Esophageal Dysphagia in Adults: When It Sticks.

Esophageal dysphagia is a common yet difficult to diagnose condition. This article underscores the role of detailed patient history and physical examinations, including prompt endoscopic evaluation, for accurate differentiation between esophageal and oropharyngeal dysphagia. The authors discuss the heightened importance of early intervention in certain patient groups, such as elderly individuals and patients with head and neck cancer, to mitigate the risk of malnutrition and infection. The authors delve into etiologic factors highlighting the complexity of clinical presentations and the significance of tailored management strategies.

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.

Can EAT-10 Become EAT-5? Improving Measurement Efficiency of Dysphagia with Item Response Theory.

OBJECTIVES: To assess: (1) the Eating Assessment Tool (EAT-10) with item response theory (IRT) to determine which individual items provide the most information, (2) the extent to which dysphagia is measured with subsets of items while maintaining precise score estimates, and (3) if 5-item scales have the differing discriminatory ability, as compared to the parent 10-item instrument. METHODS: Prospectively collected data from 2,339 patients who completed the EAT-10 questionnaire during evaluation at a tertiary care otolaryngology clinic were utilized. IRT analyses provided discrimination and location parameters associated with individual questions. Residual item correlations were also assessed for redundant information. Based on these results, three 5-item subsets were further evaluated using item information function curves. Areas under receiver-operator characteristic curves (ROC-AUC) were also calculated to evaluate the discriminatory ability for dysphagia-related clinical diagnoses. RESULTS: Item discrimination parameter estimates ranged from 1.71 to 5.46, with higher values indicating more information. Residual item correlations were determined within item pairs, and location parameters were calculated. Based on these data, in combination with clinical utility, three 5-item subsets were proposed and assessed. ROC-AUC analyses demonstrated no significant difference between the EAT-5-Alpha subset and the original 10-item instrument for discriminating dysphagia as a primary diagnosis (0.88, 0.88). The EAT-5-Clinical subset outperformed the original 10 instruments in ROC-AUC for aspiration. The EAT-5-Range subset was significantly associated with problems with thin liquids. CONCLUSIONS: IRT analyses distinguished three proposed 5-item subsets of the EAT-10 instrument, supporting shorter survey options, while still reflecting the impact of dysphagia without significant loss of discrimination. LEVEL OF EVIDENCE: 3 (Diagnostic testing with consistently applied reference standards, partial blinding). Laryngoscope, 133:3327-3333, 2023.

Predictive Outcomes of Deep Learning Measurement of the Anterior Glottic Angle in Bilateral Vocal Fold Immobility.

OBJECTIVE: (1) To compare maximum glottic opening angle (anterior glottic angle, AGA) in patients with bilateral vocal fold immobility (BVFI), unilateral vocal fold immobility (UVFI) and normal larynges (NL), and (2) to correlate maximum AGA with patient-reported outcome measures. METHODS: Patients wisth BVFI, UVFI, and NL were retrospectively studied. An open-source deep learning-based computer vision tool for vocal fold tracking was used to analyze videolaryngoscopy. Minimum and maximum AGA were calculated and correlated with three patient-reported outcomes measures. RESULTS: Two hundred and fourteen patients were included. Mean maximum AGA was 29.91° (14.40° SD), 42.59° (12.37° SD), and 57.08° (11.14° SD) in BVFI (N = 70), UVFI (N = 70), and NL (N = 72) groups, respectively (p < 0.001). Patients requiring operative airway intervention for BVFI had an average maximum AGA of 24.94° (10.66° SD), statistically different from those not requiring intervention (p = 0.0001). There was moderate negative correlation between Dyspnea Index scores and AGA (Spearman r = -0.345, p = 0.0003). Maximum AGA demonstrated high discriminatory ability for BVFI diagnosis (AUC 0.92, 95% CI 0.81-0.97, p < 0.001) and moderate ability to predict need for operative airway intervention (AUC 0.77, 95% CI 0.64-0.89, p < 0.001). CONCLUSIONS: A computer vision tool for quantitative assessment of the AGA from videolaryngoscopy demonstrated ability to discriminate between patients with BVFI, UVFI, and normal controls and predict need for operative airway intervention. This tool may be useful for assessment of other neurological laryngeal conditions and may help guide decision-making in laryngeal surgery. LEVEL OF EVIDENCE: III Laryngoscope, 133:2285-2291, 2023.

Benefits of Side-Firing Optical Fibers in Endoscopic Laser Treatment of the Larynx.

OBJECTIVE: To elucidate potential tissue coverage of side-firing optical fibers in office-based endoscopic laser treatment of larynx, as well as to demonstrate their enhanced ability to address challenging anatomic areas. METHOD: We performed a comparative study of four different fiber designs: a traditional forward-facing fiber, and three side-firing fibers that emit light at an angle of 45°, 70°, and 90°, respectively. The study was conducted in simulation, using eight three-dimensional models of the human larynx generated from microtomography x-ray scans. A computer program simulated the insertion of the endoscope into the larynx, and the Möller-Trumbore algorithm was used to simulate the application of laser light. RESULTS: Side-firing laser fibers increased potential tissue coverage by a mean of 50.2 (standard deviation [SD] 25.8), 73.8 (SD 41.3), and 84.0 (SD 47.6) percent for angles of 45°, 70°, and 90°, respectively, compared to forward-facing fibers. Angled fibers provided access to areas of the larynx considered difficult to address by traditional methods, including the infraglottis, laryngeal ventricle, and right vocal fold. CONCLUSION: Simulation results suggest that side-firing optical fibers have the potential to enhance anatomical access during in-office endoscopic laser procedures in the larynx. Further research is needed to better understand the benefits and any potential risks or contraindications of side-firing optical fibers. LEVEL OF EVIDENCE: NA Laryngoscope, 133:1205-1210, 2023.

Preliminary Results on the Safety and Efficacy of Silk-Hyaluronic Acid for Treatment of Glottic Insufficiency.

OBJECTIVES: Silk-Hyaluronic Acid (Silk-HA) is a novel vocal fold augmentation material that has been used in humans since July 2020. There is a paucity of published data on Silk-HA and its longevity remains a question. This study aimed to evaluate a single surgeon's initial experience performing Silk-HA injection laryngoplasty for the treatment of glottic insufficiency. METHODS: Retrospective chart review of Silk-HA injections between July 2020 and December 2021. Subject demographics, diagnoses, volume of material injected, VHI-10 data, and complications were collected. A blinded perceptual voice analysis of voice samples was performed by two voice-specialized speech-language pathologists (SLP) for a subset of unilateral vocal fold paralysis patients before and 3-months following silk-HA injection. Univariate assessment of the change in VHI-10 and perceptual voice analyses at 3-month follow up was determined. RESULTS: 58 patients (43.1% female) underwent Silk-HA injection with a mean age of 64 (range 21-88). 38 subjects had unilateral paralysis (65.6%), and the remaining had scar, atrophy, paresis or a combination thereof. 49 injections were unilateral (84.5%). Mean volume of silk injected was 0.26 mL. Complications were rare, most notable though for 2 admissions for dyspnea and laryngoscopic evidence of hemi-laryngeal edema (3.4%). Mean change in CAPE-V overall severity rating was -32.9 (P<0.0001), and VHI-10 was -14.6 ± 10 (P=0.0013). 14 patients underwent a repeat silk-HA injection for ongoing glottic insufficiency (loss of augmentation vs under-augmentation). CONCLUSIONS: Preliminary results for Silk-HA show potential for ongoing improvement of glottic insufficiency at 3 months from date of augmentation. Clinician and patient perception of voice outcomes showed overall improvement at three months, though longevity remains to be determined. While overall well tolerated and without serious complications in 96% of the cohort, patients should be counseled on the potential for airway edema and symptomatic dyspnea requiring steroid management and observation.

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.

Does the Reflux Symptom Index Predict Increased Pharyngeal Events on HEMII-pH Testing and Correlate with General Quality of Life?

OBJECTIVES: To determine the ability of the reflux symptom index (RSI) to predict objective impedance and pH-probe testing, and to examine the relationship between disease-specific and general health status in patients diagnosed with laryngopharyngeal reflux (LPR). METHODS: Adults presenting to a tertiary care academic center with a primary voice complaint completed the RSI and the Patient-Reported Outcomes Measurement Information System 10-item global health instrument (PROMIS). An RSI score ≥13 was considered abnormal. Objective testing for LPR was performed using hypopharyngeal-esophageal multichannel intraluminal impedance catheter with dual pH (HEMII-pH) testing; a positive test was defined as more than one pharyngeal impedance events over 24 hours. Spearman rho analyses were applied, and the sensitivity and specificity of the RSI to detect HEMII-pH findings were determined. RESULTS: One hundred four patients underwent HEMII-pH testing. Mean scores were 16.7 (95%CI 15.1-18.3) for RSI. Sixty-three (60.6%) patients were diagnosed with LPR by HEMII-pH testing. RSI scores were moderately correlated with PROMIS physical (Spearman rho 0.43, P < 0.0001), social (Spearman rho 0.33, P < 0.0001) and mental health (Spearman rho 0.33, P < 0.0001) scores. The RSI has a sensitivity and specificity of 66.7% and 31.7%, respectively, for detecting pharyngeal events on HEMII-pH testing. CONCLUSIONS: There is moderate sensitivity and lack of specificity of the RSI for detecting increased pharyngeal reflux events. Reflux-specific and general health status instruments are correlated. Further investigation could assess the diagnostic ability of RSI compared proximal reflux events on HEMII-pH, as well as whether health status instruments can be used to detect clinically meaningful change in the LPR population.

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.

National Variation of Insurance Coverage for Gender-Affirming Facial Feminization Surgery.

Background: Gender-affirming surgery may be pursued by individuals experiencing gender dysphoria. Although genital and chest procedures are classified as medically necessary, facial feminization surgeries (FFSs) are often considered cosmetic. Insurance companies may limit coverage of these procedures, especially in states less supportive of transgender individuals. Objectives: To determine insurance coverage and ease of finding policy information for FFSs, and to analyze differences based on state advocacy. Methods: Insurance policies for the top three commercial health plans per state were reviewed. Coverage status was determined by web-based search and telephone interviews. Ease of gathering policy information was assessed using a post-task questionnaire graded on a 7-point Likert scale, with higher numbers (e.g., 7) representing relative ease. State advocacy was determined by the number of state laws and policies affecting the transgender community. Results: Of the 150 insurance policies, only 27 (18%) held favorable policies for FFS. Most favorable companies covered chondrolaryngoplasty, with 78% (n = 21) offering preauthorization. Mean ease of use was rated 6, with 12 companies requiring a telephone interview. Insurance policies in states with laws driving transgender equity covered more FFS procedures (p = 0.043), whereas those in restrictive states offered less overall coverage (p = 0.023). Conclusions: FFS is rarely covered by commercial insurance companies, especially in states with less legal support for transgender individuals. Policy information remains difficult to obtain, with variable coverage by employer and no standardized medical necessity criteria. Limited coverage, lack of easily accessible information, and absence of universal criteria may act as barriers to FFS.

Does Ibuprofen Increase Bleed Risk for Pediatric Tonsillectomy?

OBJECTIVE: To evaluate risk factors for pediatric posttonsillectomy hemorrhage (PTH) and the need for transfusion using a national database. STUDY DESIGN: Retrospective cohort study. SETTING: The study was conducted using the Pediatric Health Information System (PHIS) database. METHODS: Children ≤18 years who underwent tonsillectomy with or without adenoidectomy (T±A) between 2004 and 2015 were included. We evaluated the risk of PTH requiring cauterization according to patient demographics, comorbidities, indication for surgery, medications, year of surgery, and geographic region. RESULTS: Of the 551,137 PHIS patients who underwent T±A, 8735 patients (1.58%) experienced a PTH. The risk of PTH increased from 1.33% (95% confidence interval [CI]: 1.15%, 1.53%) in 2010 to 1.91% (95% CI: 1.64%, 2.24%) in 2015 (P < .001). Older age (≥12 vs <5 years old: adjusted odds ratio [aOR] 3.17; 95% CI: 2.86, 3.52), male sex (aOR 1.11; 95% CI: 1.05, 1.17), medical comorbidities (aOR 1.18; 95% CI: 1.08, 1.29), recurrent tonsillitis (aOR 1.15; 95% CI: 1.07, 1.24), and intensive care unit admission (aOR 1.74; 95% CI: 1.55, 1.95) were significantly associated with an increased risk of PTH. Use of ibuprofen (aOR 1.36; 95% CI: 1.22, 1.52), ketorolac (aOR 1.39; 95% CI: 1.14, 1.69), anticonvulsant (aOR 1.23; 95% CI: 1.03, 1.76), and antidepressants (aOR 1.35; 95% CI: 1.03, 1.76) were also associated with an increased risk of PTH. The need for blood transfusion was 2.1% (181/8735). CONCLUSION: The incidence of PTH increased significantly between 2011 and 2015, and ibuprofen appears to be one contributing factor. Given the benefits of ibuprofen, it is unclear whether this increased risk warrants a change in practice.

Single-surgeon parotidectomy outcomes in an academic center experience during a 15-year period.

OBJECTIVE: As large single-surgeon series in the literature are lacking, we sought to review a single-surgeon's experience with parotidectomy in an academic center, with a focused analysis of pathology, technique, and facial nerve (FN) weakness. Benchmark values for complications and operative times with routine trainee involvement and without continuous FN monitoring are offered. MATERIALS AND METHODS: All patients who underwent parotidectomy, performed by D. G. D., for benign and malignant disease between January 2004 and December 2018 at an academic center were reviewed. RESULTS: A total of 924 parotidectomies, with adequate evaluatable data were identified. The majority of patients had benign tumors (70.9%). Partial/superficial parotidectomy was the most common approach (65.7%). Selective FN branch sacrifice was rare (12.3%), but significantly more common among patients with malignant pathology (33.8% vs 3.5% for benign, P < .0001). Among patients with intact FN, post-operative short- and long-term FN weaknesses were rare (6.5% and 1.7%, respectively). These rates were lower among patients with benign tumors (5.4% and 1.3%). Partial/superficial parotidectomy for benign tumors was associated with a low rate of short- and long-term FN weaknesses (2.7% and 0.9%). Mean OR time was 185 minutes. CONCLUSION: This is the largest single-surgeon series on parotidectomy, spanning 15 years. We demonstrate excellent long- and short-term FN paresis rates with acceptable operative times without regular use of continuous FN monitoring and with routine trainee involvement. These findings may provide valuable insight into parotid tumor pathology, FN outcomes, and feasibility and expectations of performing parotidectomy in an academic setting. LEVEL OF EVIDENCE: 4.

Assessment of Gender Differences in Clinical Productivity and Medicare Payments Among Otolaryngologists in 2017.

Importance: Women comprise an increasing proportion of the otolaryngology workforce. Prior studies have demonstrated gender-based disparity in physician practice and income in other clinical specialties; however, research has not comprehensively examined whether gender-based income disparities exist within the field of otolaryngology. Objective: To determine whether diversity of practice, clinical productivity, and Medicare payment differ between male and female otolaryngologists and whether any identified variation is associated with practice setting. Design, Setting, and Participants: Retrospective cross-sectional analysis of publicly available Medicare data summarizing payments to otolaryngologists from January 1 through December 31, 2017. Male and female otolaryngologists participating in Medicare in facility-based (FB; hospital-based) and non-facility-based settings (NFB; eg, physician office) for outpatient otolaryngologic care were included. Main Outcomes and Measures: Number of unique billing codes (diversity of practice) per physician, number of services provided per physician (physician productivity), and Medicare payment per physician. Outcomes were stratified by practice setting (FB vs NFB). Results: A total of 8456 otolaryngologists (1289 [15.2%] women; 7167 [84.8%] men) received Medicare payments in 2017. Per physician, women billed fewer unique codes (mean difference, -2.10; 95% CI, -2.46 to -1.75; P < .001), provided fewer services (mean difference, -640; 95% CI, -784 to -496; P < .001), and received less Medicare payment than men (mean difference, -$30 246 (95% CI, -$35 738 to -$24 756; P < .001). When stratified by practice setting, women in NFB settings billed 1.65 fewer unique codes (95% CI, -2.01 to -1.29; P < .001) and provided 633 fewer services (95% CI, -791 to -475; P < .001). In contrast, there was no significant gender-based difference in number of unique codes billed (mean difference, 0.04; 95% CI, -0.217 to 0.347; P = .81) or number of services provided (mean difference, 5.1; 95% CI, -55.8 to 45.6; P = .85) in the FB setting. Women received less Medicare payment in both settings compared with men (NFB: mean difference, -$27 746; 95% CI, -$33 502 to -$21 989; P < .001; vs FB: mean difference, -$4002; 95% CI, -$7393 to -$612; P = .02), although the absolute difference was lower in the FB setting. Conclusions and Relevance: Female sex is associated with decreased diversity of practice, lower clinical productivity, and decreased Medicare payment among otolaryngologists. Gender-based inequity is more pronounced in NFB settings compared with FB settings. Further efforts are necessary to better evaluate and address gender disparities within otolaryngology.

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.