Preference Phenotypes in Thyroid Nodule Management: A Patient Segmentation Approach.

OBJECTIVE: Patient preferences regarding thyroid nodules are poorly understood. Our objective is to (1) employ a discrete choice experiment (DCE) to explore risk tradeoffs in thyroid nodule management, and (2) segment respondents into preference phenotypes. STUDY DESIGN: DCE. SETTING: Thyroid surgery clinic, online survey. METHODS: A DCE including 5 attributes (cancer risk, voice concerns, incision/scar, medication requirement, follow-up frequency) was refined with qualitative patient and physician input. A final DCE including 8 choice tasks, demographics, history, and risk tolerance was administered to participants with and without thyroid disease. Analysis was performed with multinomial logit modeling and latent class analysis (LCA) for preference phenotyping. RESULTS: A total of 1026 respondents were included; 480 had thyroid disease. Risk aversion was associated with increasing age (P < .001), female gender (P < .001), and limited education (P = .038), but not previous thyroid disease. Cancer risk most significantly impacted decision-making. Of the total possible utility change from thyroid nodule decision-making, 47.8% was attributable to variations in cancer risk; 20.0% from medication management; 14.9% from voice changes; 12.7% from incision/scar; and 4.6% from follow-up concerns. LCA demonstrated 3 classes with distinct preference phenotypes: the largest group (64.2%) made decisions primarily based on cancer risk; another group (18.2%) chose based on aversion to medication; the smallest group (17.7%) factored in medication and cancer risk evenly. CONCLUSION: Cancer risk and the need to take medication after thyroid surgery factor into patient decision-making most heavily when treating thyroid nodules. Distinct preference phenotypes were demonstrated, reinforcing the need for individual preference assessment before the treatment of thyroid disorders.

ChatGPT-4 accuracy for patient education in laryngopharyngeal reflux.

INTRODUCTION: Chatbot Generative Pre-trained Transformer (ChatGPT) is an artificial intelligence-powered language model chatbot able to help otolaryngologists in practice and research. The ability of ChatGPT in generating patient-centered information related to laryngopharyngeal reflux disease (LPRD) was evaluated. METHODS: Twenty-five questions dedicated to definition, clinical presentation, diagnosis, and treatment of LPRD were developed from the Dubai definition and management of LPRD consensus and recent reviews. Questions about the four aforementioned categories were entered into ChatGPT-4. Four board-certified laryngologists evaluated the accuracy of ChatGPT-4 with a 5-point Likert scale. Interrater reliability was evaluated. RESULTS: The mean scores (SD) of ChatGPT-4 answers for definition, clinical presentation, additional examination, and treatments were 4.13 (0.52), 4.50 (0.72), 3.75 (0.61), and 4.18 (0.47), respectively. Experts reported high interrater reliability for sub-scores (ICC = 0.973). The lowest performances of ChatGPT-4 were on answers about the most prevalent LPR signs, the most reliable objective tool for the diagnosis (hypopharyngeal-esophageal multichannel intraluminal impedance-pH monitoring (HEMII-pH)), and the criteria for the diagnosis of LPR using HEMII-pH. CONCLUSION: ChatGPT-4 may provide adequate information on the definition of LPR, differences compared to GERD (gastroesophageal reflux disease), and clinical presentation. Information provided upon extra-laryngeal manifestations and HEMII-pH may need further optimization. Regarding the recent trends identifying increasing patient use of internet sources for self-education, the findings of the present study may help draw attention to ChatGPT-4's accuracy on the topic of LPR.

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.

Prevalence of Voice Disorders in the United States: A National Survey.

OBJECTIVES: The prevalence of voice disorders has not been explored in the context of recent trends in voice use, including voice assistant technology and increased use of teleconferencing for remote work. The objective of this research is (1) to determine the prevalence of voice disorders in the adult population of the United States, and (2) to understand the association of voice disorders with demographic and voice use factors, including vocal demands, and use of teleconferencing and voice assistant technology. METHODS: A survey pertaining to voice disorders and voice use was developed and administered to a representative sample of US population. Demographics and information related to risk factors for voice disturbance, including high vocal demands, teleconferencing, and voice-assistant use were also analyzed. RESULTS: A total of 1522 responses were included. Of these, 20.6% reported having had a voice disorder at some point in their life. This rate was higher in employed respondents, singers, and teachers (all p < 0.0001) and was notably higher in those who used teleconferencing technology and voice assistant technology (both p < 0.0001). Approximately 60% of this subset reported seeking medical care for their voice, 12.6% reported a current voice disorder, and 9.5% reported a voice problem that had recurred multiple times. CONCLUSIONS: Approximately 1 in 5 Americans surveyed has had a voice disorder. Risk factors for voice disorders include use of teleconferencing technology, voice assistant use, and occupational factors. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:347-352, 2024.

Anxiety and Depression Diagnoses and the Cough Severity Index: A Retrospective Study.

Background: As mental health comorbidities can impact patient perception of symptoms, understanding a potential association of anxiety and depression with patients' perception of their cough may provide insight into preferred treatment plans. Methods: A retrospective cohort study of patients presenting with chronic cough was completed. Demographics, anxiety and depression diagnoses, and patient-reported outcome measures were collected. Patient-reported outcomes between the four groups of patients-anxiety only, depression only, anxiety and depression, and none of these conditions-were compared using Kruskal-Wallis and Mann-Whitney U tests that were used for post-hoc analysis. Results: Cough Severity Index scores were higher in those with both anxiety and depression as compared to neither, with a median score of 26 (range: 5-39) versus 19 (range: 1-38), respectively (P = .041). These results were persistent also after controlling for sex and smoking status in the robust regression analysis. Conclusions: Patients with prior diagnoses of anxiety and depression self-reported more severe symptoms for chronic cough. Adequately understanding the association of mental health with perceived cough severity may help for more individualized, successful treatment plans.

Do You Like Your Voice? A Population-Based Survey of Voice Satisfaction and Voice Enhancement.

OBJECTIVES: Voice enhancement for patients without obvious vocal pathology or loss of function is rarely discussed clinically or in academic research. Our objectives were to: (1) determine voice satisfaction on a population level, and (2) assess willingness to consider interventions to change one's voice. METHODS: A standardized questionnaire was created to assess current and past voice disorders. Questions assessed demographics, health status, prevalence of voice disorders, and questions regarding satisfaction with voice. Iterative survey testing and piloting were performed. A cohort with age, gender, and geographic distribution of the general adult population was then queried in an online survey. Qualitative analysis and both descriptive and multivariate statistics were performed. RESULTS: A total of 1522 respondents were included, with an age, gender, and regional distribution reflective of the US population. A minority (38.8%) of respondents reported that they did not like the sound of their own voice in normal conversation; when asked about listening to a recording of their own voice, a majority (57.5%) reported dissatisfaction with voice. Discontent with one's voice was associated with being middle age (p = 0.005), female gender (p < 0.0001), and white race (p < 0.0001). Approximately 50.6% of respondents without a history of dysphonia would consider interventions to change their voice. Of those who indicated they may elect to change their voice, qualities regarding clarity and pitch were paramount. CONCLUSION: Dissatisfaction with one's speaking voice is common. A considerable percentage of the general population without a voice disorder would consider interventions to change their voice. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:3455-3461, 2023.

Patient Experiences With Thyroid Nodules: A Qualitative Interview Survey.

Objective: To qualitatively explore the broad set of preferences and attitudes patients have about thyroid nodules, which influence the decision-making process. Study Design: A descriptive survey design was administered as interviews. Setting: Outpatient thyroid surgery clinic. Methods: Semistructured interviews were conducted with 20 patients presenting for initial evaluation of thyroid nodules at a surgeon's office. Probative, open-ended questions were posed regarding diagnosis, treatment, risk attitudes, and the decision-making process. Thematic analysis was used to develop code-transcribed interviews, and an iterative refinement resulted in underlying themes. Results: During the diagnostic process, patients integrated emotional responses (fear, anxiety, and shock) with rationale concerns (likelihood of cancer, risk assessment), and ultimately relied heavily on expert opinion and recommendation. Contextualization with other personal or familial health problems served as helpful touchstones for decision-making. Overtreatment and overdiagnosis were not commonly discussed. When thinking about potential therapies, there was a strong bias to action rather than surveillance among patients. Surgical risk and the possibility of lifelong medication, however, were strong motivators for a subset of patients to seek nonsurgical alternatives. Conclusion: Patients describe a decision-making process that incorporates emotional response and rational consideration of risks, contextualized within the personal experience and physician expertise. The bias for action and intervention is strong, and most patients strongly weighted physicians' recommendations. Themes from this qualitative analysis may serve as the backbone for future stated preference research pertaining to thyroid disease.

Voice Disorders Associated With the Use of Inhaled Corticosteroids.

OBJECTIVE: Inhaled corticosteroids (ICS) have been demonstrated to be associated with voice changes. The goal was to determine the strength of the association between ICS use and a diagnosis of dysphonia made by an otolaryngologist and to determine whether inhaler particle type or medication type influenced this risk. STUDY DESIGN: A case-control study from 2018 to 2020. SETTING: Urban academic medical system. METHODS: Adult patients with dysphonia diagnosed by an otolaryngologist, and control patients matched on age, gender, race, and health status, were included. Exposure to ICS was assessed, and the odds ratio (OR) of the association of ICS with dysphonia was calculated. RESULTS: A total of 6551 cases and 6551 matched controls were included. We found that ICS use was significantly associated with dysphonia (OR: 5.11, 95% confidence interval: 4.23-6.17, p < .001). Subset analyses demonstrated no significant differences between inhaler particle types or specific active medications. CONCLUSION: This study emphasizes the importance of identifying ICS use in the evaluation and treatment of patients with dysphonia.

Delayed-Onset Bilateral Vocal Fold Paralysis Following Anterior Cervical Discectomy and Fusion Surgery.

A 68-year-old man with heart disease and obesity who had undergone surgery for cervical spondylotic myelopathy presented with difficulty breathing. What is your diagnosis?

Correlation Between a Diagnosis of Anxiety or Depression and Initial VHI-10 Scores in Benign Dysphonia.

OBJECTIVE: Anxiety and depression have demonstrated a positive correlation with vocal handicap among patients with benign causes of dysphonia. Our objective is to explore differences in initial Vocal Handicap Index-10 (VHI-10) scores between patients with a mental health history of anxiety or depression and those without. STUDY DESIGN: Retrospective cohort study. SETTING: Demographic data, diagnoses, and initial VHI-10 scores were collected for patients presenting with dysphonia to 2 tertiary laryngology clinics. METHODS: A Kruskal-Wallis test and subsequent Mann-Whitney U test for pairwise comparisons were used to compare distribution of VHI-10 scores among patients with anxiety, depression, anxiety and depression, and no such conditions. Bonferroni correction was used to control for multiple comparisons. Robust regression was used for multivariable analysis. RESULTS: A total of 620 cases of benign dysphonia were analyzed. Forty-two percent of the patient cohort had a preexisting diagnosis of anxiety (n = 121, 20%), depression (n = 64, 10%), or anxiety and depression (n = 74, 12%). VHI-10 scores were higher in patients with depression than in those without anxiety or depression (median difference, 4 [95% CI, 1-8]; P = .005) but did not differ significantly among the other groups. The effects of depression and anxiety status on initial VHI-10 scores among the causes of benign dysphonia varied. CONCLUSIONS: Patients with a history of depression who presented with dysphonia had worse vocal handicap than those without anxiety/depression history. Future studies may clarify how optimization of anxiety and depression can affect patient-reported vocal handicap.

Curbing the Cough: Multimodal Treatments for Neurogenic Cough: A Systematic Review and Meta-Analysis.

OBJECTIVES/HYPOTHESIS: Neurogenic cough affects 11% of Americans and causes significant detriment to quality of life. With the advent of novel therapies, the objective of this review is to determine how procedural therapies (e.g., superior laryngeal nerve block) compare to other established pharmacologic and non-pharmacologic treatments for neurogenic cough. METHODS: With the assistance of a medical librarian, a systematic review was performed using PICOS (patients, interventions, comparator, outcome, study design) format: adults with neurogenic cough receiving any pharmacologic or non-pharmacologic treatment for neurogenic cough compared to adults with neurogenic cough receiving any other relevant interventions, or treated as single cohorts, assessed with cough-specific quality of life outcomes, in all study designs and case series with ≥ 10 cases. Case reports, review articles, non-human studies, non-English language articles, and unavailable full-text articles were excluded. RESULTS: There were 2408 patients with neurogenic cough in this review, treated with medical therapy (77%), speech therapy (19%), both medical and speech therapy (1%), and procedural therapy (3%). The included studies ranged from low to intermediate quality. Overall, most interventions demonstrated successful improvement in cough. However, the heterogeneity of included study designs precluded direct comparisons between intervention types. CONCLUSION: This meta-analysis compared various treatments for neurogenic cough. Procedural therapy should be considered in the armamentarium of neurogenic cough treatments, particularly in patients refractory to, or intolerant of, the side effects of medical therapy. Lastly, this review illuminates key areas for improving neurogenic cough diagnosis, such as strict adherence to diagnostic and treatment guidelines, sophisticated reflux testing, and standardized, consistent outcome reporting. Laryngoscope, 132:107-123, 2022.

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.

How Patients Choose a Laryngologist: A Pilot Stated Preference Study.

OBJECTIVE: Patients consider many factors when deciding how to receive medical care. This study used best-worst scaling (BWS), a technique novel to otolaryngology, to quantitatively examine preferences among patients choosing a laryngologist. Our objective was to quantify in a pilot cohort the relative importance patients place on a variety of attributes when seeking a laryngologist. STUDY DESIGN: BWS survey. SETTING: Academic voice clinic. METHODS: New patients were recruited to take a computerized BWS survey developed using attributes derived from patient input, expert opinion, and literature review. Attributes were grouped into 4 categories: physician reputation, physician qualifications, hospital-related factors, and other nonclinical factors. Responses were analyzed using multinomial logit regression to determine importance scores and associations with other variables. RESULTS: Eighty-seven of 93 patients recruited participated (93.5% response rate). Physician qualifications were the most important attributes to patients, with specialty laryngology training receiving the highest importance score (20.8; 95% CI, 20.2 to 21.5; P < .0001). Recommendations from referring physicians (15.6; 95% CI, 14.3 to 16.9) and use of cutting-edge technology (11.9; 95% CI, 10.7 to 13.1) were the second and third most important, respectively. Least important were nonclinical factors, including wait time to get an appointment (4.3; 95% CI, 2.8 to 5.8) and convenience of office location (1.5; 95% CI, 0.9 to 2.1). Just over half of patients (51.2%) reported willingness to wait 4 weeks for an appointment with a laryngologist. Older patients were less concerned with convenience-related factors. CONCLUSION: Nonclinical factors were less important to patients than clinical factors, and laryngology-specific training was paramount. Stated preference methodologies can elucidate underlying preferences and help providers make care more patient centered.

Application of a Computer Vision Tool for Automated Glottic Tracking to Vocal Fold Paralysis Patients.

OBJECTIVES: (1) Demonstrate true vocal fold (TVF) tracking software (AGATI [Automated Glottic Action Tracking by artificial Intelligence]) as a quantitative assessment of unilateral vocal fold paralysis (UVFP) in a large patient cohort. (2) Correlate patient-reported metrics with AGATI measurements of TVF anterior glottic angles, before and after procedural intervention. STUDY DESIGN: Retrospective cohort study. SETTING: Academic medical center. METHODS: AGATI was used to analyze videolaryngoscopy from healthy adults (n = 72) and patients with UVFP (n = 70). Minimum, 3rd percentile, 97th percentile, and maximum anterior glottic angles (AGAs) were computed for each patient. In patients with UVFP, patient-reported outcomes (Voice Handicap Index 10, Dyspnea Index, and Eating Assessment Tool 10) were assessed, before and after procedural intervention (injection or medialization laryngoplasty). A receiver operating characteristic curve for the logistic fit of paralysis vs control group was used to determine AGA cutoff values for defining UVFP. RESULTS: Mean (SD) 3rd percentile AGA (in degrees) was 2.67 (3.21) in control and 5.64 (5.42) in patients with UVFP (P < .001); mean (SD) 97th percentile AGA was 57.08 (11.14) in control and 42.59 (12.37) in patients with UVFP (P < .001). For patients with UVFP who underwent procedural intervention, the mean 97th percentile AGA decreased by 5 degrees from pre- to postprocedure (P = .026). The difference between the 97th and 3rd percentile AGA predicted UVFP with 77% sensitivity and 92% specificity (P < .0001). There was no correlation between AGA measurements and patient-reported outcome scores. CONCLUSIONS: AGATI demonstrated a difference in AGA measurements between paralysis and control patients. AGATI can predict UVFP with 77% sensitivity and 92% specificity.

Managing Otolaryngologic Complications in Cardiothoracic Surgery.

BACKGROUND: Cardiothoracic procedures are often lifesaving operations, and because of their complexity they are not without complications. Although major complications are often recognized and treated immediately, there are many less commonly identified complications that can and frequently should be addressed by otolaryngology colleagues during a patient's hospital course. METHODS: This comprehensive review describes otolaryngologic complications of cardiac and thoracic surgery. RESULTS: Dysphonia, dysphagia, stridor, tracheotomy hemorrhage, and pharyngeal tear are all complications of cardiothoracic procedures. Indications for treatment and treatment options are reviewed. The impact on quality of life and long-term morbidity is also discussed. CONCLUSIONS: Otolaryngologic complications are common after cardiothoracic procedures. An otolaryngologist should be asked to evaluate a patient with dysphonia, dysphagia, or stridor while the patient is an inpatient. Patients experiencing persistent or nonacute problems should be referred to otolaryngologists to discuss more long-term interventions.

Current Opioid Prescribing Patterns after Microdirect Laryngoscopy.

BACKGROUND: The prevalence of opioid abuse has become epidemic in the United States. Microdirect laryngoscopy (MDL) is a common otolaryngological procedure, yet prescribing practices for opioids following this operation are not well characterized. OBJECTIVE: To characterize current opioid-prescribing patterns among otolaryngologists performing MDL. METHODS: A cross-sectional survey of otolaryngologists at a national laryngology meeting. RESULTS: Fifty-eight of 205 physician registrants (response rate 28%) completed the survey. Fifty-nine percent of respondents were fellowship-trained in laryngology. Respondents performed an average of 13.3 MDLs per month. Thirty-four percent of surgeons prescribe opioids for over two-thirds of their MDLs, while only 7% of surgeons never prescribe opioids. Eighty-eight percent of surgeons prescribed a combination opioid and acetaminophen compound, hydrocodone being the most common opioid component. Many surgeons prescribe non-opioid analgesics as well, with 70% and 84% of surgeons recommending acetaminophen and ibuprofen after MDL respectively. When opioids were prescribed, patient preference, difficult exposure and history of opioid use were the most influential patient factors. Concerns of opioid abuse, the physician role in the opioid crisis, and literature about postoperative non-opioid analgesia were also underlying themes in influencing opioid prescription patterns after MDL. CONCLUSIONS: In this study, over 90% of practicing physicians surveyed are prescribing opioids after MDL, though many are also prescribing non-opioid analgesia as well. Further studies should be completed to investigate the needs of patients following MDL in order to allow physicians to selectively and appropriately prescribe opioid analgesia postoperatively.

The minimal clinically important difference of the dyspnea index in laryngotracheal stenosis.

OBJECTIVE: The Dyspnea Index (DI) is a validated patient-reported outcome (PRO) instrument that has been used in the management of laryngotracheal stenosis (LTS). The minimal clinically important difference (MCID) is an established concept to help determine the change in a PRO instrument that reflects meaningful change for the patient. It is not known what change in the DI is of clinical significance in airway surgery. This study aims to determine the MCID for the DI in patients undergoing surgical treatment for LTS. METHODS: This is a prospective cohort study in which 26 patients with LTS completed the DI (score range 0 to 40) before and 6 to 8 weeks postoperatively, in addition to a Global Ratings Change Questionnaire (GRCQ), scored from -7 to +7, at the postoperative interval. A hypothesis test was carried out to test the association between GRCQ and change in DI. The MCID for change in DI was determined using anchor-based analysis. RESULTS: Overall mean change in DI was -11, and mean change in GRCQ was +5. Change in DI scores were significantly different among the improvement and no improvement groups (P value <0.002). Area under the receiver operating curve was 0.92, demonstrating high discriminatory ability of the change in DI score. A change of -4 was determined to be the threshold that discriminated between significant improvement and no improvement. CONCLUSION: A decrease of 4 in the DI can be considered as the MCID for patients with LTS after surgical treatment. LEVEL OF EVIDENCE: 2b Laryngoscope, 130:1775-1779, 2020.