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The objective of this review was to discuss the emerging role of botulinum toxin in the treatment of temporomandibular disorders (TMD), to review the current literature, recent clinical trials, as well as preliminary data from our own clinical study, and to formulate an algorithm for the work-up and treatment of TMD. [ABSTRACT FROM AUTHOR]

Objective: Chondrolaryngoplasty, also known as thyroid cartilage reduction, alleviates gender dysphoria by reducing the thyroid cartilage to conform to a patient's gender identity. Reduction of the thyroid cartilage prominence ("Adam's apple") is often performed with a scalpel, but in cases of cartilage calcification, rongeurs or drills are utilized. This study aims to characterize the success rate with scalpel-only excision and relate this to patient age and operative time., Methods: Billing records were screened for chondrolaryngoplasties performed between 2020 and 2023 by a single surgeon. Patient demographics, operative notes, and operation duration were recorded. Type of instrumentation was categorized as scalpel only, rongeur, or drill. All cases began with attempted scalpel excision of cartilage and were transitioned to rongeur or drill if there was calcification that prevented sharp excision. Descriptive statistics were used to describe patient and surgical factors., Results: 52 individuals underwent chondrolaryngoplasty: 30 cases (57.7%) had soft cartilage requiring only a blade, 22 (42.3%) required use of either drill or rongeur. The average age of these groups was 25.7 (SE 1.8) and 41.3 years (SE 2.2), respectively; this difference was statistically significant (p < 0.0001). Cases requiring a drill or rongeur lasted on average 78.5 min (SE 2.3), whereas those using only a blade were shorter at 66.8 min (SE 2.7); this difference was significant (p = 0.0017)., Conclusion: Cartilage calcification should be expected in a significant number of chondrolaryngoplasties, and surgeons should be prepared for this scenario. The need for alternative instrumentation is higher in older individuals and may extend procedural time., Level of Evidence: 4 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

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, 134:3713-3718, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The impact of disease states can be measured using health state utilities, which are values that reflect economic preferences for health outcomes. Utilities for dysphonia have not been studied using direct methods. The objective of this project was to establish the baseline health utilities of mild and severe dysphonia from a societal perspective., Study Design: Direct utility elicitation survey., Methods: Four health states (monocular blindness, binocular blindness, mild dysphonia, and severe dysphonia) were evaluated by a convenience sample of adults recruited from the general public with three computer-aided estimation techniques (visual analog scale [VAS], standard gamble [SG], and time trade-off [TTO]). Standardized descriptions and voice recordings from multiple dysphonic patients were employed. Perfect health was defined as a utility of 1, with death 0. Analysis of variance with post hoc pairwise comparison was used to calculate significant differences between health states., Results: Three hundred participants were surveyed, and 225 (75.0%) responses met quality thresholds. Severe dysphonia (VAS = 48.3, SG = 0.810, TTO = 0.798) was valued significantly worse than monocular blindness (VAS = 56.2, SG = 0.834, TTO = 0.839) on the VAS (P < .001) and equivalent on SG and TTO; it was preferred over binocular blindness (VAS = 25.7, SG = 0.631, TTO = 0.622; P < .001) with all methods. Mild dysphonia evaluated favorably with all methods to the other health states (VAS = 78.5, SG = 0.902, TTO = 0.908; P < .001)., Conclusions: Voice disorders may have a measurable impact on utility, with severe dysphonia valued equivalently to monocular blindness. Mild dysphonia has a utility decrement from perfect health. These estimates are critical for quality-of-life assessment and could be used to assess cost-effectiveness of treatments for voice disorders., Level of Evidence: NA Laryngoscope, 130:1256-1262, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To systematically characterize and describe voice and swallowing manifestations in patients with X-linked dystonia parkinsonism (XDP) and correlate with quality-of-life (QOL) measures., Methods: Thirty-four patients with XDP with communication and swallowing difficulties underwent neurological examination, head and neck examination, nasopharyngoscopy, QOL surveys (Swallowing Quality of Life questionnaire [SWAL-QOL] and Voice Handicap Index [VHI]), and functional endoscopic evaluation of swallowing (FEES) to assess the extent of dysfunction., Results: All patients showed high rates of lingual, oromandibular, and laryngeal dysfunction, as well as severe QOL changes in swallowing and communication ability. The most common head and neck manifestations of dystonic symptoms were difficulty coordinating the mouth and tongue (79%), uncontrollable tongue thrusting (53%), and jaw opening (35%). Laryngeal symptoms including vocal strain (adductor voice breaks) or stridor (32%), as well as velopharyngeal insufficiency (20%), were also identified. Of the patients with laryngeal symptoms, 18% had respiratory dystonia. Swallowing assessments showed significant abnormalities in oral bolus control and oropharyngeal dysphagia. FEES examinations showed that 87.5% of the study group had penetration or aspiration. QOL scores showed an average VHI of 94.4 (severe dysfunction), and SWAL-QOL showed an average of 37.7 (severe dysfunction)., Conclusion: Swallowing and voice impairment in XDP is not well characterized and presents a more distinctive phenomenology than other neurological disorders, with a unique set of challenges for treatment. This is the first study to systematically evaluate laryngeal and pharyngeal dysfunction in XDP patients and correlate with QOL measures., Level of Evidence: 4 Laryngoscope, 130:171-177, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine the relationship between force metrics measured by the laryngeal force sensor (LFS) during suspension microlaryngoscopy (SML) and perioperative narcotic requirements., Study Design: Prospective observational study., Methods: Compressive tissue forces were recorded during SML using the LFS and correlated with postoperative narcotic requirements in the postanesthesia care unit (PACU) at an academic tertiary center. Patients were prospectively enrolled and had force metrics recorded throughout each procedure including maximum force, average force, suspension time, and total impulse. Narcotic administration in the intraoperative period and PACU were also recorded and converted into intravenous morphine equivalents (ME). Surgeons were blinded to the force recordings during surgery to prevent operator bias., Results: Eighty-two patients completed the study. Of these patients, the mean perioperative ME requirement was 16.96 mg (range, 0.15-79.82 mg). Univariate analysis demonstrated a positive correlation between perioperative narcotic requirements and total suspension time (P < .001) as well as total impulse (P = .007). A positive correlation was also seen with maximum force, although not significantly. On multiple linear regression, total suspension time was a significant predictive variable for perioperative narcotic use, with a marginal incremental increase of 0.273 mg of ME per minute of total suspension time (0.273 mg/min, 95% confidence interval: 0.040-0.507 mg/min, P = .022)., Conclusions: Intraoperative force metrics including total suspension time are predictive of increased perioperative narcotic requirement after SML. Total impulse during SML may also correlate with increased perioperative narcotic requirements., Level of Evidence: 2 Laryngoscope, 129:2563-2567, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Endoscopic management of bilateral vocal fold paralysis (BVFP) includes cordotomy and arytenoidectomy, and has become a well-accepted alternative to tracheostomy. However, the costs and quality-of-life benefits of endoscopic management have not been examined with formal economic analysis. This study undertakes a cost-effectiveness analysis of tracheostomy versus endoscopic management of BVFP., Study Design: Cost-effectiveness analysis., Methods: A literature review identified a range of costs and outcomes associated with surgical options for BVFP. Additional costs were derived from Medicare reimbursement data; all were adjusted to 2014 dollars. Cost-effectiveness analysis evaluated both therapeutic strategies in short-term and long-term scenarios. Probabilistic sensitivity analysis was used to assess confidence levels regarding the economic evaluation., Results: The incremental cost effectiveness ratio for endoscopic management versus tracheostomy is $31,600.06 per quality-adjusted life year (QALY), indicating that endoscopic management is the cost-effective short-term strategy at a willingness-to-pay (WTP) threshold of $50,000/QALY. The probability that endoscopic management is more cost-effective than tracheostomy at this WTP is 65.1%. Threshold analysis demonstrated that the model is sensitive to both utilities and cost in the short-term scenario. When costs of long-term care are included, tracheostomy is dominated by endoscopic management, indicating the cost-effectiveness of endoscopic management at any WTP., Conclusions: Endoscopic management of BVFP appears to be more cost-effective than tracheostomy. Though endoscopic cordotomy and arytenoidectomy require expertise and specialized equipment, this model demonstrates utility gains and long-term cost advantages to an endoscopic strategy. These findings are limited by the relative paucity of robust utility data and emphasize the need for further economic analysis in otolaryngology., Level of Evidence: NA Laryngoscope, 127:691-697, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The hypoglossal nerve (XII) has been used as a donor nerve in facial and laryngeal reinnervation. The purpose of this study was to investigate the neuromuscular changes that occur within the tongue following partial or complete transection of XII using a canine model., Study Design: Histopathological comparison of tongue denervation following two types of XII resection in a canine model., Methods: Ten adult canines underwent complete unilateral resection of XII or resection of only the medial terminal branch of the hypoglossal nerve (mXII). After 6 months of recovery, tongue specimens were analyzed histopathologically using whole cross-sections. Routine histologic sections were assessed by two neuropathologists blinded to the type of denervation. The cross-sectional area was calculated of both sides of the tongue, and the amount of myosin was quantified morphometrically using immunohistochemistry for myosin (antimyosin heavy chain, fast isotype). Statistical comparison between partial and complete denervation was performed using the Student t test., Results: Six months following XII transection, quantitative measures of the cross-sectional area of the tongue and content of myosin demonstrated severe muscle atrophy on the operated side of the tongue for both groups, compared to the nonoperated side. For partial transection involving only mXII, the degree of atrophy was less severe (P < .05)., Conclusions: This study provides new histological information demonstrating that partial resection of the hypoglossal nerve, sacrificing only the proximal medial branch of the hypoglossal nerve (mXII), results in less severe atrophy of the tongue than complete transection of the entire hypoglossal nerve., Level of Evidence: NA Laryngoscope, 126:2689-2693, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: A precise molecular schema for classifying the different cell types of the normal human vocal fold epithelium is lacking. We hypothesize that the true vocal fold epithelium has a cellular architecture and organization similar to that of other stratified squamous epithelia including the skin, cornea, oral mucosa, and esophagus. In analogy to disorders of the skin and gastrointestinal tract, a molecular definition of the normal cell types within the human vocal fold epithelium and a description of their geometric relationships should serve as a foundation for characterizing cellular changes associated with metaplasia, dysplasia, and cancer., Study Design: Qualitative study with adult human larynges., Methods: Histologic sections of normal human laryngeal tissue were analyzed for morphology (hematoxylin and eosin) and immunohistochemical protein expression profile, including cytokeratins (CK13 and CK14), cornified envelope proteins (involucrin), basal cells (NGFR/p75), and proliferation markers (Ki67)., Results: We demonstrated that three distinct cell strata with unique marker profiles are present within the stratified squamous epithelium of the true vocal fold. We used these definitions to establish that cell proliferation is restricted to certain cell types and layers within the epithelium. These distinct cell types are reproducible across five normal adult larynges., Conclusion: We have established that three layers of cells are present within the normal adult stratified squamous epithelium of the true vocal fold. Furthermore, replicating cell populations are largely restricted to the parabasal strata within the epithelium. This delineation of distinct cell populations will facilitate future studies of vocal fold regeneration and cancer., Level of Evidence: N/A., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: This study evaluated the efficacy of botulinum toxin type A injected into the interarytenoid muscle to treat recalcitrant vocal process granulomas., Study Design: Retrospective clinical review at a tertiary care center., Methods: Eight patients with vocal process granulomas refractory to a variety of prior treatments including surgical resection, proton pump inhibitor therapy, and voice therapy underwent percutaneous injection of botulinum toxin type A into the interarytenoid muscle, performed in an office setting. Doses ranged from 5 U to 25 U in one to two injections., Results: One patient demonstrated no improvement, two patients demonstrated partial resolution, and five patients demonstrated complete resolution of their granulomas. Four patients noted transient breathiness. There were no other side effects. All patients tolerated the injections without difficulty., Conclusion: Botulinum toxin injection into the interarytenoid muscle appears to be a safe and effective modality for treating recalcitrant vocal process granuloma., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: A variety of materials as well as approaches have been used to treat glottic insufficiency, but the ideal procedure has yet to be determined. The goal of this study was evaluate the safety and efficacy of cross-linked hyaluronic acid (Restylane) for office-based injection laryngoplasty for the treatment of vocal fold (VF) immobility., Study Design: Retrospective chart review., Methods: Twenty-seven patients were with diagnosed VF immobility. Twenty-five received Restylane VF injections in the office setting via percutaneous, trans-thyrohyoid injection with distal chip endoscopic guidance. Two patients received injections using suspension microlaryngoscopy under general anesthesia. Voice outcomes were followed using the Voice-Related Quality of Life Survey and the Voice Outcome Survey., Results: Four patients were lost to follow-up immediately after injection. 20 of 23 patients (87%) reported subjective improvement in voice. Analysis of subjective surveys from nine patients revealed a trend toward improvement of V-RQOL from 34 to 23 (P = 0.083) but did not reach significance. After compilation of all VOS questions, 69% of all follow-up responses noted improvement of symptoms, 24% were unchanged and 7% were worse., Conclusions: Office-based injection laryngoplasty with Restylane appears to be a safe procedure that improves vocal function in patients with glottal insufficiency due to impaired VF mobility. Further studies are required to quantify the benefits and to compare the effects with other injectable materials.