documents of recommendations toward safe practice have been developed for this purpose. OBJECTIVE: To assess adjustments that have been undertaken by phoniatricians and otolaryngologists in the delivery of health-care services during the pandemic in order to reduce staff exposure to COVID-19 and improve safety. STUDY DESIGN: Cross-sectional. METHODS: An online self-administered survey was used during the first wave of the COVID-19 pandemic in June 2020 to collect data related to demographics of participants, their sources of information, administrative alterations, and changes they adopted when meeting patients for a consultation/procedure/surgery. RESULTS: The eligible 154 responses were grouped into 4 groups based on country of residence. Alterations to service delivery amongst the different groups were compared. CONCLUSIONS: The majority of participants were following the suggested recommendations to service delivery adjustments, with some inconsistencies in practice across countries.

Sinonasal inverted papilloma - malignant transformation and non-sinonasal malignancies.

OBJECTIVES: To assess malignant transformation rate, non-sinonasal malignancies, and factors contributing to recurrence in patients treated for sinonasal inverted papilloma (SNIP). STUDY DESIGN: Retrospective study. METHODS: We retrospectively reviewed medical records of all patients treated for SNIP (n = 296) between the years 1984-2014 at Helsinki University Hospital. Data from the Finnish Cancer Registry confirmed the number of those patients with sinonasal and non-sinonasal malignancies. RESULTS: Only 2 of 296 (0.7%) patients primarily diagnosed with benign SNIP developed sinonasal cancer in a mean follow-up of 5.8 years. The most common non-sinonasal cancer sites were similar to those reported for the whole Finnish population. None of the patients presented with an HPV-associated non-sinonasal malignancy. The recurrence rate among patients who underwent attachment-oriented surgery was significantly lower compared to those operated on with other approaches (40.2% vs. 56.6%, p = 0.006). Dysplasia in SNIP was associated with a higher recurrence rate (p < 0.001). CONCLUSIONS: Malignant transformation of SNIP was rare. Patients with SNIP were not prone to HPV-associated non-sinonasal malignancies. Endoscopic resection and attachment-oriented surgery have become predominant approaches in the treatment of SNIP; meanwhile, the total number of SNIP recurrences has decreased. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:506-511, 2023.

Speech Symptoms of Velopharyngeal Insufficiency and the Incidence of Secondary Speech Surgery in 10-Year-Old Children With Unilateral Cleft Lip and Palate: Comparison of 2 Randomized Surgical Methods for Primary Palatal Surgery.

OBJECTIVE: To compare speech symptoms of velopharyngeal insufficiency (VPI) and incidence of secondary speech surgery in 10-year-old Finnish children with unilateral cleft lip and palate (UCLP) following primary palatal surgery using 2 surgical methods. DESIGN: Single center analysis within the Scandcleft multicenter randomized controlled trial of primary surgery for UCLP. MATERIALS AND METHODS: Patients comprised 79 nonsyndromic 10-year-old children with UCLP. Two randomized surgical methods were used in the primary palatal surgery: soft palate closure at 4 months and hard palate closure at 12 months (Arm A) and closure of both the soft and hard palate at 12 months (Arm C). Speech symptoms of VPI were analyzed from standardized video recordings by 2 experienced speech pathologists. The incidences of surgery for correcting VPI, fistula closure, and speech therapy were evaluated retrospectively from patient records. RESULTS: No differences in speech symptoms of VPI, need for VPI surgery or speech therapy were found between the surgical methods. Of all 79 children, 33% had had VPI surgery and 61% had speech therapy. The number of fistulas was significantly higher in Arm A (25%) than in Arm C (2%). Moderate to severe speech symptoms of VPI (hypernasality, continuous nasal air leakage, weak pressure consonants, and/or compensatory articulation) were found in 11% of the children. CONCLUSION: No differences were present between groups in speech symptoms of VPI or need for VPI surgery or speech therapy between the 2 surgical methods. One third of the children had undergone VPI surgery. Most of the children (89%) had good or relatively good speech.

Position Statement of the Union of European Phoniatricians (UEP): Fees and Phoniatricians' Role in Multidisciplinary and Multiprofessional Dysphagia Management Team.

The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician's role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases.

Combining Phi6 as a surrogate virus and computational large-eddy simulations to study airborne transmission of SARS-CoV-2 in a restaurant.

COVID-19 has highlighted the need for indoor risk-reduction strategies. Our aim is to provide information about the virus dispersion and attempts to reduce the infection risk. Indoor transmission was studied simulating a dining situation in a restaurant. Aerosolized Phi6 viruses were detected with several methods. The aerosol dispersion was modeled by using the Large-Eddy Simulation (LES) technique. Three risk-reduction strategies were studied: (1) augmenting ventilation with air purifiers, (2) spatial partitioning with dividers, and (3) combination of 1 and 2. In all simulations infectious viruses were detected throughout the space proving the existence long-distance aerosol transmission indoors. Experimental cumulative virus numbers and LES dispersion results were qualitatively similar. The LES results were further utilized to derive the evolution of infection probability. Air purifiers augmenting the effective ventilation rate by 65% reduced the spatially averaged infection probability by 30%-32%. This relative reduction manifests with approximately 15 min lag as aerosol dispersion only gradually reaches the purifier units. Both viral findings and LES results confirm that spatial partitioning has a negligible effect on the mean infection-probability indoors, but may affect the local levels adversely. Exploitation of high-resolution LES jointly with microbiological measurements enables an informative interpretation of the experimental results and facilitates a more complete risk assessment.

"As protective gear began to run low, guidance on protection became looser" - Healthcare workers' perspectives on infection prevention and control during the COVID-19 pandemic.

Objectives: The COVID-19 pandemic has posed several risk factors to healthcare workers' (HCWs') emotional distress. The purpose of the study was to enhance understanding of the experiences and feelings of HCWs during the COVID-19 pandemic, with specific reference to infection prevention and control (IPC) practices and guidance, focusing on the quality and availability of personal protective equipment (PPE), guidelines, and management. With a qualitative approach, we aimed to enable a wider narrative; to gain a more detailed understanding related to PPE use and identify experiences that can be overlooked in forced-choice questionnaires. Methods: An online questionnaire was conducted among HCWs of the City of Helsinki and Helsinki University Hospital between 12.6.2020 and 5.4.2021. Altogether 1,580 HCWs participated in the study, from whom 579 shared 1,666 free-text responses. These responses were analyzed qualitatively, and the results were combined with statistical data on the participants' working conditions and backgrounds. Results: We identified problems in PPE availability and changing guidelines as factors causing the most distress in the participants. Regarding availability, running out of masks and respirators emerged as the most worrying issue, and inadequate PPE was associated with the excessive workload (OR 1.51, CI 95% 1.01-2.25). The results also highlight the importance of transparent and clear communication regarding IPC instructions and guidance, and clear IPC guidance was associated with better levels of reported recovery from work (OR 1.51, CI 95% 1.06-2.14). Conclusions: Our study highlights the importance of adequate PPE provision, transparent communication, clear guidance, and supportive supervisory work in this ongoing pandemic and potential new ones. We suggest more rigorous preparation, with crisis communication planning and emergency storage of PPE.

How Early Can We Predict the Need for VPI Surgery?

Velopharyngeal dimensions change as a child with cleft palate (CP) grows. The aim of this study was to assess if the decision for velopharyngeal insufficiency (VPI) surgery can be made by the age of 3 years among CP children with moderate-to-severe VPI. In addition, we sought to clarify if speech therapy before VPI surgery is beneficial for VPI speech characteristics. Methods: This retrospective study reviewed documentation of children with moderate-to-severe VPI at age 3 years who did not undergo VPI surgery until age 5 years. Based on the national cleft register, 959 patients with syndromic and nonsyndromic CP were treated by the craniofacial team at Helsinki University Hospital, Finland between 2000 and 2014. Eighty-six patients fulfilled the study inclusion criteria. The speech pathologist evaluated velopharyngeal function at age 3, 5, and 8 years. Results: Of the 86 children presenting with moderate-to-severe VPI at age 3 years, 94% still had moderate-to-severe VPI at age 5 years, even though speech therapy was offered to 77%. Of those whose velopharyngeal function improved by age 5 years, function regressed to incompetent over time. Overall, 93% underwent VPI surgery and 82% underwent VPI surgery between ages 5 and 8 years. Only 23% at age 8 years still had moderate-to-severe VPI. Speech therapy alone did not improve VPI speech characteristics. Conclusions: Moderate-to-severe VPI did not improve from 3 to 5 years or improved but subsequently relapsed. This suggests that the decision for VPI surgery can be made for children aged 3 years with moderate-to-severe VPI.

SARS-CoV-2 indoor environment contamination with epidemiological and experimental investigations.

SARS-CoV-2 has been detected both in air and on surfaces, but questions remain about the patient-specific and environmental factors affecting virus transmission. Additionally, more detailed information on viral sampling of the air is needed. This prospective cohort study (N = 56) presents results from 258 air and 252 surface samples from the surroundings of 23 hospitalized and eight home-treated COVID-19 index patients between July 2020 and March 2021 and compares the results between the measured environments and patient factors. Additionally, epidemiological and experimental investigations were performed. The proportions of qRT-PCR-positive air (10.7% hospital/17.6% homes) and surface samples (8.8%/12.9%) showed statistical similarity in hospital and homes. Significant SARS-CoV-2 air contamination was observed in a large (655.25 m3 ) mechanically ventilated (1.67 air changes per hour, 32.4-421 L/s/patient) patient hall even with only two patients present. All positive air samples were obtained in the absence of aerosol-generating procedures. In four cases, positive environmental samples were detected after the patients had developed a neutralizing IgG response. SARS-CoV-2 RNA was detected in the following particle sizes: 0.65-4.7 µm, 7.0-12.0 µm, >10 µm, and <100 µm. Appropriate infection control against airborne and surface transmission routes is needed in both environments, even after antibody production has begun.

Mental well-being of healthcare workers in 2 hospital districts during the first wave of the COVID-19 pandemic in Finland: a cross-sectional study.

OBJECTIVES: The COVID-19 pandemic has caused unseen pressure on healthcare systems in many countries, jeopardizing the mental well-being of healthcare workers. The authors aimed to assess the mental well-being of Finnish healthcare workers from 2 hospital districts (Helsinki University Hospital [HUS] and Social and Health Services in Kymenlaakso [Kymsote]) with differing COVID-19 incidence rates during the first wave of the COVID-19 pandemic in spring 2020. MATERIAL AND METHODS: A total number of 996 healthcare workers (HUS N = 862, Kymsote N = 134) participated in this prospectively conducted survey study during summer 2020. Symptom criteria of self-reported mental health symptoms followed ICD-10 classification, excluding duration criteria. Participants were divided into symptom categories "often/sometimes", and "rarely/never". These groups were compared to sociodemographic factors and factors related to work, workload, and well-being. RESULTS: The degree of mental health symptoms did not differ between the 2 healthcare districts despite differing COVID-19 incidences (p = 1). The authors observed a significant relationship between self-reported diagnostic mental health symptoms and experiences of insufficient instructions for protection against COVID-19 (in HUS cohort p < 0.001), insufficient recovery from work (p < 0.001), and subjective increased workload (p < 0.001). CONCLUSIONS: The authors' results show the importance of well-planned and sufficient instructions for protection from SARS-CoV-2 for healthcare workers, indicating their need to feel safe and protected at work. The workload of healthcare workers should be carefully monitored to keep it moderate and ensure sufficient recovery. Sufficient control of the epidemic to keep the burden of the healthcare system low is vital for healthcare workers' well-being. Int J Occup Med Environ Health. 2022;35(6):708-18.

SARS-CoV-2 requires acidic pH to infect cells.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cell entry starts with membrane attachment and ends with spike (S) protein-catalyzed membrane fusion depending on two cleavage steps, namely, one usually by furin in producing cells and the second by TMPRSS2 on target cells. Endosomal cathepsins can carry out both. Using real-time three-dimensional single-virion tracking, we show that fusion and genome penetration require virion exposure to an acidic milieu of pH 6.2 to 6.8, even when furin and TMPRSS2 cleavages have occurred. We detect the sequential steps of S1-fragment dissociation, fusion, and content release from the cell surface in TMPRRS2-overexpressing cells only when exposed to acidic pH. We define a key role of an acidic environment for successful infection, found in endosomal compartments and at the surface of TMPRSS2-expressing cells in the acidic milieu of the nasal cavity.

ALS patients in otorhinolaryngology: A retrospective study.

Objectives: Given its rarity and the lack of clear clinical markers, amyotrophic lateral sclerosis (ALS) remains a diagnostic challenge. Because bulbar-onset ALS (buALS) presents with impaired speech or swallowing, patients are often primarily referred to an otolaryngologist (ORL) or phoniatrician. The objectives of this retrospective cohort study were to analyze the role of ORLs and phoniatricians in ALS diagnostics and treatment and the potential diagnostic delay related to initial visit to aforementioned specialists. Methods: We reviewed data for all 327 patients treated for ALS through the Hospital District of Helsinki and Uusimaa (HUS) between 2010 and 2014, focusing specifically on 110 (34%) patients presenting with bulbar nerve onset (buALS). Their presenting symptoms, referral to specialized care, and delay in referral to a neurology clinic were assessed. Indications and findings from swallowing studies were reviewed as well as the incidence of percutaneous endoscopic gastrostomy (PEG) and tracheostomy. Results: Among the 110 patients with buALS, 64 (58%) were primarily referred to a neurologist, 28 (25%) to an ORL, and five (5%) to a phoniatrician. The most common presenting symptom was dysarthria in 89 patients, (81%), followed by dysphagia in 26 (24%). In most cases, an ORL or phoniatrician suspected a neuromuscular disease; however, in eight (24%) cases, the neurological etiology of symptoms was missed. Overall, 49 (45%) patients underwent a swallowing study and 86 (78%) patients underwent PEG placement. Conclusions: Among buALS patients, 30% initially consulted an ORL or phoniatrician and 45% underwent a swallowing study. Based on our results, swallowing studies rarely lead to immediate PEG placement. An initial visit to other specialists had no impact on diagnostic delays or survival.

Aerosol Generation During Otologic Surgery.

OBJECTIVE: To assess whether aerosol generation occurs during otologic surgery, to define which instruments are aerosol generating, and to identify factors that enhance safety in protection against airborne pathogens, such as severe acute respiratory syndrome coronavirus 2. STUDY DESIGN: An observational prospective study on aerosol measurements during otologic operations recorded between August and December 2020. SETTING: Aerosol generation was measured with an Optical Particle Sizer as part of otologic operations with anesthesia. Particles with a size range of 0.3 to 10 µm were quantified. Aerosol generation was measured during otologic operations to analyze aerosols during drilling in transcanal and transmastoid operations and when using the following instruments: bipolar electrocautery, laser, suction, and cold instruments. Coughing is known to produce significant concentration of aerosols and is commonly used as a reference for high-risk aerosol generation. Thus, the operating room background concentration and coughing were chosen as reference values. PATIENTS: Thirteen otologic operations were included. The average drilling time per surgery was 27.00 minutes (range, 2.00-71.80 min). INTERVENTION: Different rotation speeds during drilling and other instruments were used. MAIN OUTCOME MEASURES: Aerosol concentrations during operations were recorded and compared with background and cough aerosol concentrations. RESULTS: Total aerosol concentrations during drilling were significantly higher than background ( p < 0.0001, d = 2.02) or coughing ( p < 0.0001, d = 0.50). A higher drilling rotation speed was associated with higher particle concentration ( p = 0.037, η2 = 0.01). Aerosol generation during bipolar electrocautery, drilling, and laser was significantly higher than with cold instruments or suction ( p < 0.0001, η2 = 0.04). CONCLUSION: High aerosol generation is observed during otologic surgery when drill, laser, or bipolar electrocautery is used. Aerosol generation can be reduced by using cold instruments instead of electric and keeping the suction on during aerosol-generating procedures. If drilling is required, lower rotation speeds are recommended. These measures may help reduce the spread of airborne pathogens during otologic surgery.