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Transgender individuals strive to match their voice and gender identity. An increased glottal gap is often noted on stroboscopy without a clear etiology. We hypothesize this gap can be quantified and results from hormone replacement therapy impacting laryngeal tissues.Videostroboscopy exams were retrospectively collected for transgender patients from a tertiary care laryngology practice over two years. Data included hormone duration/type and voice therapy duration. Modal pitch videostroboscopy frame counts determined the open quotient in consecutive vocal fold cycles. Glottal opening was measured using the widest still frame gap during stroboscopy with fully adducted arytenoids.Sixteen transgender patients, along with male and female controls, were included, with 15 patients on hormone therapy (mean = 18 months). Voice therapy, employed in 9/16 patients, ranged from 0 to 23 months (mean = 10.67). One-way ANOVA testing revealed a difference between the open quotient in transgender individuals, males, and females.Tukey's post hoc test identified transgender patients as different from both male (P0.001) and female (P = 0.037) controls. Length of hormone therapy did not correlate to glottal area measurement or open quotient. Conversely, voice therapy length correlated to increased glottal area (Kendall's Tau = 0.03). Mean phonation time, VHI-10, and mean pitch did not correlate to measured glottal area on stroboscopy.The increased glottal gap noted in many transgender patients, quantified via the open quotient, differs from male and female controls. Results suggest these findings may correlate to duration of voice therapy.

Summary Objective Military drill instructors have extreme vocal demands that place them at risk for phonotrauma. Characterization of laryngeal pathology and vibratory characteristics among drill instructors presenting for specialized voice care is lacking. Methods A retrospective review in a specialized voice clinic over a two-year period was conducted. Patients identified as current drill instructors between the ages of 28-43 with a diagnosis of dysphonia were included. Laryngeal pathology was diagnosed by a fellowship trained laryngologist and vibratory characteristics were evaluated utilizing the Voice-Vibratory Assessment with Laryngeal Imaging (VALI) rating form. All patients were also evaluated by a speech-language pathologist. Patient reported outcome measures were collected along with perceptual voice evaluations utilizing the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). Results Twelve current drill instructors were identified, and all had phonotraumatic lesions. Lesions were categorized as vocal fold hemorrhage (8%), ectasia (25%), unilateral epithelial thickening (33.3%), bilateral epithelial thickening (58.3%), ventricular cyst (8%), polyp (25%), and sulcus vocalis (25%). Vibratory abnormalities were assessed with the VALI rating scale and correlated to CAPE-V perceptual ratings with 83% having reduced mucosal wave, 75% reduced amplitude of lateral excursion, 50% aperiodic vibrations, 50% asymmetric or chasing wave, 58% glottal insufficiency, 100% supraglottic hyperfunction, and an average CAPE-V overall severity of 50% with severe perceptual dysphonia. The average Voice Handicap Index (VHI-10) and Reflux Symptom Index (RSI) score was 15.5 and 14.7, respectively. Conclusion Phonotraumatic lesions were universally present in drill instructors complaining of hoarseness, suggesting early referral, and intervention may be warranted in this population. Level of Evidence: 4

Summary Objectives/Hypothesis To determine the prevalence of otologic complaints in subjects with dysphonia and traumatic brain injury (TBI) in a sample population of the US Army. Study Design Cross-sectional study. Methods A total of 292 subjects were identified with a new diagnosis of voice disorder during a 3.5-year period at three large military medical centers. Of them, 70 subjects were also identified with TBI and had no history of dysphonia before this time period. In those with voice disorders and TBI, documentation of hearing complaints, hearing loss, tinnitus, or vertigo was recorded. Time to visit an otolaryngologist and audiologist were also recorded. Results A total of 70 soldiers were identified with a diagnosis of a voice disorder and TBI. Of these soldiers, 83% had at least one otologic complaint and 50% had more than one. Approximately 60%, 39%, and 44% of the subjects reported tinnitus, hearing loss, or vertigo, respectively. A total of 62% of the subjects with otologic complaints, TBI, and dysphonia were seen by an otolaryngologist. Time until an otolaryngologist evaluated these soldiers varied widely, with an average of 17 months and standard deviation of 12.5 months. Conclusions Otologic manifestations are common in soldiers with dysphonia and TBI. Careful consideration of communication impairment from otologic dysfunction in those with speech disorders after TBI is warranted.

Summary Objectives This study aims (1) to present a case of asystole during direct laryngoscopy in an otherwise healthy patient at an outpatient surgery center and (2) to review literature on cardiac complications, specifically asystole and bradycardia, during direct laryngoscopy. Methods A 67-year-old woman with no prior cardiac history underwent induction with succinylcholine and remifentanil for direct laryngoscopy and vocal fold augmentation. During suspension laryngoscopy, the patient became asystolic, and advanced care life support measures were started. The patient regained a cardiac rhythm after chest compressions and epinephrine and was transferred to a tertiary care hospital for further treatment. She remained intubated overnight, requiring pressors, and regained normal cardiac function over the next few days. Results A structured literature review uncovered few reports of asystole during suspension laryngoscopy. Although bradycardia is common during suspension laryngoscopy, likely secondary to stimulation of afferent visceral sensory parasympathetic fibers of the vagus nerve, asystole is rare. Conclusions Cardiac complications are possible in otolaryngologic surgery, especially with activation of the oculocardiac or trigeminocardiac reflexes. Asystole during direct laryngoscopy, although rare, is not always predictable from medicine or cardiac risk indices. Awareness, rapid recognition, and early implementation of advanced care life support are crucial to avoid further complications.