Ultrasound-guided injection into the lateral crico-arytenoid muscle: a pilot study.

OBJECTIVES: The anterior, percutaneous Botulinum neurotoxin (BoNT) injection in the lateral cricoarytenoid muscle (LCA) guided by laryngeal electromyography (LEMG) is considered the golden standard treatment for several neurolaryngological disorders. The study presented in this article aims to assess the effectiveness of an alternative approach by which the injection is performed laterally under ultrasound monitoring. STUDY DESIGN: Anatomical dissection study in human cadavers. SETTINGS: Academic health care center. METHODS: Ultrasound-guided bilateral dye (0.1 mL of dye solution containing cold-curing polymers, latex, acrylates, acrylic esters, alcohol, and green color) injection in the LCA was performed by means of 24G needles and 1 mL syringes using the lateral approach. The dye location and distribution were assessed by anatomic dissection, performed immediately after the injection. RESULTS: In 9/10 specimens, the dye was exclusively detectable in the LCA. In 1/10 case (left side), the dye could not be delivered in the LCA because of unintended penetration of the thyroid cartilage by the needle during injection. Anatomic dissection confirmed that the dye spread neither into the thyroarytenoid (TA) nor the cricothyroid muscle (CT). CONCLUSIONS: The anatomic dissection following lateral dye injection in the LCA under ultrasound guide confirmed the precision of this approach in delivery a substance exclusively in a pre-determined target. This feature makes this method an interesting addition or alternative to the standard LEMG-guided BoNT injection at least when the LCA is its target. LEVEL OF EVIDENCE: III.

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.

Differences in Glottal Closure and Visibility of the Anterior Commissure during Rigid-90°, Rigid-70°, and Flexible Laryngostroboscopy.

INTRODUCTION: The conventional rigid-90° and rigid-70° laryngostroboscopy has been so far considered the gold standard in assessing the vibratory behavior of the vocal folds and the glottal closure configuration during phonation. Meanwhile, this rigid laryngostroboscopy is more and more replaced by flexible chip-on-tip systems. The aim of this study was to evaluate the influence of these different endoscopic techniques on glottal closure configuration and on visibility of the complete focal fold length including anterior commissure during phonation. METHODS: Twenty-one euphonic subjects were enrolled (mean age 34.6 ± 9.5; m = 10, f = 11). They were examined with the three laryngoscopic techniques (conventional rigid-90°, rigid-70°, and flexible chip-on-tip laryngoscopy during low and high voice pitch with soft and loud voice intensity). For evaluating the degree of glottal closure, a modified classification of Södersten et al. was applied and the visibility of the anterior commissure was evaluated. The correlation of the three endoscopic techniques was assessed with Cohen and Fleiss' kappa. RESULTS: In even low loud phonation, the rigid-90° and rigid-70° endoscopies revealed a complete closure of the glottis in only 47.6% of subjects but with flexible endoscopy in 81%. The complete vocal fold length with anterior commissure was best visible with flexible endoscopy in 90.5% in low-soft and high-soft phonation. The rigid-90° endoscopy showed a slight agreement in comparison with the flexible endoscopy in regard to the types of vocal fold closure with a Cohen's kappa coefficient k = 0.199. The rigid-90° endoscopy showed an almost perfect agreement with k = 0.84 when compared to the rigid-70° endoscopy. The flexible endoscopy compared to the rigid-70° endoscopy showed a fair agreement with k = 0.346. CONCLUSION: We found mainly corresponding results in both rigid-90° and rigid-70° endoscopic techniques which can be explained by the same transoral approach with the tongue pulled out, whereas the flexible transnasal endoscopy mainly gives a better view on the anterior commissure. The influence of transorally or transnasally guided endoscopic techniques needs to be considered in interpretation of laryngostroboscopic parameters like vocal fold closure and supraglottal hyperactivity.

Electromyography of the posterior cricoarytenoid muscles: a consensus guideline.

PURPOSE: Since the introduction of transcutaneous-transcricoidal needle approaches, electromyography (EMG) of the posterior cricoarytenoid muscle (PCA) became easier to perform and teach. Among the Neurolaryngology working group of the European Laryngological Society, several centers have adopted PCA EMG as part of their routine EMG workup in vocal fold immobility collectively gathering long-term experience. The purpose is to give an update and an extension to already existing guidelines on laryngeal EMG with specific regard to PCA EMG. METHODS: Consensus of all co-authors is based on continuous exchange of ideas and on joint laryngeal EMG workshop experiences over at least 7 years. A Delphi method of consensus development was used, i.e., the manuscript was circulated among the co-authors until full agreement was achieved. RESULTS: Step-by-step instructions on how to perform and interpret PCA EMG are provided. CONCLUSIONS: Further research should include the establishment of normal values for PCA and thyroarytenoid muscle (TA) EMG as well as studies on the nature of some unusual activation pattern commonly seen in chronically lesioned PCA.

Effect of FFP2/3 Masks on Voice Range Profile Measurement and Voice Acoustics in Routine Voice Diagnostics.

INTRODUCTION: Voice diagnostics including voice range profile (VRP) measurement and acoustic voice analysis is essential in laryngology and phoniatrics. Due to COVID-19 pandemic, wearing of 2 or 3 filtering face piece (FFP2/3) masks is recommended when high-risk aerosol-generating procedures like singing and speaking are being performed. Goal of this study was to compare VRP parameters when performed without and with FFP2/3 masks. Further, formant analysis for sustained vowels, singer's formant, and analysis of reading standard text samples were performed without/with FFP2/3 masks. METHODS: Twenty subjects (6 males and 14 females) were enrolled in this study with an average age of 36 ± 16 years (mean ± SD). Fourteen patients were rated as euphonic/not hoarse and 6 patients as mildly hoarse. All subjects underwent the VRP measurements, vowel, and text recordings without/with FFP2/3 mask using the software DiVAS by XION medical (Berlin, Germany). Voice range of singing voice, equivalent of voice extension measure (eVEM), fundamental frequency (F0), sound pressure level (SPL) of soft speaking and shouting were calculated and analyzed. Maximum phonation time (MPT) and jitter-% were included for Dysphonia Severity Index (DSI) measurement. Analyses of singer's formant were performed. Spectral analyses of sustained vowels /a:/, /i:/, and /u:/ (first = F1 and second = F2 formants), intensity of long-term average spectrum, and alpha-ratio were calculated using the freeware praat. RESULTS: For all subjects, the mean values of routine voice parameters without/with mask were analyzed: no significant differences were found in results of singing voice range, eVEM, SPL, and frequency of soft speaking/shouting, except significantly lower mean SPL of shouting with FFP2/3 mask, in particular that of the female subjects (p = 0.002). Results of MPT, jitter, and DSI without/with FFP2/3 mask showed no significant differences. Further mean values analyzed without/with mask were ratio singer's formant/loud singing, with lower ratio with FFP2/3 mask (p = 0.001), and F1 and F2 of /a:/, /i:/, /u:/, with no significant differences of the results, with the exception of F2 of /i:/ with lower value with FFP2/3 mask (p = 0.005). With the exceptions mentioned, the t test revealed no significant differences for each of the routine parameters tested in the recordings without and with wearing a FFP2/3 mask. CONCLUSION: It can be concluded that VRP measurements including DSI performed with FFP2/3 masks provide reliable data in clinical routine with respect to voice condition/constitution. Spectral analyses of sustained vowel, text, and singer's formant will be affected by wearing FFP2/3 masks.

Diagnostic limitation of laryngostroboscopy in comparison to laryngeal electromyography in synkinesis in unilateral vocal fold paralysis.

PURPOSE: In clinical practice, laryngo(strobo)scopy (LS) is still mainly used for diagnostics and management of unilateral vocal fold paralysis (UFVP), although only laryngeal electromyography (LEMG) can provide information on causes of vocal fold immobility, especially on possible synkinetic reinnervation after recurrent laryngeal nerve (RLN) injury. The goal of this retrospective study was the evaluation whether signs of synkinetic reinnervation in LS can be objectified in comparison to LEMG data. METHODS: Between 1/2015 and 2/2018, 50 patients with laryngostroboscopically suspected UVFP received routine LEMG examination. The LEMG findings were retrospectively compared with LS findings. The LEMG data analysis focused on the diagnosis of synkinetic reinnervation of the TA/LCA and/or PCA. The digital LS recordings were retrospectively re-evaluated by phoniatricians considering 22 selected laryngostroboscopic parameters. RESULTS: LEMG revealed synkinesis in 23 (46%) and absence of synkinesis in 27 (54%) patients. None of the 22 parameters showed significant association between patients with synkinetic reinnervation and LS findings. The only laryngostroboscopic parameter that was significantly associated with a silent LEMG signal compared to single fiber activity in LEMG was a length difference on the side of the UVFP (p-value 0.0001; OR 14.5 (95% CI 3.047-66.81; Sensitivity 0.5; Specificity 0.9355). CONCLUSION: Our findings show that synkinesis cannot be diagnosed using only LS. This study underlines the importance of LEMG in clinical routine for detection of laryngeal synkinesis in patients with UVFP before any further therapeutic steps are initiated to avoid later therapy failure.

Comparison of voice therapy and selective electrical stimulation of the larynx in early unilateral vocal fold paralysis after thyroid surgery: A retrospective data analysis.

OBJECTIVES: The goal of the retrospective study was to investigate the 3-month-outcome after treatment of patients with early unilateral vocal fold paralysis (UVFP) with either standard voice therapy (VT) or selective electrical stimulation of the larynx (SES). DESIGN: Non-randomised retrospective study. SETTING: 1519 patients who underwent thyroid surgery between 2015 and 2018 were analysed according vocal fold mobility; UVFP patients were treated either by VT or SES. PARTICIPANTS: 51 UVFP patients. MAIN OUTCOME MEASURES: 51 UVFP patients have been advised regarding treatment options like either VT (group 1) or SES (group 2). The patients of group 1 (n = 26) and 2 (n = 25) were re-assessed up to 3 months post-operatively regarding UVFP persistence/recovery and perceptive voice sound quality. At follow-ups, perceptual analysis of voice sound (using roughness=R/breathiness=B/hoarseness=H scale) and endoscopic laryngoscopy have been performed. Position of immobile vocal fold, shape of glottal closure and RBH parameters have been considered for statistical analyses. RESULTS: Restitution of UVFP with regular respiratory vocal fold mobility of both vocal folds occurred in 53.8% of group 1 (VT), and in 40.0% of group 2 (SES) after 3 months of therapy between both groups. No difference could be seen for RBH, type of glottal closure and position of ailing vocal folds in patients with persisting UVFP within both groups and between the groups. CONCLUSIONS: The study reveals that SES can achieve similar functional outcome in early UVFP. Thus, it should be considered as an equivalent therapy alternative to VT for treatment of early UVFP patients since no significant difference in vocal outcome and glottal configuration between the two groups could be demonstrated.

[Voice diagnostics in phonosurgical interventions]. / Stimmdiagnostik bei phonochirurgischen Eingriffen.

Voice diagnostics before and after phonosurgical interventions should aim at detailed planning of surgical techniques and evaluability of postoperative outcome. They should consider multimodal concepts and include measurements of perceptual voice analysis, laryngostroboscopy, voice acoustics, aerodynamics, and self-evaluation by the patients. Selected methods for voice diagnostics should reflect current knowledge and define the departmental procedure.

Pre- and intraoperative acoustic and functional assessment of the novel APrevent® VOIS implant during routine medialization thyroplasty.

PURPOSE: Persistent unilateral vocal fold paralysis (UFVP) with glottal insufficiency often requires type I medialization thyroplasty (MT). Previous implants cannot be adjusted postoperatively if necessary. The newly developed APrevent® VOIS implant (VOIS) can provide postoperative re-adjustment to avoid revision MT. The objective of this pilot study is to evaluate the VOIS intraoperatively concerning voice improvement, surgical feasibility and device handling. METHODS: During routine MT, VOIS was applied short time in eight patients before the regular implantation of the Titanium Vocal Fold Medialization Implant (TVFMI™). In all patients, perceptual voice sound analysis using R(oughness)-B(reathiness)-H(oarseness)-scale, measurement of M(aximum)-P(honation)-T(ime) and glottal closure in videolaryngoscopy were performed before and after implanting VOIS/TVFMI™. Acoustic analyses of voice recordings were performed using freeware praat. Surgical feasibility, operative handling and device fitting of VOIS and TVFMI™ were assessed by the surgeon using V(isual)-A(nalog)-S(cale). Data were statistically analyzed with paired t test. RESULT: All patients showed significant improvement of voice sound parameters after VOIS/TVFMI™ implantation. The mean RBH-scale improved from preoperative R = 2.1, B = 2.3, H = 2.5 to R = 0.6, B = 0.3, H = 0.8 after VOIS and R = 0.5, B = 0.3, H = 0.8 after TVFMI™ implantation. The mean MPT increased from preoperative 7.9 to 14.6 s after VOIS and 13.8 s after TVFMI™ implantation. VOIS/TVFMI™ achieved complete glottal closure in 7/8 patients. The satisfaction with intraoperative device fitting and device handling of VOIS was as good as that of TVFMI™. CONCLUSION: The novel APrevent® VOIS implant showed similar intraoperative voice improvement compared to routinely used TVFMI™ without adverse device events and with safe device fitting.

Objectivation of laryngeal electromyography (LEMG) data: turn number vs. qualitative analysis.

PURPOSE: This paper describes a first attempt to quantify LEMG data based on turn number calculation. The results obtained for both healthy and ailing thyroarytenoid (TA) muscles of patients with unilateral vocal fold immobility (UVFI) were compared with the respective qualitative evaluation concerning volitional activity to determine whether the two types of analyses deliver similar results. METHODS: LEMG data obtained from 44 adults with UVFI were considered for the study. Semiquantitative evaluation of TA volitional activity and turn number were assessed for the ailing and the healthy TA and the difference in percentage was calculated. Paired data were compared with the Wilcoxon signed-rank test. The volitional activity assessment and the turn number evaluation were compared with the Kruskal-Wallis test, and their relationship was tested with the Kendall rank correlation. RESULTS: Datasets of 27 patients were considered compatible with turns/s calculation. The results showed that complete paralysis correlated with no turns; single fiber volitional activity with 62-208 turns/s, strongly decreased volitional activity with 198-501 turns/s; and dense volitional activity with 441-1234 turns/s. On the ailing VF only, the Kruskal-Wallis test showed a statistically significant difference (p = 0.0001), and the Kendall rank correlation a positive relationship (r = 0.853,p ≤ 0.0001) between the volitional activity rating and the turn number assessment. CONCLUSIONS: Our preliminary results showed that turn number evaluation is an effective tool to confirm LEMG qualitative analysis, and that, in combination with laryngostroboscopy and voice assessment, can help improving the accuracy of the diagnosis and prognosis and the effectiveness of the chosen therapy.

Inter-rater reliability of seven neurolaryngologists in laryngeal EMG signal interpretation.

PURPOSE: Laryngeal electromyography (LEMG) has been considered as gold standard in diagnostics of vocal fold movement impairment, but is still not commonly implemented in clinical routine. Since the signal interpretation of LEMG signals (LEMGs) is often a subjective and semi-quantitative matter, the goal of this study was to evaluate the inter-rater reliability of neurolaryngologists on LEMGs of volitional muscle activity. METHODS: For this study, 52 representative LEMGs of 371 LEMG datasets were selected from a multicenter registry for a blinded evaluation by 7 experienced members of the neurolaryngology working group of the European Laryngological Society (ELS). For the measurement of the observer agreement between two raters, Cohen's Kappa statistic was calculated. For the interpretation of agreements of diagnoses among the seven examiners, we used the Fleiss' Kappa statistic. RESULT: When focusing on the categories "no activity", "single fiber pattern", and "strongly decreased recruitment pattern", the inter-rater agreement varied from Cohen's Kappa values between 0.48 and 0.84, indicating moderate to near-perfect agreement between the rater pairs. Calculating with Fleiss' Kappa, a value of 0.61 showed good agreement among the seven raters. For the rating categories, the Fleiss' Kappa value ranged from 0.52 to 0.74, which also showed a good agreement. CONCLUSION: A good inter-rater agreement between the participating neurolaryngologists was achieved in the interpretation of LEMGs. More instructional courses should be offered to broadly implement LEMG as a reliable diagnostic tool in evaluating vocal fold movement disorders in clinical routine and to develop future algorithms for therapy and computer-assisted examination.

Use of the myocutaneous serratus anterior free flap for reconstruction after salvage glossectomy.

PURPOSE: To describe the use of a myocutaneous serratus anterior free flap (SAFF) for tongue reconstruction after salvage subtotal (STG) and total glossectomy (TG). METHODS: In this prospective case series, seven patients underwent salvage STG or TG and reconstruction with a myocutaneous SAFF between 10/2015 and 02/2017. Functional and oncologic outcomes were prospectively evaluated. Donor side morbidity was determined using the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: SAFF with mean skin paddles of 6.7 cm × 8.7 cm was used in five STG and two TG patients, respectively. There was a 100% flap survival and a mean DASH score of 10.8 reflected normal arm and shoulder function after surgery. One year after salvage surgery, 1 (14.3%) and 4 (57.1%) patients were tracheostomy and gastrostomy tube dependent. Gastrostomy tube dependence was significantly worse in patients with tumors of the base of tongue compared to other tumor sites (p = 0.030) and in patients who underwent transcervical compared to transoral tumor resection (p = 0.008). Local recurrence rate was 57.1% with a disease-free survival of 17.6 months. CONCLUSION: The myocutaneous SAFF represents a safe and reliable flap for tongue reconstruction after salvage glossectomy with satisfying functional outcomes and low donor side morbidity.

Evaluation of culture conditions for mixed biofilm formation with clinically isolated non-albicans Candida species and Staphylococcus epidermidis on silicone.

Silicone is frequently used in clinical and medical fields for medical devices. Mixed biofilms composed of Candida and bacterial species causes frequently failure of medical silicone devices, In this in vitro study, we analyzed mixed biofilm formation of clinically isolated non-albicans Candida species and Staphylococcus epidermidis, including Candida tropicalis, Candida krusei and Candida parapsilosis under the influence of different growth media (RPMI 1640, BHI and TSB) and several culture variables (incubation period, feeding conditions and FBS). Our results showed that culture conditions strongly influence mixed biofilm formation. TSB and BHI resulted in larger amount of biofilm formations with stronger metabolic activity of biofilms. Growth conditions may also influence the biofilm formation, which was enhanced by longer incubation period, using a fed-batch system and FBS. Therefore, the potential influences of external environmental factors are very important for mixed biofilm formation with clinically isolated non-albicans Candida species and S. epidermidis, which should be considered when designing or studying the mixed biofilm under in vitro conditions.

Dispersal of single and mixed non-albicans Candida species biofilms by ß-1,3-glucanase in vitro.

ß-1,3-glucan plays a role in non-albicans Candida species biofilm formation and survival of biofilm Candida to stresses. In this study, we evaluated the antibiofilm activity of ß-1,3-glucanase, which can degrade poly-ß(1 â†’ 3)-glucose of non-albicans Candida species biofilms, on single and mixed species biofilm of non-albicans Candida species, including Candida tropicalis, Candida parapsilosis and Candida krusei. Biofilm by all tested species in microplate were dispersed more than 60%. ß-1,3-glucanase also detached mixed species biofilm in microplate and on medical material surface. ß-1,3-glucanase had no effect on Candida planktonic growth as well as adhesion. However, further biofilm formation was inhibited with ß-1,3-glucanase added at 24 h after biofilm initiation. ß-1,3-glucanase markedly enhanced the antifungal susceptibility of amphotericin B. The examination using confocal laser scanning microscopy and scanning electron microscope confirmed the antibiofilm activity of ß-1,3-glucanase. Our findings demonstrate that ß-1,3-glucanase may be useful as an antibiofilm agent.

Inhibition activity of Lactobacilli supernatant against fungal-bacterial multispecies biofilms on silicone.

Fungal-bacterial multispecies biofilms play a major role in failure of medical silicone devices, such as voice prostheses in laryngectomiy. In this study, we determined the effect of Lactobacilli supernatant (cell free) on mixed biofilm formation of fungi and bacteria on silicone in vitro. Lactobacilli supernatant inhibited the adhesion (90 min) of mixed fungi and bacteria species with an efficiency of >90%. Mixed biofilm formation and the metabolic activity of the biofilms were inhibited by 72.23% and 58.36% by Lactobacilli supernatant. The examination using confocal laser scanning microscopy and scanning electron microscopy confirmed that Lactobacilli supernatant inhibited the growth of mixed biofilm and damaged the cells. Moreover, Lactobacilli supernatant also inhibited Candida yeast-to-hyphal transition. Therefore, Lactobacilli supernatant may serve as a possible antibiofilm agent to limit biofilm formation on voice prostheses.

Oral health status and dental care behaviours of head and neck cancer patients: a cross-sectional study in an Austrian tertiary hospital.

OBJECTIVES: This study aimed to assess the oral health status and dental care behaviours of patients treated for head and neck squamous cell carcinoma (HNSCC) in an Austrian tertiary hospital. MATERIALS AND METHODS: Dental care behaviours, oral hygiene level, caries, and periodontal parameters were assessed in 48 patients treated for HNSCC >6 months ago. RESULTS: Only 52 % requested a dental check-up after HNSCC diagnosis and prior to treatment, and of those, 80 % received some type of dental treatment. At time-point of clinical examination, 69 % of the patients had consulted a dentist within the last year, but 88 % still needed dental treatment; 75 % had at least one tooth with caries and 78 % had moderate to severe periodontitis. CONCLUSION: Although it was recommended, only half of the patients did consult a dentist prior to HNSCC treatment and oral health appeared, in general, low prioritized. CLINICAL RELEVANCE: About 90 % of the current group of head and neck squamous cell carcinoma cancer patients presented large treatment needs, both in regard with caries and periodontal disease, about 20 months after cancer treatment.

Diplophonia Disturbs Jitter and Shimmer Measurement.

OBJECTIVES: The aims of this study are to investigate the effects of diplophonia on jitter and shimmer and to identify measurement limitations with regard to material selection and clinical interpretation. MATERIALS AND METHODS: Four hundred and ninety-eight audio samples of sustained phonations were analyzed. The audio samples were assessed for the grade of hoarseness and the presence of diplophonia. Jitter and shimmer were reported with regard to perceptual ratings. We investigated cycle marker positions exemplarily and qualitatively to understand their implications for perturbation measurements. RESULTS: Medians of jitter and shimmer were higher for diplophonic voices than for nondiplophonic voices with equal grades of hoarseness. The variance of jitter for moderately dysphonic voices was larger than the variance observed in a corpus from which diplophonic samples had been discarded. The positions of cycle markers in diplophonic voices did not match the positions of the pulses, indicating that the validity of jitter and shimmer values for these voices were questionable. CONCLUSION: Diplophonia biases the reporting of dysphonia severity via perturbation measures, and their validity is questionable for these voices. In addition, diplophonia is an influential source of variance in jitter measurements. Thus, diplophonic fragments of voice samples should be excluded prior to perturbation analysis.

Voice prostheses, microbial colonization and biofilm formation.

Total laryngectomy is performed in advanced laryngeal and hypopharyngeal cancer stages and results in reduced quality of life due to the loss of voice and smell, permanent tracheostoma and occasionally dysphagia. Therefore, successful voice rehabilitation is highly beneficial for the patients' quality of life after surgery. Over the past decades, voice prostheses have evolved to the gold standard in rehabilitation and allow faster and superior voicing results after laryngectomy compared to esophageal speech. Polyspecies biofilm formation has become the limiting factor for device lifetimes and causes prosthesis dysfunction, leakage and in consequence pneumonia, if not replaced immediately. Although major improvements in prosthesis design have been made and scientific insight in the complexity of biofilm evolution and material interaction progresses, the microbial colonization continues to restrict device lifetimes, causing patient discomfort and elevated health costs. However, present scientific findings and advances in technology yield promising future approaches to improve the situation for laryngectomized patients.

Teaching laryngeal electromyography.

To achieve consensus in the methodology, interpretation, validity, and clinical application of laryngeal electromyography (LEMG), a working group on neurolaryngology from the European Laryngological Society (ELS) was founded in 2010. The main task of the working group was to teach key techniques like LEMG procedures. The objective of this study was to collect information on the teaching techniques used and describe them. A multicenter registry was created to analyze the data collected from LEMGs in 14 departments. We screened how often different departments participated in teaching events. Teaching events were classified retrospectively: presentations at conferences and meetings; workshops with hands-on training on patients; workshops with hands-on training on animal models; workshops with hands-on training on anatomic specimens; and supervision by experts to perform LEMG together. Both, supervision to perform LEMG together and the total number of PCA-LEMGs (r = 0.713), as well as supervision to perform LEMG together and the PCA/total-number-of-LEMG ratio (r = 0.814) were correlated significantly (p < 0.05). Similarly, the sum of teaching events was correlated significantly with the total number of PCA-LEMGs (r = 0.605), and so did the sum of teaching events with the PCA/total-number-of-LEMG ratio (r = 0.704). Participation in hands-on training in humans was correlated significantly with the PCA/total-number-of-LEMG ratio (r = 0.640). The data presented herein suggest that multimodal teaching techniques are most effective. To promote multimodal learning an interactive webpage ( http://www.lemg.org) providing videos and animations, and the possibility to discuss cases with other experts was established.