Dysphagia as a predictor of voice handicap and voice restoration in unilateral vocal fold immobility

OBJECTIVE

Dysphagia is multifactorial in unilateral vocal fold immobility (UVFI). Severe dysphagia could indicate greater functional deficits in UVFI. The purpose of this study is to evaluate the association of dysphagia with the need for surgical voice restoration in patients with UVFI.

STUDY DESIGN

Retrospective chart review.

SETTING

Single-institution, tertiary referral center.

METHODS

Records of UVFI patients from 2008 to 2018 were examined. Dysphagia severity was extracted from patient history. Etiology of UVFI and other relevant variables were analyzed to determine their association with dysphagia. Dysphagia severity and other clinical variables were then analyzed for their association with surgical voice restoration.

RESULTS

Eighty patients met selection criteria out of 478 patients with UVFI. There was significant concordance between dysphagia severity extracted from patient history and patient-reported EAT-10 scores (R = 0.59, p = 0.000035). Patients' EAT-10 scores were correlated with VHI-10 scores (R = 0.45, p = 0.011). Severe dysphagia (p = 0.037), high VHI-10 score on presentation (p = 0.0009), and longer duration of hoarseness before presentation (p = 0.008) were associated with surgical voice restoration in UVFI patients.

CONCLUSION

In this pilot study, severe dysphagia and increased voice handicap on presentation were associated with the need for surgical voice restoration in UVFI patients. Presenting dysphagia may be an additional variable for clinicians to consider for management of UVFI.

Cost-Effectiveness of Steroids for Prolonging the Surgery-Free Interval in Subglottic Stenosis

OBJECTIVES

Repeat endoscopic dilation (ED) in the operating room for subglottic stenosis (SGS) remains an economic burden to patients. The cost-effectiveness (CE) of adjuvant serial intralesional steroid injections (SILSI) to prolong the surgery-free interval (SFI) in SGS patients requiring ED has yet to be studied.

METHODS

Details of the cost of SILSI and ED were received from our tertiary academic center. SFI, cost of intervention, and the effect of SILSI on prolonging SFI were collected from a systematic review by Luke et al. SGS etiologies in the review included idiopathic, iatrogenic, or autoimmune. A break-even analysis, comparing the cost of SILSI alone with the cost of repeat ED, was performed to determine if SILSI injections were cost-effective in prolonging the SFI.

RESULTS

Average extension of the SFI with SILSI was an additional 219.3 days compared to ED alone based on a systematic review of the literature. 41/55 (74.5%) cases did not require further ED once in-office SILSI management began. SILSI administered in a 4-dose series in 3-to-7-week intervals (~$7,564.00) is CE if the reported recurrence rate of SGS requiring ED (~$39,429.00) has an absolute risk reduction (ARR) of at least 19.18% with the use of SILSI. Based on the literature, SILSI prevents ~3 out of every 4 cases of SGS at sufficient follow-up from undergoing repeat ED, resulting in an ARR of ~75%.

CONCLUSIONS

SILSI is economically reasonable if it prolongs the SFI of at least one case of recurrence out of 5. SILSI, therefore, can be CE in extending the interval for surgical ED.

LEVEL OF EVIDENCE

NA Laryngoscope, 133:3436-3442, 2023.

Vocal Fold Pathologies Among Undergraduate Singing Students In Three Different Genres

OBJECTIVE

This study aimed to compare the prevalence and incidence of vocal fold pathologies among undergraduate classical, musical theatre, and contemporary commercial music (CCM) students over two-time points.

METHODS

This study is part of a longitudinal investigation. Videostroboscopic examinations were rated, with consensus among three of four expert blinded raters confirming the presence of pathology. Association between genre of singer and the presence of pathology, interrater reliability, and intra-rater reliability were calculated. Prevalence and incidence of pathologies were compared across genres.

RESULTS

During first-year evaluations, 32% of musical theatre, 18% of CCM, and 0% of classical students had vocal pathologies. The prevalence at third-year evaluations showed 22% of classical, 39% of musical theatre, and 27% of CCM participants having vocal fold pathologies. The incidence of pathologies was 67% of musical theatre students compared to 22% of classical students and 27% of CCM students. The four raters demonstrated fair to moderate interrater agreement. Singing Voice Handicap Index-10 scores were normal for CCM singers at both time points but elevated for musical theatre and classical singers.

CONCLUSION

No classical singers were found to have pathology during first-year evaluations, although CCM and musical theatre singers showed evidence of vocal fold pathologies. At third-year evaluations, all three genres had an apparent increase in prevalence of pathologies. Implications of this study suggest that more time in the field and intense voice usage may lead to a greater risk of pathology for all singers, regardless of genre.

LEVEL OF EVIDENCE

2 Laryngoscope, 133:2317-2324, 2023.

Independence of Vocal Load From Vocal Pathology Across Singing Genres

OBJECTIVE

To investigate the extent to which vocal load is associated with previous diagnosis of a vocal pathology among four major genres of singers (primarily classical, primarily musical theatre (MT), classical and MT combined, and contemporary commercial music only).

STUDY DESIGN

Cross sectional survey.

METHODS/DESIGN

An anonymous online survey was sent out to about 1000 professional singers through convenience sampling to touring companies, opera companies, MT companies, agents, directors and musical directors. Social media and email were used to solicit participation in the study. We utilized means and standard deviations for continuous characteristics and frequencies and percentages for categorical characteristics and calculated P values to assess whether differences were statistically significant.

RESULTS

A total of 396 professional singers completed the survey, yielding a 40% response rate. Nonprofessional singers, incomplete surveys, and respondents <18 years old were excluded, resulting in a total of 238 responses. Among the 238 participants, 32% were performing in the classical style primarily, 33% in the MTstyle primarily, 15% in both classical and MT, and 20% in other contemporary styles only. Mean age was highest among CV + MT and lowest among primarily MT. Combined classical/MT singers were most likely to have a career outside of vocal performance and continue to work in that career followed by other contemporary styles, classical and MT (P = 0.02). Participants in the combined classical/MT group were most likely to have a reported history of vocal pathology followed by classical, other contemporary styles and MT (not statistically significant). However, participants in the contemporary styles were most likely to have a history of more than one type of vocal pathology. Mean vocal load was highest for the MT group. Other nonsinging factors proved significant such as allergy, hydration and acid reflux. Symptoms of allergies were found to be significant across singing genres. A possible reverse causality association was identified in regards to water intake. Participants with acid reflux were three times more likely to have ever reported vocal pathology.

CONCLUSION

Vocal load was not significantly associated with vocal pathology across singing genres; however other nonsinging factors such as allergy, reflux and water intake were significantly associated with vocal pathology.

Identification of abstract features presented at the combined otolaryngology spring meeting predicting publication in impactful peer-reviewed journals

OBJECTIVES

Review abstracts presented at the Combined Otolaryngology Society Meeting (COSM) to determine subsequent publication and identify abstract features predictive of publication in high impact journals.

METHODS

A selection of abstracts accepted in the 2015 COSM scientific programs were retrospectively reviewed. MEDLINE searches via PubMed and Google Scholar were performed to determine publication rates. The Journal of Citation Reports was used to determine impact factors for published abstracts. Binomial regression analyses were used to identify factors related to publication in high impact journals.

RESULTS

62.4% of reviewed abstracts (n = 623) were subsequently published, with a mean publication time of 14 ± 12 months. Abstract features predictive of publication were basic science type, other science type, prospective studies, multi-institutional involvement, and presentation at the American Laryngologic Association and American Otologic Society meetings. Based on Wald score, podium presentation was found to have the biggest effect on publication. Factors positively associated with publication in high impact (impact factor > 2.272) journals were increased author number and sample size.

CONCLUSIONS

Overall publication rate of abstracts selected for presentation at COSM in 2015 was on the higher end of previously reported otolaryngology meetings. Abstracts detailing basic science, other science, prospective and multi-institutional studies were more likely to lead to future publication. Additionally, increased number of authors and sample size lead to publication in higher impact journals.

LEVEL OF EVIDENCE

N/A.

Glottic Keratosis: Significance and Identification of Laryngoscopic Findings

Objective

Glottic keratosis poses a challenge because a decision to biopsy must weigh the likelihood of dysplasia and cancer against the voice outcome after biopsy. We determined the significance of laryngoscopic findings and agreement among clinicians to identify those specific findings.

Study Design

Retrospective case-control study.

Setting

Tertiary care university hospital.

Methods

Adults with glottic keratosis with preoperative office laryngoscopies were included. Preoperative videostroboscopies were reviewed by a blinded reviewer. Multivariable logistic regression was used to examine the correlation between laryngoscopic appearance of glottic keratosis and presence or absence of high-grade dysplasia or carcinoma on biopsies. Consensus among head and neck cancer surgeons to detect specific laryngoscopic findings was evaluated by presenting representative laryngoscopies to a blinded cohort. Interrater reliability was calculated using Fleiss’s κ.

Results

Sixty glottic keratotic lesions met inclusion criteria. On logistic regression, both erythroplakia and aberrant microvasculature like vascular speckling were significantly associated with high-grade dysplasia and carcinoma, P = .002 and P = .03, respectively. Interrater reliability among clinicians to identify erythroplakia and aberrant microvasculature was minimal, κ = 0.35 and κ = 0.29, respectively. Interrater reliability was improved with the use of virtual chromoendoscopy.

Conclusion

The presence of erythroplakia and aberrant microvasculature in glottic keratosis is associated with the presence of high-grade dysplasia or carcinoma. Virtual chromoendoscopy can be used to improve reliability for detecting erythroplakia and vascular speckling, and this is a potential area for practice-based learning. Clinicians should identify and consider immediate diagnostic biopsy of suspicious glottic keratosis.

Quantifying Subjective and Objective Measures of Singing After Different Warm-Up Durations

BACKGROUND

Performing vocal warm-ups prior to singing repertoire has been shown to change the perceived quality and acoustic parameters of the voice. To date, there are no studies that specifically compare singers' and listeners' perceptions of vocal quality after various warm-up durations.

OBJECTIVE

To determine if specific warm-up durations (0, 5, 10, or 15 minutes) change subjective and objective measures of voice.

STUDY DESIGN

Prospective cohort study.

METHODS

Information related to demographics, singing practice, medical history, and vocal hygiene were collected. First- and second-year collegiate classical voice majors completed a series of four warm-up times, 1 week apart, prior to singing Caro mio ben in a standard key for their voice type. A modified Voice Range Profile (mVRP), and the Evaluation of the Ability to Sing Easily (EASE) scale were completed. Participants blindly rated 30-second recorded audio clips using the Auditory-Perceptual Rating Instrument for Operatic Singing. Four independent expert blinded listeners rated all audio clips for each participant in random order.

RESULTS

Six first-year and three second-year classical vocal performance majors completed all measures. Results of the EASE scale showed decreased scores with 5- and 10-minute warm-up duration, compared to 0 and 15 minutes of warm-up (P = 0.029 for the total EASE score and P = 0.044 for Rasch score). Delayed perceptual analysis of voice yielded nearly equal medians between warm-up durations for both self and expert-listener ratings. The mVRP showed that both 5 and 10 minutes of warm-up duration led to increased highest fundamental frequency for females (P = 0.017).

CONCLUSION

This pilot study demonstrates the immediate self-perceived benefit for all participants and increased frequency range for females after performing 5 and 10 minutes of vocal warm-up. No significant differences were found in delayed perceptual analyses completed by the participants or the expert raters after the different warm-up durations. Future investigations should include a larger population and different levels of education and genres of singing.

Office-based corticosteroid injections as adjuvant therapy for subglottic stenosis

Objective

Subglottic stenosis (SGS) is a serious, potentially life‐threatening disorder that is difficult to treat due to significant recurrence rates. While conventional treatment of SGS relies heavily on serial endoscopic dilation procedures, this study aims to characterize the efficacy of incorporating subglottic corticosteroid injections in increasing surgery‐free intervals (SFIs) for a cohort of patients at a university‐based medical system.

Study Design

Retrospective chart review.

Methods

All SGS patients who underwent endoscopic dilation and at least one adjuvant office‐based serial intralesional steroid injection (SILSI) were reviewed. Patients were excluded if they had synchronous airway lesions or stenosis outside of the subglottis. Charts were reviewed for demographic and treatment‐specific data. The SFI was calculated for patients both prior to the initiation of SILSI and after. Groups were compared via Mann–Whitney U test, with P < .05 as the threshold for significance.

Results

Thirteen patients met criteria, with mean age 50.1 ± 14.1 years and 7:6 female to male ratio. Eight of the thirteen (61.5%) had intubation‐related stenosis, while 4/13 were idiopathic and 1/13 was due to Wegener's granulomatosis. Mean follow‐up was 20.4 months. Patients underwent an average of 4.2 ± 2.2 postoperative injections, beginning 45.9 ± 19.0 days after surgery. The mean SFI prior to initiating SILSI was 288.6 ± 362.0 days; while after receiving SILSI, the mean interval was significantly longer (545.5 ± 152.7 days, P = .0041).

Conclusions

We demonstrate that office‐based corticosteroid injection for SGS was associated with a statistically significant improvement in the SFI and is a promising adjuvant approach. Future prospective studies should evaluate if the efficacy is reproducible on a large scale and if SILSI can and/or should be incorporated into the standard management paradigm for SGS treatment.

Level of Evidence

4

The Role of Observation and Mentorship in Voice Pedagogy Training

BACKGROUND

Voice teachers are seeking increasing amounts of pedagogical instructions in the form of observerships, coursework, and clinical experiences. Yet to date there has been no formalized attempt to categorize or set guidelines for these educational experiences.

OBJECTIVES

The aim of this study was to investigate (a) the number of hours of observations required or electively completed during pedagogical training (voice lessons, masterclasses) and clinical observations; (b) the number of hours of mentorship (critical observation of a student by a mentor) during pedagogical training; and (c) differences in the training backgrounds of voice teachers based on the level of training, position, and genre.

METHODS

We distributed a survey to 700 voice teachers (102 respondents) of various levels from private to university and across age range of students. The surveys contained questions about the role of observation in the teacher's training. We ran descriptive analysis and examined whether the proportion of participants with ≥10 observation and mentorship hours was different for classical versus the other musical genres.

RESULTS

The number of respondents actively observing and being observed during their training was low. Most observations occurred within the classical and musical theater singing styles. Mentored critical observations of students were lower across genres than student observations, with the majority of respondents (67-92%) reporting no hours in genres other than classical. For all genres except classical, there was a larger percentage of respondents who reported teaching the genre than who reported receiving pedagogical training in the genre. Reported clinical voice observation hours were low (28.4% with ≥10 hours), and few respondents had >0 hours of operating room observation experience (11.8%).

CONCLUSIONS

There is wide disparity across genres in the number of hours of observation and critical mentoring, and voice teachers' genre of instruction does not frequently match with the genre of pedagogical instruction they have received. More research is needed to determine the significance of this mismatch and whether increased hours of observation and mentoring would benefit voice instruction.

Initial Experience With Low-Dose Methotrexate as an Adjuvant Treatment for Rapidly Recurrent Nonvasculitic Laryngotracheal Stenosis

Importance

Adult laryngotracheal stenosis (LTS) is typically managed surgically, but some patients fail treatment because of rapid restenosis or granulation tissue formation. The need for frequent surgery or tracheostomy reduces the quality of life in these patients and poses a significant challenge for the treating physician. New adjuvant treatments are required to reduce the surgical burden of this condition.

Objective

To examine whether patients with rapidly recurrent nonvasculitic LTS who fail surgical management of their stenosis (ie, requiring dilation more frequently than every 6 months) experience longer intervals between surgical procedures when receiving adjuvant treatment with low-dose methotrexate.

Design, Setting, and Participants

This study was a retrospective case series study of patients treated with methotrexate from January 2014 to January 2016 at a tertiary academic medical center. Participants were 10 patients with LTS without any diagnosis of vasculitis or granulomatous disease who underwent low-dose methotrexate therapy.

Interventions

Once-weekly treatment with oral methotrexate, 15 or 20 mg.

Main Outcomes and Measures

The mean number of days between operations before and after starting methotrexate therapy was compared. Clinical courses and adverse effects of each patient were also reviewed.

Results

Among 10 patients, the mean (SD) age at the outset of study inclusion was 52 (19) years; 8 were female and 2 were male. All 10 patients experienced some clinical improvement. Three patients who were previously tracheostomy dependent were able to be decannulated. Two other patients who were tracheostomy dependent and had failed endoscopic management of their granulation tissue had complete resolution. In 6 patients who underwent at least 1 surgical procedure before and after the initiation of methotrexate treatment, the mean (SD) interval between operations increased from 61 (35) days (95% CI, 26-96 days) before starting methotrexate therapy to 312 (137) days (95% CI, 175-449 days) after starting methotrexate therapy, for an absolute difference of 251 (58) days (95% CI, 193-309 days). The median number of days between surgical procedures was 44 days before starting methotrexate therapy and 289 days after starting methotrexate therapy. Adverse effects observed included mild hair thinning and onychomycosis in 2 patients and herpes zoster infection in 1 patient.

Conclusions and Relevance

Low-dose methotrexate appears to be an effective adjunct to surgery in select patients with LTS that is resistant to surgical management and leads to a substantial increase in the number of days between surgical procedures. The patient and clinician must be aware of the adverse effects of methotrexate therapy and balance these factors against the risk of poorly controlled airway stenosis. Randomized, placebo-controlled, double-blind trials are needed to examine whether the clinical efficacy in this series of patients translates to a larger population.

Open airway reconstruction in adults: Outcomes and prognostic factors

PURPOSE

The purpose was to assess the success of open tracheal resection and re-anastomosis for non-malignant tracheal stenosis in adults. Successful operations were defined as T-tube or tracheostomy-free status by 6months post-operatively.

MATERIALS AND METHODS

Retrospective chart review was performed and data were recorded in a de-identified manner. The primary outcome was T-tube or tracheostomy-free status by 6months following tracheal resection. Clinical and demographic characteristics were evaluated as potential prognostic variables.

RESULTS

Thirty-two patients met inclusion criteria, with a median age of 46. Seven patients underwent tracheal resection with primary closure, without stenting. Successful tracheal resection was defined as tracheostomy or T-tube free by 6months post-operation, and this was possible in 21 patients (66%). Eighty-two percent of patients with cricoid cartilage-sparing tracheal resection had a successful outcome, versus 30% of patients who underwent cricoid cartilage resection (HR 5.02, 95% CI 1.46-17.3; p=0.011). Patients with a history of tracheostomy-dependence were four times more likely to remain tube-dependent at 6months (HR 4.15, 95% CI 1.56-10.86; p=0.004).

CONCLUSIONS

Tracheal stenosis remains a very difficult problem to treat. In our series, we confirm that patients with cricoid involvement or with a history of tracheostomy were more likely to be tube dependent at 6-months post-operation.

Type I Thyroplasty in Previously Irradiated Patients

Objectives

(1) Review and report our experience performing medialization thyroplasty (MT) in previously irradiated patients and (2) compare complications and voice outcomes in 2 cohorts (irradiated vs nonradiated) to evaluate safety and efficacy.

Study Design

Case series with chart review.

Setting

Academic medical center.

Subjects

All patients (44 total) who underwent MT from 2011 to 2015.

Methods

Demographic data, complications, and acoustic and subjective voice outcome parameters were collected. The complication rates and voice outcome results were compared between 2 cohorts: patients with a history of radiation to the neck versus those with no radiation history.

Results

There were 7 previously irradiated patients and 37 nonradiated patients, with median follow-up of 314 and 538 days, respectively. One complication was noted in each group, and this complication rate was not significantly different ( P = .26). Both cohorts demonstrated significant postoperative improvement in subjective voice assessment ( P = .04, P < .0001) as well as maximum phonation time ( P = .02, .001) when compared with preoperative data.

Conclusions

Our study suggests that MT can be safely and effectively performed in irradiated patients. We found no statistically significant difference in the safety of performing MT in irradiated versus nonradiated patients, and there was significant improvement in subjective voice parameters and maximum phonation time in both groups. A larger prospective study is required to statistically determine whether the significant improvements in objective parameters seen in the nonradiated group are present in irradiated patients as well.

The economic impact of vocal attrition in public school teachers in Miami-Dade County

OBJECTIVES/HYPOTHESIS

Teachers are a known at-risk population for voice disorders. The prevalence and risk factors for voice disorders have been well studied in this population, but little is known about the associated economic cost. The purpose of this study is to assess the economic impact of voice dysfunction in teachers and understand the difference between the cost of absenteeism and presenteeism as a direct result of voice dysfunction.

STUDY DESIGN

Cross-sectional analysis via self-administered online questionnaire.

METHODS

A total of 14,256 public school teachers from Miami-Dade County, Florida, were asked to participate. Questions were formatted based on the previously validated Work Productivity and Activity Impairment: Specific Health Problem questionnaire adapted for hoarseness and voice disorders. Additional demographic questions were included in the questionnaire.

RESULTS

A total of 961 questionnaire responses were received. The demographic characteristics of respondents closely matched known statistics for public school teachers in Miami-Dade County. Economic calculations were performed for each questionnaire respondent and summed for all respondents to avoid bias. Per week, absenteeism-related costs were $25,000, whereas presenteeism-related costs were approximately $300,000. These figures were used to extrapolate annual cost. Per year, absenteeism-related costs were $1 million, whereas presenteeism-related costs were approximately $12 million.

CONCLUSION

The economic impact of voice dysfunction on the teaching profession is enormous. With the above calculations only including lost wages and decreased productivity, the actual figures may in fact be larger (cost of substitute teachers, impact on nonwork activities, etc.). Research investigating preventative measures for voice dysfunction in teachers is necessary to reduce this costly issue.

LEVEL OF EVIDENCE

2C. Laryngoscope, 126:665-671, 2016.

Trends in Utilization of Vocal Fold Injection Procedures

Office-based vocal fold injections have become increasingly popular over the past 15 years. Examination of trends in procedure coding for vocal fold injections in the United States from 2000 to 2012 was undertaken to see if they reflect this shift. The US Part B Medicare claims database was queried from 2000 through 2012 for multiple Current Procedural Terminology codes. Over the period studied, the number of nonoperative laryngoscopic injections (31513, 31570) and operative medialization laryngoplasties (31588) remained constant. Operative vocal fold injection (31571) demonstrated marked linear growth over the 12-year study period, from 744 procedures in 2000 to 4788 in 2012—an increase >640%. The dramatic increased incidence in the use of code 31571 reflects an increasing share of vocal fold injections being performed in the operating room and not in an office setting, running counter to the prevailing trend toward awake, office-based injection procedures.

Lipoma and liposarcoma of the larynx: case reports and literature review

OBJECTIVE

Two cases of laryngeal lipomatous tumors are presented. Their diagnoses and management are discussed and contrasted.

METHODS

Case report and literature review.

RESULTS

Patient 1 is a 58 year old male presenting with five years of progressive shortness of breath, dysphagia, and globus sensation. Clinical exam and imaging study showed a 3.5 cm hypodense laryngeal mass, and he underwent transoral robotic-assisted surgery for complete excision. Final pathology revealed a well-differentiated liposarcoma. Patient 2 is a 79 year old female presenting with one year of non-progressive hoarseness and globus sensation. Clinical examination and imaging study revealed a 1.8 cm hypodense laryngeal mass. Transoral endoscopic complete excision of the submucosal mass was performed. Final pathology revealed benign spindle-cell lipoma.

CONCLUSION

Liposarcoma and lipoma may present with similar symptomatology, clinical, and imaging findings. Pathology evaluation is of utmost importance for definitive diagnosis. Therefore, diagnosis and treatment of laryngeal lipomatous lesions are best accomplished with complete excision of the mass.

A Survey of Equipment in the Singing Voice Studio and Its Perceived Effectiveness by Vocologists and Student Singers

OBJECTIVES

Speech-language pathologists have long used technology for the clinical measurement of the speaking voice, but present research shows that vocal pedagogues and voice students are becoming more accepting of technology in the studio. As a result, the equipment and technology used in singing voice studios by speech-language pathologists and vocal pedagogues are changing. Although guides exist regarding equipment and technology necessary for developing a voice laboratory and private voice studio, there are no data documenting the current implementation of these items and their perceived effectiveness. This study seeks to document current trends in equipment used in voice laboratories and studios.

METHODS

Two separate surveys were distributed to 60 vocologists and approximately 300 student singers representative of the general singing student population. The surveys contained questions about the inventory of items found in voice studios and perceived effectiveness of these items. Data were analyzed using descriptive analyses and statistical analyses when applicable.

RESULTS/CONCLUSIONS

Twenty-six of 60 potential vocologists responded, and 66 student singers responded. The vocologists reported highly uniform inventories and ratings of studio items. There were wide-ranging differences between the inventories reported by the vocologist and student singer groups. Statistically significant differences between ratings of effectiveness of studio items were found for 11 of the 17 items. In all significant cases, vocologists rated usefulness to be higher than student singers. Although the order of rankings of vocologists and student singers was similar, a much higher percentage of vocologists report the items as being efficient and effective than students. The historically typical studio items, including the keyboard and mirror, were ranked as most effective by both vocologists and student singers.

Familial congenital bilateral vocal fold paralysis: a novel gene translocation

OBJECTIVES

True vocal fold (TVF) paralysis is a common cause of neonatal stridor and airway obstruction, though bilateral TVF paralysis is seen less frequently. Rare cases of familial congenital TVF paralysis have been described with implied genetic origin, but few genetic abnormalities have been discovered to date. The purpose of this study is to describe a novel chromosomal translocation responsible for congenital bilateral TVF immobility.

METHODS

The charts of three patients were retrospectively reviewed: a 35 year-old woman and her two children. The mother had bilateral TVF paralysis at birth requiring tracheotomy. Her oldest child had a similar presentation at birth and also required tracheotomy, while the younger child had laryngomalacia without TVF paralysis. Standard karyotype analysis was done using samples from all three patients and the parents of the mother, to assess whether a chromosomal abnormality was responsible.

RESULTS

Karyotype analysis revealed the same balanced translocation between chromosomes 5 and 14, t(5;14) (p15.3, q11.2) in the mother and her two daughters. No other genetic abnormalities were identified. Neither maternal grandparent had the translocation, which appeared to be a spontaneous mutation in the mother with autosomal dominant inheritance and variable penetrance.

CONCLUSIONS

A novel chromosomal translocation was identified that appears to be responsible for familial congenital bilateral TVF paralysis. While there are other reports of genetic abnormalities responsible for this condition, we believe this is the first describing this particular translocation.

Trends in Utilization of Vocal Fold Injection Procedures

Objectives:

Office-based laryngeal procedures, vocal fold injections in particular, have become increasingly popular over the past 15 years. The purpose of this study was to examine trends in the use of different vocal fold injection techniques in the United States from 2000 to 2012 and see if they reflect this shift.

Methods:

The United States Part B Medicare claims database was queried from the years 2000 through 2012. The Current Procedural Terminology codes for indirect laryngoscopy with injection (31513), direct laryngoscopy with injection (31570), and direct laryngoscopy with injection, aided by telescope or operating microscope (31571) were used. For comparison, data for medialization laryngoplasty (31588) were also examined. The volume of procedures performed was tabulated for each code by year.

Results:

Over the time period studied, the number of non-operative laryngoscopic injections (31513, 31570) and operative medialization laryngoplasties remained constant. Operative vocal fold injection (31571) demonstrated significant, linear growth over the 12-year study period, from 744 procedures in 2000 to 4788 in 2012, an increase of over 640%.

Conclusions:

The dramatic increased incidence in the use of code 31571 reflects an increasing share of vocal fold injections being performed in the operating room and not in an office setting, which runs counter to the prevailing trend within laryngology of awake, office-based injection procedures. This may indicate that these procedures have become more popular over time within the otolaryngology community and are being performed increasingly by providers more comfortable with the controlled operating room setting.

The cosmetic Z-plasty: restoring and refining an old technique for neck rejuvenation

Direct excision of the "turkey neck" skin fold with Z-plasty closure was introduced in the 1970s, but it has fallen out of favor in an era in which much emphasis is placed on minimizing visible scars. Although the newer techniques may effectively improve the aesthetic contour of the neck without leaving visible scars, they may not be optimal for selected patients who want a quick, "no-hassle" correction of their neck contour without changing the overall appearance of their face. We conducted a retrospective study of 50 patients--47 men and 3 women, aged 59 to 80 years (mean: 70)--who had undergone cosmetic Z-plasty performed by the senior author (A.N.L.) over a 9-year period. These patients either did not want or were not candidates for a face-lift or other procedure. Patients' charts were examined for demographic data, complications, and overall satisfaction with the procedure. In 46 of the 50 cases, the initial cosmetic result was acceptable to both the patient and the surgeon. The only complications were recurrent or residual areas of skin redundancy or dissatisfaction with the scar, but these were easily corrected with a second procedure using local anesthesia in the office setting. We conclude that cosmetic Z-plasty is a safe and effective means of correcting turkey neck deformity in patients who desire a procedure with a short operating time, a brief recovery period, a low complication rate, and a minimal effect on the overall appearance of their face. Although cosmetic Z-plasty is frequently considered to be antiquated, we believe refined versions of this procedure can still be of value to the plastic surgeon. In addition to describing our study results, we also describe in detail our surgical technique, including several contemporary refinements.

Considerations for Initial Dosing of Botulinum Toxin in Treatment of Adductor Spasmodic Dysphonia

Objectives

To assess the effect on voice improvement and duration of breathiness based on initial dose of onabotulinum toxin A (BTX-A) in the management of adductor spasmodic dysphonia (SD) and to compare voice outcomes for initial bilaterally injected doses of 1.25 units (group A) vs 2.5 units (group B) of BTX-A.

Study Design

Case series with chart review of patients with adductor SD treated at a tertiary care facility from 1990 to 2011.

Setting

Academic subspecialty laryngology practice.

Methods

Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between groups A and B using the Student t test and χ2 analysis.

Results

Of 478 patients identified, 305 (223 in group A, 82 in group B) patients met inclusion criteria. The average age was 56.2 years in group A and 57.4 years in group B ( P = .5). The female to male ratio was 2.91 for group A vs 3.56 for group B ( P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients vs 94% of group B ( P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 days for group B ( P = .54). The average duration of breathiness was 10.88 days for group A vs 15.42 days for group B ( P = .02).

Conclusion

Patients injected with 1.25 units bilaterally had a statistically significant shorter duration of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial BTX-A dose be used with subsequent titration to achieve improved voice outcomes.

Initial Dosing of Botox A in Adductor Spasmodic Dysphonia

Objective: 1) Assess effect on voice improvement and duration of breathiness based on initial dose of BotoxA in management of adductor spasmodic dysphonia. 2) Compare voice outcomes for initial bilaterally injected doses of 1.25 units Botox A (Group A) versus 2.5 units (Group B).

Method: A retrospective chart review was undertaken of all adductor spasmodic dysphonia patients treated at a tertiary care facility between 1990 and 2011. Demographic data (age and sex), voice rating, duration of voice improvement, and breathiness were evaluated and compared between Groups A and B using Student’s t test and chi-square analysis.

Results: Of 478 patients identified, 305 (group A: 223; group B: 82) patients met inclusion criteria. The average age of group A was 56.2 years and group B was 57.4 years ( P = .5). The female/male ratio was 2.91 for group A versus 3.56 for group B ( P = .61). Good voice outcomes (grade 3 or 4) were reported by 91% of group A patients versus 94% of group B ( P = .75). The average duration of voice improvement was 99.7 days for group A and 108.3 for group B ( P = .54). The average duration of breathiness was 10.88 days for group A versus 15.42 for group B ( P = .02).

Conclusion: Patients injected with 1.25 units bilaterally had a statistically significant shorter duration period of breathiness without a statistically significant difference in clinical effectiveness or voice outcome. It is therefore recommended that a relatively low initial Botox dose be used with subsequent titration to achieve improved voice outcomes.

Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy

OBJECTIVES

To review our experience with intracapsular tonsillectomy using powered instrumentation (PIT) in the management of tonsillar hypertrophy.

DESIGN

Retrospective database review of pediatric patients undergoing PIT.

METHODS

The medical records of 636 patients under 11 years of age who underwent PIT performed by the senior author (RFW), predominantly for obstructive sleep disturbance, were reviewed. Data were subsequently analyzed from 559 of these patients for clinical evidence of tonsillar regrowth, post-operative tonsillar hemorrhage, and post-operative dehydration due to pain. Specific information for possible correlation of age at the time of surgery and any increased rate of regrowth was primarily examined.

RESULTS

There were a total of 33 patients who had clinical evidence of regrowth. Children less than 5 years of age had 5 times the incidence of regrowth (p<0.001). Out of the group that exhibited regrowth, 5 patients exhibited evidence of recurrent upper airway obstruction and underwent a complete tonsillectomy. The age of this complete tonsillectomy group ranged from 1.1 to 2.7 years. Out of all patients undergoing PIT, there was 1 incident of delayed post-operative dehydration due to emesis but not due to pain. There were 2 incidents of delayed post-operative tonsillar bleeds. All three complications were self-limited and did not require re-hospitalization.

CONCLUSIONS

PIT is a safe procedure with a small risk of tonsillar regrowth being age related. The incidence of postoperative complications following PIT is relatively low (0.54%).

Laryngoscopy of vocal fold paralysis: evaluation of consistency of clinical findings

OBJECTIVES/HYPOTHESIS

Laryngoscopy is the principal tool for the clinical assessment of vocal fold paralysis (VFP). Yet no consistent, unified vocabulary to describe laryngoscopic findings exists, compromising the evaluation and comparison of cases, outcomes, and treatment. The goal of this investigation was to evaluate laryngoscopic findings in VFP for inter- and intra-rater consistency.

STUDY DESIGN

Prospective survey-based study.

METHODS

Half-minute excerpts from stroboscopic exams of 22 patients with VFP were mailed to 22 fellowship-trained laryngologists. Each reviewer was sent exams in randomized order, with three random repeats included to determine intra-rater reliability. Twelve laryngoscopic criteria were assessed and recorded on preprinted sheets. Eleven criteria were binary in nature (yes/no); glottic insufficiency was rated on a four-point scale (none/mild/moderate/severe). Raters were blinded to clinical history, each other's ratings, and to their own previous ratings. Inter-rater agreement was calculated by Fleiss' kappa.

RESULTS

Twenty reviewers (91%) replied. Intra-rater reliability by reviewer ranged from 66% to 100% and by laryngoscopic criterion from 77% to 100%. Of the laryngoscopic criteria used, glottic insufficiency (kappa = 0.55), vocal fold bowing (kappa = 0.49), and salivary pooling (kappa = 0.45) showed moderate agreement between reviewers. Arytenoid stability (kappa = 0.1), arytenoid position (kappa = 0.12), and vocal fold height mismatch (kappa = 0.12) showed poor agreement. The remainder showed slight to fair agreement.

CONCLUSIONS

Inter-rater agreement on commonly used laryngoscopic criteria is generally fair to poor. Glottic insufficiency, vocal fold bowing, and salivary pooling demonstrated the most agreement among responding laryngologists. These findings suggest a need for a standardized descriptive scheme for laryngoscopic findings in VFP.

Sialodochostomy as treatment for imperforate submandibular duct: a systematic literature review and report of two cases

OBJECTIVE

To better understand the diagnosis, treatments, and outcomes of congenitally imperforate salivary ducts.

METHODS

A systematic literature review was performed using the following terms: imperforate submandibular duct, imperforate Wharton's duct, congenital atresia submandibular duct, congenital atresia sublingual duct, and congenital ranula. Only papers focusing on congenital floor of mouth cysts arising from imperforate salivary ducts were included. Two additional patients from our own experience are also discussed.

RESULTS

Seventeen papers published since 1950 met inclusion criteria. A total of 26 patients underwent therapy ranging from mere observation to complete excision of the cyst with the sublingual gland. Both of our 2 additional patients both underwent simple sialodochostomy (excision of the imperforate sublingual caruncle) with cyst decompression. For all 28 patients, there have been no reported recurrences, with mean follow-up of 24.8 months and median follow-up of 14.8 months.

CONCLUSIONS

Congenital floor of mouth cysts arising from imperforate salivary ducts are rare, but they may mimic the appearance of a ranula. Unlike ranulas, these cysts may be safely and effectively cured by simple sialodochostomy. To date, 26 other cases have been described in the literature, and nearly all have been successfully treated with simple incision or marsupialization without recurrence. Care should be taken to exclude ranula as a diagnosis, as incomplete excision may likely result in recurrence.

Reduction in surgical innovation, 1988 to 2006

OBJECTIVE

We hypothesize that increasing regulation of human subject research has reduced the number of published reports of surgical innovation in otolaryngology.

STUDY DESIGN

A systematic review of a predetermined subset of otolaryngology literature.

METHODS

We randomly selected half of the articles published in 1988 and 2006 in three prominent journals. After identifying information was concealed, abstracts were classified independently by two authors into three groups: innovation, modification, or neither. Disagreements were resolved by a third author who read the entire article. Proportions were compared with chi(2) analysis.

RESULTS

The proportion of articles classified as innovation or modification decreased significantly from 67 of 367 (18.3%) in 1988 to 59 of 548 (10.8%) in 2006 (P = 0.001). The elimination of radiology and pathology quiz cases yielded similar results: 11.1 percent vs 18.9 percent, P = 0.001. Innovation or modification in animal model research also decreased (0.9% vs 3.8%, P = 0.003). Overall, only 4 articles were actually classified as true innovation.

CONCLUSIONS

The frequency of true innovation was low in both years, but articles that described surgical modifications decreased significantly over this 18-year period. One reason may be increased administrative barriers for clinical research approval. Although our analysis cannot determine cause and effect, it is an important finding that deserves further study.

Is Surgical Innovation Reduced with More Strict Regulations?

Objective

With ever-increasing regulatory requirements on human subject research, we postulated that there would be a corresponding decline in the number of published reports of surgical innovation in the otolaryngology literature.

Methods

We defined innovations as new procedures, techniques, or approaches that should require IRB approval in 2007, and modifications as non-substantive changes in existing procedures or techniques that should not require IRB approval. We reviewed every abstract from 4 months of the years 1988 and 2006, from the journals Laryngoscope, Oto-HNS, and Archives. After identifying information was concealed, abstracts were reviewed and classified independently by two authors, for innovation, modification, or neither. All disagreements were judged by a third author, who reviewed the entire article. Proportions were compared using chi-square analysis.

Results

There were 367 publications reviewed from 1988, and 548 from 2006. The proportion of articles representing either innovation or modification was significantly lower in 2006 than 1988: 59/548 (10.8%) vs. 67/367 (18.3%), p<0.001. Eliminating radiology and pathology quiz cases yielded similar results: 11.1% vs. 18.9%, p<0.001. Very few articles (4 total) were classified as innovation.

Conclusions

The proportion of published studies describing surgical innovations and modifications was significantly lower in 2006 than in 1988. One cause of this decrease in innovation could be increased barriers for research approval in the current era. However, other explanations are plausible, such as increased publication of other study types, e.g., basic research. While our analysis does not prove cause and effect, it is an important finding that deserves further study.

Imaging of acute mesenteric ischemia using multidetector CT and CT angiography in a porcine model

Acute mesenteric ischemia, a frequently lethal disease, requires prompt diagnosis and intervention for favorable clinical outcomes. This goal remains elusive due, in part, to lack of a noninvasive and accurate imaging study. Traditional angiography is the diagnostic gold standard but is invasive and costly. Computed tomography (CT) is readily available and noninvasive but has shown variable success in diagnosing this disease. The faster scanning time of multidetector row CT (M.D.CT) greatly facilitates the use of CT angiography (CTA) in the clinical setting. We sought to determine whether M.D.CT-CTA could accurately demonstrate vascular anatomy and capture the earliest stages of mesenteric ischemia in a porcine model. Pigs underwent embolization of branches of the superior mesenteric artery, then imaging by M.D.CT-CTA with three-dimensional reconstruction protocols. After scanning, diseased bowel segments were surgically resected and pathologically examined. Multidetector row CT and CT angiography reliably defined normal and occluded mesenteric vessels in the pig. It detected early changes of ischemia including poor arterial enhancement and venous dilatation, which were seen in all ischemic animals. The radiographic findings--compared with pathologic diagnoses-- predicted ischemia, with a positive predictive value of 92%. These results indicate that M.D.CT-CTA holds great promise for the early detection necessary for successful treatment of acute mesenteric ischemia.