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Background: Unilateral vocal fold pseudocysts have been hypothesized to result from vocal fold paresis, but no explanation has been proposed for bilateral lesions. This study compares patients with unilateral to those with bilateral pseudocysts for insights into pathogenesis., Methods: Adults with unilateral and bilateral pseudocysts evaluated between 2018 and 2023 were retrospectively studied. Patient demographics, laryngeal stroboscopic findings, management strategies employed, and treatment outcomes were recorded. Fisher's exact and student's t-tests were performed to assess unilateral and bilateral cohorts for differences., Results: One hundred ninety-six patients (109 with bilateral and 87 with unilateral pseudocysts) were studied. The average age was 29 years (bilateral: 29 years, unilateral: 30 years; p = 0.3846). The groups differed with respect to sex (172 females: 105 bilateral, 67 unilateral; 24 males: 4 bilateral, 20 unilateral; p < 0.0001) and clinical diagnosis of paresis (bilateral: 13.8%, unilateral: 34.5%; p = 0.0010). Treatment was similar between cohorts for rates of voice therapy (bilateral: 67.0%, unilateral 63.2%; p = 0.6511) and surgery (bilateral: 12.8%, unilateral 17.2%; p = 0.4228). There were a total of six recurrences (bilateral: 2, unilateral: 4; p = 0.3898)., Conclusions: Bilateral pseudocysts occur almost exclusively in women and with a relative absence of paresis. Unilateral pseudocysts are more likely to occur in the presence of paresis and in a significantly higher proportion of men. This suggests that unilateral and bilateral disease evolve in different clinical conditions, although they may share glottic insufficiency as a predisposing factor., Level of Evidence: 3 Laryngoscope, 135:234-238, 2025., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective(s): The objective of this study is to compare treatment outcomes for vocal fold polyps (VFPs) between operating room microlaryngoscopy and office-based photoangiolysis with the potassium titanyl phosphate (KTP) laser., Methods: Prospective nonrandomized cohort study of patients with VFPs undergoing microlaryngoscopy ("OR group") or KTP laser photoangiolysis ("KTP group"). Voice outcomes (patient-reported outcome measures [Voice Handicap Index-10 (VHI-10) and Singing VHI-10 (SVHI-10)], auditory-perceptual measures [Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V)], videostroboscopic characteristics [Voice-Vibratory Assessment of Laryngeal Imaging (VALI)], and acoustic and aerodynamic measures) were performed at baseline and regular intervals after intervention., Results: Forty-four subjects (17 OR group, 27 KTP group) with VFPs were enrolled. Mean VHI-10 significantly improved from baseline to each follow-up interval in both groups, except for the 1-2-week interval in the OR group. Mean SVHI-10 improved for both groups at some intervals. Growth curve models and time-to-event analyses for patient-reported outcomes did not differ between groups. There were significant improvements in all categories of auditory-perceptual voice quality and some categories of videostroboscopic characteristics in both groups. No significant trends were identified in acoustic and aerodynamic measures. Improvements in most outcomes did not significantly differ between groups or based on polyp size. There were no major complications., Conclusions: Significant improvements in patient-reported voice outcomes measures, auditory-perceptual voice evaluation, and videostroboscopic characteristics occur following surgical treatment of vocal fold polyps with either microlaryngoscopy or office-based KTP laser. Long-term voice outcomes do not significantly differ between treatment modalities., Level of Evidence: 3 Laryngoscope, 134:S1-S20, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To examine patterns of recurrence of benign phonotraumatic vocal fold lesions over time for insights into pathophysiology., Study Design: Case series with mathematical modeling., Methods: Medical records and stroboscopic exams of adults who underwent microlaryngoscopic resection of phonotraumatic vocal fold lesions over a 13-year period were reviewed for time to recurrence after surgery. Uniform and log-normal probability distributions were fitted to the time to recurrence curves for vocal fold polyps, midfold masses, and pseudocysts. Model fits were compared using the Akaike information criterion corrected, a standard measure of the goodness of fit. Stochastic simulations were used to verify that the mechanistic hypotheses were concordant with the selected probability distributions and empiric data., Results: Of 567 patients who underwent microlaryngoscopic resection, 65 had a recurrence (16 polyps, 14 midfold masses, and 35 pseudocysts). Midfold mass and pseudocyst recurrences were predominantly seen in younger women. Polyps were best fit by a uniform distribution rather than log-normal, whereas midfold masses and pseudocysts were better fit by log-normal rather than uniform. Stochastic simulations suggest that polyps recur sporadically according to a paroxysmal-developmental model, whereas midfold mass and pseudocyst recurrences follow a force-multiplication, damage-accumulation process., Conclusions: Vocal fold polyps are acute lesions evenly distributed by age and gender that recur uniformly over time, suggesting they arise from sudden tissue reactions to phonotraumatic stress. Pseudocysts and midfold fibrous masses are chronic lesions predominantly found in young women that recur with log-normal distribution over time, suggesting gradual damage accumulation in larynges predisposed to enhanced phonotrauma., Level of Evidence: 4 Laryngoscope, 131:2523-2529, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine the natural history of vocal fold cysts, by undertaking a retrospective analysis of data from a single clinical institute., Methods: All patients diagnosed with vocal fold cysts were identified from January 2006 to June 2018. A total of 87 patients that elected not to have surgery or who had an interval of observation greater than 90 days prior to surgical intervention were further analyzed. The primary outcome was whether the cyst enlarged, reduced in size, resolved or ruptured. The secondary outcome measures were whether cyst characteristics (translucent or opaque by gross appearance and/or the presence of inflammation), voice therapy or duration of follow up (≤/> 300 days) had an impact upon natural history., Results: There were 65 females and 22 males (47 years ±17). The mean duration of follow up was 589 days (Range 21 - 4523 days). The majority of cysts did not change (70.11%). The rest enlarged (12.64%), reduced in size (13.79%), resolved (1.15%) or ruptured (1.15%). There was no statistically significant relationship between the presence or absence of clinical signs of inflammation (P = .633) or voice therapy (P = .785) on natural history. There was an equivocal relationship between gross cyst appearance and natural history (P = .054), however there was a statistically significant relationship between the duration of follow up (P = .006) and natural history., Conclusion: Most vocal fold cysts appear to remain static in size over time. About 30% change, with half of these enlarging and half shrinking. In addition to some possibility of change in size, there is a small chance of resolution or spontaneous rupture with potentially serious consequences to the voice., Level of Evidence: 4. Laryngoscope, 130:2202-2207, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Sulcus is an epithelial invagination of the membranous vocal fold. Its phonatory effects are usually attributed to fibrosis, thinning, and/or the absence of the superficial lamina propria (SLP). Surgical treatment is typically focused on reconstruction of the SLP. The purpose of this study is to assess the effects of excision without SLP reconstruction or replacement., Methods: Records of patients who underwent surgical treatment of sulcus vocalis (Ford type 3) by excision without reconstruction were reviewed for demographic and historical information. Pre- and postoperative stroboscopic examinations were evaluated blindly by fellowship-trained laryngologists using a modified Voice-Vibratory Assessment with Laryngeal Imaging assessment. A Wilcoxon signed-rank test was used to compare pre- and postoperative amplitude, mucosal wave, nonvibrating portion, regularity, erythema, and vascularity., Results: Examinations of 16 vocal folds in 13 patients (8 females:5 males; mean age = 30 years, range 13 to 48 years) were evaluated by six raters each, yielding 168 sets of observations. Statistically significant improvement was seen in amplitude (95% confidence interval [CI] 3.6,14.3), mucosal wave (95% CI 6.1, 17.9), nonvibrating portion (95% CI -19.6, -2.7), erythema (95% CI -19.9, -3.3), and vascularity (95% CI -19.0, -0.75). The parameter of regularity, although improved, did not prove to be significant., Conclusion: Excision alone appears to be an adequate and generally successful treatment for sulcus vocalis (Ford type 3). In contrast to established paradigms, restoration of the SLP does not appear to be essential to meaningful clinical improvement. Significant pathologic effects of sulcus vocalis may result from epithelial abnormalities alone., Level of Evidence: 4 Laryngoscope, 130:2208-2212, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To determine recurrence rates for benign phonotraumatic vocal fold lesions after microlaryngoscopic surgery., Study Design: Retrospective review., Methods: Records of adults who underwent microlaryngoscopy between 2006 and 2017 for vocal fold cysts, midfold masses, polyps, pseudocysts, sulcus vocalis (Ford type 3), and varices were reviewed for demographics, medical history, treatment, and lesion recurrence. Patients operated for nonphonotraumatic lesions (e.g., granuloma, keratosis/leukoplakia, papilloma) were excluded. Stroboscopic examinations were re-reviewed to confirm diagnosis and outcome., Results: Five hundred ten adults (223 male:287 female; mean age 40.3 ± 14.9 years) were included. Overall, 62 of 510 (12.2%) recurred (median time to recurrence: 70.0 months). Of these, 44 (71.0%) recurred to the same lesion type and 49 (79.0%) to the same side. Recurrence rates by initial lesion type were as follows: cysts, two of 92 (2.2%); midfold masses, four of 18 (22.2%); polyps, 25 of 235 (10.6%); pseudocysts, 30 of 145 (20.7%); sulcus vocalis, one of 18 (5.6%); and varices, zero of two (0%) (χ 2 = 28.7, degrees of freedom [df] = 5, P < 0.001). No significant difference in recurrence existed between males (21 of 223, 9.4%) and females (41 of 287, 14.3%). However, young adults (17 of 86, 19.8%) had significantly higher recurrence rates compared to middle-aged (12 of 155, 7.7%) and older adults (3/60, 5.0%) (χ 2 = 9.5, df = 3, P = 0.023). Of 62 recurrences, 18 were re-operated and four re-recurred., Conclusion: Benign phonotraumatic vocal fold lesions recur at variable rates. This variation suggests pathophysiologic differences between categories that may not be entirely explained by behavioral factors., Level of Evidence: 4 Laryngoscope, 130: 1989-1995, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Fitness instructors are at risk for phonotraumatic injury caused by a combination of occupation-driven environmental and physiologic factors., Objectives: This study analyzes phonotraumatic injury in a cohort of fitness instructors to define the spectrum of disease, inform treatment, and make educational recommendations., Study Design: Retrospective chart review., Methods: Fitness instructors seen over a 2-year period comprised the study population. Stroboscopic findings, recommended treatment modalities, and treatment outcomes, including postoperative recurrence (when applicable) were analyzed. Demographic information (gender, age), past medical history, VHI-10 scores, and concurrent relevant vocal demands (performer vs. non-performer) were reviewed. Descriptive statistics and bivariate analyses with Fisher's exact test and Wilcoxon rank sum test were used to determine statistical significance of various factors in relation to phonotraumatic injury and response to treatment. Cochran-Armitage trend tests were performed to analyze trends in injuries across fitness types in relation to increased vocal demand. Occupational concerns reported by subjects were analyzed descriptively., Results: The subject cohort consisted of 24 fitness instructors (20F; 4M) who taught a variety of fitness methods. Thirteen subjects (54.2%) were diagnosed with pseudocysts (five unilateral, eight bilateral), five (20.8%) with bilateral midfold masses, five (20.8%) with polyps (four unilateral, one bilateral), and one (4.2%) with cyst. Fourteen subjects (58.3%) were prescribed medication (oral steroids, reflux medication, and/or allergy medication). All were referred for behavioral management. Ten (41.7%) chose surgical intervention after failure to return to satisfactory function with behavioral management; Four (40%) experienced postoperative lesion recurrence. There were no statistically significant findings in relation to demographic information, past medical history, concurrent relevant vocal demands, or occupational vocal demands with choice for surgery. Trend test analysis found that lesions that are typically more likely to require surgical intervention (eg, polyps) tended to be found more frequently as vocal demand increased. The primary occupational concerns reported by subjects were related to amplification (lack of amplification, inadequate amplification/amplification problems) and scheduling (too many consecutive classes without adequate breaks)., Conclusion: Fitness instructors are subject to a variety of phonotraumatic vocal fold injuries, nearly half which require surgical treatment. One in four recurs after such intervention. Instructors could benefit greatly from education on vocal health, strategies to improve and/or reduce voice use while in the fitness environment, and to help aid in recognizing early "red flags" for phonotraumatic injury. Occupational factors that place fitness instructors at risk for phonotraumatic injury (scheduling, environment, amplification) may be improved with education directed to studio owners and managers., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To review available information regarding in-office procedures for benign vocal fold lesions (BVFL)., Methods: PubMed term search on office/awake laryngeal procedures for any of the following specific lesions: Reinke's edema (RE), polyps, nodules, varices, vocal process granuloma, and vocal fold (VF) scar., Results: In-office ablative and nonablative laser procedures have been described for BVFL, including RE, polyps, varices, and granuloma. Fiber-based lasers used include potassium titanyl phosphate, pulsed dye laser, and more recently CO 2 . In-office intralesional steroid injection (ISI) for BVFL targets the inflammatory process involved with the lesion and may induce regression of polyps, nodules, RE, and granuloma. Botulinum toxin-induced "voice rest" has been described as adjunctive treatment for refractory VF nodules or vocal process granuloma. Most in-office techniques for treating BVFL rely on induction of lesion regression rather than complete lesion removal, as in conventional operative microsurgery. When treating VF scarring, in-office procedures aim to alter the wound-healing process; ISI targets the inflammatory phase and angiolytic lasers target the proliferative phase., Conclusion: In-office procedures for BVFL apply new technology that can potentially lower risk and cost. Although numerous case series have shown the potential of these procedures, data that thoroughly compares outcomes with those of microlaryngoscopic techniques is needed. Laryngoscope, 129:2131-2138, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

A 29-year-old otherwise healthy woman presented with a lifetime history of hoarseness because it had begun to interfere with her career. Examination of both the woman and her 60-year-old father revealed bilateral sulcus vergeture, without inflammation or lesions attributable to phonotrauma. The woman responded well to injection augmentation; the father declined treatment. Combined with existing descriptions of other family groupings, all with sulcus vergeture without signs of inflammation, clinical progression, and little or no apparent behavioral component, this report further suggests that sulcus vergeture (Ford type 2) and sulcus vocalis (Ford type 3) are entirely different entities, despite architectural similarity., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Sulcus vocalis is an epithelial invagination adherent to deep tissues of the vocal fold. Traditionally, dysphonia is believed to result from attenuation or absence of lamina propria and consequent alteration of mucosal dynamics. This conception does not account for several clinical features of the lesion, most notably inflammation. The goal of this study is to elucidate the clinical nature of sulcus by re-examination of its histopathology., Study Design: Retrospective review., Methods: Clinical features, including stroboscopic examination, and hematoxylin and eosin sections of 19 lesions in 15 patients who underwent surgery were reviewed., Results: Epithelial change was found uniformly in all specimens, consisting of parakeratosis (78.9%), epithelial thickening (77.8%), dyskeratosis (63.2%), basement membrane thickening (47%), epithelial inflammation (52.6%), and retention of keratin debris (36.8%). In contrast, submucosal findings were less prevalent. Seven patients (36.8%) had essentially normal subepithelial tissues. Submucosal inflammation was present in seven (36.8%), and other submucosal changes in four of 17 (23.5%). Clinical characteristics demonstrated general improvement after surgical intervention in most cases., Conclusions: Sulcus vocalis appears to have an important component of epithelial pathology, with especially high prevalence of parakeratosis, dyskeratosis, and epithelial thickening. Clinical changes may result from prominent perilesional inflammation related to epithelial changes instead of or in addition to any alteration of the lamina propria. Surgical treatment, when necessary, should refocus on removal of pathologic epithelium as a source of inflammation independent of reconstructive considerations., Level of Evidence: 4 Laryngoscope, 126:1397-1403, 2016., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

We review contemporary concepts of the pathophysiology of neurogenic cough, and its evaluation and treatment based on scientific publications addressing neurogenic cough. Neurogenic cough is thought to be the result of sensory neuropathy, most commonly idiopathic. Because it is principally a sensory phenomenon, clinical evaluation is challenging, the diagnosis most often being made by exclusion. Identification of motor paresis, either by laryngoscopy or laryngeal electromyography, may suggest the presence of sensory neuropathy. The utility of amitriptyline and gabapentin has been demonstrated in randomized clinical trials, and retrospective series and case reports have suggested efficacy of pregabalin, baclofen, and botulinum toxin. Sensory neuropathy appears to be an important cause of chronic refractory cough, and appears amenable to treatment with a variety of pharmacologic agents., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To examine rates of lesion recurrence and functional impairment after surgical removal of vocal fold pseudocysts and determine factors predictive of recurrence., Study Design: Prospective cohort study., Methods: Patients who underwent surgical removal of pseudocyst were recruited for 12 months of postoperative follow-up. A clinical consensus cohort of 10 laryngologists blindly reviewed pre- and postoperative videostroboscopic examinations to determine presence of pseudocyst and concurrent clinical variables (reactive lesion, varix, paresis). Patients completed a postoperative Voice Handicap Index-10 (VHI-10) and follow-up questionnaire. Results were analyzed to determine lesion recurrence rates, degree of postoperative functional impairment, and predictors of recurrence., Results: Eighteen surgeries on 17 patients (15F:2M) with pseudocyst were examined. All underwent perioperative behavioral treatment. Lesion recurrence rates were 22% (per treating laryngologist) to 33% (per clinical consensus cohort). No demographic variables proved predictive of lesion recurrence. No clinical variables predicted recurrence, although there was suggestion of paresis as a contributing factor. Postoperative VHI-10 scores were within normal limits for all patients, but 12% of patients experienced recurrent functional impairment requiring further treatment., Conclusion: Most individuals (15/17) returned to normal voice use without limitation after surgery. Some individuals appear predisposed to lesion recurrence, which occurs relatively swiftly. Demographic features and clinical variables are not predictive of recurrence. The role of glottic insufficiency related to recurrence warrants further study., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective/hypothesis: Certain lesions appear to occur predominantly in one gender or in younger or older patients. We examined a large sample from a treatment-seeking population to describe gender and age associations of an array of benign vocal fold lesions., Study Design: Retrospective review., Methods: The medical records and evaluations of all adult patients presenting for care over a 5-year period were examined for demographic characteristics and lesion type. A total of 641 lesions in 602 patients were grouped into 13 broad categories, and prevalence was compared between male and female patients and three age groups., Results: Pseudocysts and bilateral midfold lesions occurred principally in young (18-39 years old) females (P < 0.0001). Reinke's edema was found in older (> 39 years old) women (P < 0.012). Polyps, contact lesions, leukoplakia (all P < 0.0001), and sulcus (P < 0.0002) were found predominantly in men., Conclusion: Certain benign mucosal lesions are strongly associated with age and especially with gender. These differences may be explained by intrinsic differences in laryngeal anatomy and phonatory physiology in these groups, including differences in phonatory frequency and air pressure, and in the ability of the membranous vocal fold to withstand phonotrauma. Such inherent differences have implications for treatment expectations and approaches., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: This study aimed to identify voice disorders commonly misidentified as reflux and sources of such misattribution., Study Design: Retrospective chart review., Methods: Twenty-six patients carrying a diagnosis of reflux alone presenting for second-opinion evaluation were identified from among 381 new patients presenting with a chief complaint of hoarseness over an 8-month period. Patients specifically referred for further workup were excluded., Results: Average duration of reflux treatment was 10.6 +/- 9.0 weeks. In no case was reflux alone the cause of hoarseness. Eleven (42%) had phonotraumatic lesions, 9 (34%) had neurologic disorders, 5 (19%) had age-related changes, and I (4%) was infectious. Twenty-two (85%) abnormalities were diagnosed by dynamic laryngeal examination with improved optics, including stroboscopy. Only 4 (15%) represented disorders routinely diagnosed with flexible fiberoptic laryngoscopy., Conclusion: Hoarse patients with no apparent cause for dysphonia other than reflux after flexible laryngoscopy, or who fail to improve with appropriate treatment, may benefit from further laryngeal investigation rather than continued empiric treatment or further reflux evaluation.

Objective: Although neurogenic cough is increasingly recognised, its pathophysiology remains obscure. We describe two cases of chronic cough following laryngeal herpes zoster, a rarely described manifestation of varicella-zoster virus reactivation, and suggest that this may be analogous to post-herpetic neuralgia. The same mechanisms may cause both phenomena., Case Reports: We describe two cases of chronic cough persisting for more than three months following an acute attack of laryngeal herpes zoster., Conclusion: Neuronal damage by varicella-zoster virus results in irritable nociceptors and deafferentation, mechanisms known to cause post-herpetic neuralgia. When the vagus nerve is affected, as in laryngeal herpes zoster, the result may be a chronic cough. Similar damage may underlie chronic neurogenic cough in other contexts.

Objectives/hypothesis: Vocal fold hemorrhage is an acute phonotraumatic injury treated with voice rest; recurrence is a generally accepted indication for surgical intervention. This study aims to identify factors predictive of recurrence based on outcomes of a large clinical series., Study Design: Retrospective cohort., Methods: Retrospective review of cases of vocal fold hemorrhage presenting to a university laryngology service. Demographic information was compiled. Videostroboscopic exams were evaluated for hemorrhage extent, presence of varix, mucosal lesion, and/or vocal fold paresis. Vocal fold hemorrhage recurrence was the main outcome measure. Follow-up telephone survey was used to complement clinical data., Results: Forty-seven instances of vocal fold hemorrhage were evaluated (25M:22F; 32 professional voice users). Twelve of the 47 (26%) patients experienced recurrence. Only the presence of varix demonstrated significant association with recurrence (P = 0.0089) on multivariate logistic regression., Conclusion: Vocal fold hemorrhage recurred in approximately 26% of patients. Varix was a predictor of recurrence, with 48% of those with varix experiencing recurrence. Monitoring, behavioral management and/or surgical intervention may be indicated to treat patients with such characteristics., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Idiopathic ulcerative laryngitis (IUL) is characterized by bilateral midmembranous vocal fold ulceration, which follows upper respiratory infection with cough. In contrast, granuloma of the membranous vocal fold can occur rarely following microlaryngoscopy, presumably secondary to surgical violation of deep tissue planes. We report a novel case of noniatrogenic membranous vocal fold granulation developing in a patient with IUL. Although the presence of granulation implied injury to the entire microstructure of the vibratory portion of the vocal fold, the lesion resolved with conservative management without adverse sequelae., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: An increasing number of laryngeal procedures are performed in the office. However, little is known about how well these procedures are tolerated and what factors determine success or failure., Study Design: Prospectively collected patient and physician surveys from five surgeons at two institutions describe patient tolerance of awake, in-office laryngeal procedures (AIOLPs)., Methods: There were 154 procedures performed in a 6-month period, including vocal fold injection (VFI) (72%), laser treatment (19%), and transnasal esophagoscopy (3%). Average duration of procedure was 13 ± 8 minutes., Results: Patients reported an average of 37 of 100 on a discomfort scale, with 0 representing no discomfort and 100 representing maximal discomfort. Ninety-three percent of patients would undergo another procedure, and 96% would recommend AIOLPs to other patients. Procedures were completed successfully in 92%. Most common surgeon-reported difficulties included copious secretions and uncontrolled gag reflex. Procedures that involved such difficulties had a significantly lower rate of procedure completion, 73% vs. 96%, P = .0001. High preprocedure anxiety did not adversely impact patient comfort or procedure completion rate. There was no difference in discomfort scores based on VFI approach or patient familiarity with AIOLPs. There was a significant difference in discomfort score between patients with successful first-approach VFI and those who required a change in VFI approach, 36.0 vs. 61.3, respectively, P = .003. The rate of requiring a second and third VFI approach was 4.6% and 2.8%, respectively., Conclusions: This study encompasses multiple diagnoses, procedures, VFI techniques, and methods of anesthesia. AIOLPs are exceptionally well tolerated by patients, resulting in extremely high completion and satisfaction rates., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

The Neurolaryngology Study Group convened a multidisciplinary panel of experts in neuromuscular physiology, electromyography, physical medicine and rehabilitation, neurology, and laryngology to meet with interested members from the American Academy of Otolaryngology Head and Neck Surgery, the Neurolaryngology Subcommittee and the Neurolaryngology Study Group to address the use of laryngeal electromyography (LEMG) for electrodiagnosis of laryngeal disorders. The panel addressed the use of LEMG for: 1) diagnosis of vocal fold paresis, 2) best practice application of equipment and techniques for LEMG, 3) estimation of time of injury and prediction of recovery of neural injuries, 4) diagnosis of neuromuscular diseases of the laryngeal muscles, and, 5) differentiation between central nervous system and behaviorally based laryngeal disorders. The panel also addressed establishing standardized techniques and methods for future assessment of LEMG sensitivity, specificity and reliability for identification, assessment and prognosis of neurolaryngeal disorders. Previously an evidence-based review of the clinical utility of LEMG published in 2004 only found evidence supported that LEMG was possibly useful for guiding injections of botulinum toxin into the laryngeal muscles. An updated traditional/narrative literature review and expert opinions were used to direct discussion and format conclusions. In current clinical practice, LEMG is a qualitative and not a quantitative examination. Specific recommendations were made to standardize electrode types, muscles to be sampled, sampling techniques, and reporting requirements. Prospective studies are needed to determine the clinical utility of LEMG. Use of the standardized methods and reporting will support future studies correlating electro-diagnostic findings with voice and upper airway function.

Objectives: We describe the clinical features of granuloma of the membranous vocal fold (as opposed to granuloma of the vocal process, or "contact granuloma"), a poorly recognized sequela of microlaryngoscopic surgery. Membranous vocal fold granuloma may mimic the initial lesion in appearance, and thus be mistaken for recurrence., Methods: We performed a retrospective review of cases from 2 institutions., Results: Fifteen cases of membranous vocal fold granuloma from 2 institutions were identified. In all but 1 case, granuloma developed in the early postoperative period, within 8 weeks. Of the 15 cases, 10 followed laser resection of carcinoma. Five were noted following cold steel resection of benign lesions (2 papillomas, 2 cysts, 1 Reinke's edema). Technical aspects of these cases suggest that membranous vocal fold granulomas result from surgical violation of deep tissue planes and/or epithelial defects. All patients were treated with proton pump inhibitors. In 12 cases, the granulomas proved self-limited, resolving over weeks to months following surgery. Three patients underwent surgical removal of the lesion, which confirmed the diagnosis. One of these cases recurred and was treated nonsurgically., Conclusions: Granuloma should be suspected when a mass lesion appears at the surgical site early in the postoperative course. Surgical excision is generally not necessary and may provoke further growth of granulation tissue.

Superficial fungal infection of the mucous membranes (thrush) isolated to the larynx is neither widely reported nor well recognized clinically. Therefore, it is often associated with ineffective treatment and delay in diagnosis, and sometimes associated with unneeded surgical intervention. Eight cases of thrush isolated to the larynx, with no oral or oropharyngeal manifestations, are presented. Four of these were isolated to the vocal folds alone. All patients were adults, and 4 were smokers. Hoarseness was always present. Pain was present inconsistently, and there was no dysphagia or odynophagia, in contrast to other forms of upper aerodigestive tract candidiasis. On average, diagnosis was not made until 6 months after the onset of symptoms. Possible causative factors included use of systemic steroids (3 cases), broad-spectrum antibiotics (1 case), or inhaled steroids (5 cases); diabetes (2 cases); and neutropenia (1 case). In 3 cases, all with thrush isolated to the vocal folds, inhaled steroids were the only causative factor identifiable--a feature reported only twice previously. Three patients underwent surgical procedures that might have been avoided had an accurate diagnosis been made. All patients responded readily to oral fluconazole and removal of predisposing factors where possible. The signs, symptoms, predisposing factors, and treatment are compared to those of 14 cases reported in the literature over 35 years.

Objectives/hypothesis: To assess factors that may be predictive of patient perception of dysphonia severity, as quantified by the Voice Handicap Index (VHI) score. We hypothesize that 1) level of vocal demand; 2) auditory-perceptual evaluation of dysphonia severity; and 3) vocal function, as defined by phonatory glottal closure and mucosal wave vibration, are the most significant predictors of VHI score., Study Design: : Retrospective review of 100 patients with benign vocal fold lesions., Methods: Variables assessed for predictive value to VHI score are level of vocal demands, auditory-perceptual evaluation of dysphonia severity, integrity of mucosal wave vibration and phonatory glottal closure, lesion type, duration of current complaint, smoking, age, and sex. Harmonic to noise ratio was assessed in a subset of 50 patients., Results: Patients with routine voice use had significantly lower VHI scores than those with more intensive (nonsinging/acting) vocal demands. Patients who quit smoking had greater VHI scores than those who currently smoke or never started. Patients with long-standing dysphonia tended to have lower VHI scores than those with shorter duration vocal complaints. Auditory-perceptual assessment of dysphonia severity and harmonic to noise ratio were weak predictors of VHI score. Age, sex, lesion type, phonatory glottal closure, and mucosal wave vibration were not significant predictors of VHI score., Conclusions: Patient perception of dysphonia severity is independent of many factors commonly assessed during the evaluation of voice disorders. It appears to be an important independent element in the assessment of the effect of a benign vocal fold lesion and critical to therapeutic decision-making.

Empirical data are often not available to guide clinical practices in the treatment of benign mucosal lesions of the vocal folds. The purpose of this report is to describe opinions and practices in order to identify areas of consensus and discrepancy and thus guide future inquiry. A 16-item survey mailed to all active US members of the American Academy of Otolaryngology-Head and Neck Surgery (n = 7,321) included questions on the use of voice therapy; diagnostic testing; perioperative use of steroids, antibiotics, and antireflux medications; and use of lasers. Responses used a Likert 5-point scale with end anchors of 1 equaling "never" and 5 equaling "always" and were stratified according to lesion (nodules, polyps, cysts). A 16.5% response rate (n = 1,208) was obtained. A lack of consensus was most evident in the use of voice therapy for lesions other than nodules; antireflux medication; and intravenous steroids. Disagreement was also noted regarding the use of lasers, oral steroids, and antibiotics. Other than voice therapy as initial intervention for nodules, no statistically significant differences by lesion type exist regarding use of voice therapy, laser, or any medication. Prospective clinical trials addressing voice therapy, antireflux medications, steroids, and antibiotics are needed to inform clinical practice. Furthermore, treatment practices appear to be largely independent of lesion type. Therefore, traditional diagnostic categories do not seem to be useful guides to treatment, and may need to be reevaluated in light of improvements in diagnostic technology and surgical technique.

Objectives/hypothesis: The objective of the study was to examine the side-effect profile of the vagal nerve stimulator. Vagal nerve stimulators have been used to treat intractable seizures in all age groups. They provide relief to the patient with a seizure disorder by decreasing the overall number and severity of seizure activities. Although significant complications are rare, many patients have some complaint, usually of their voice., Study Design: A retrospective evaluation of four patients with intractable epilepsy., Methods: Evaluation of charts and medical records and endoscopic examination of the larynx., Results: In this small series, all four patients had implantation-related paresis. Three of the four appear to have side effects from device activation., Conclusions: Patients in whom a vagal nerve stimulator is placed can have adverse side effects. These can be related to the surgical manipulation of the vagus nerve, resulting in a temporary paresis of the vocal folds. A second set of side effects is related to the actual electrical stimulation of the device, and these side effects can directly affect the laryngeal musculature.