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Introduction: Vocal fold cysts are benign mid-membranous lesions of the true vocal fold, classified as mucus retention or epidermal inclusion cysts. Treatment is surgical excision with or without postoperative voice therapy., Methods: A retrospective review was performed of the demographics, treatment approach, and outcomes of patients treated for vocal fold cysts between 2009 and 2014. Voice Handicap Index (VHI)-10 scores before and after treatment were compared using the Wilcoxon Rank-Sum test and the two-tailed Student's t test. Videostroboscopy examinations were reviewed for posttreatment changes in vibratory characteristics of the vocal folds., Results: Twenty-five patients were identified, and one was excluded for incomplete records. Mean age was 41.9 years (66.7% female), and mean follow-up time was 5.58 months. Microflap excision was pursued by 21/24 (87.5%) patients, with 14 patients (58.3%) undergoing perioperative voice therapy. One cyst recurred. Two patients elected for observation, and their cysts persisted. VHI-10 decreased from 23.8 to 6.6 (P < 0.001) overall. There was a statistically significant reduction in VHI-10 in patients undergoing surgery with and without postoperative voice therapy (P < 0.004 and 0.001), but there was no significant difference between these two groups. Mucosal wave was classified as normal or improved in the majority. Cysts were characterized as mucus retention cysts in 19/21 (90%) and as epidermal inclusion cysts in 2/21 (10%)., Conclusions: Vocal fold cysts impact mucosal wave and glottic closure. Surgical excision resulted in low rates of recurrence, and in improvement in the mucosal wave and VHI-10. Perioperative voice therapy did not offer a significant benefit. Mucus retention cysts were the majority, in contrast to other published studies., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the effectiveness of in-office potassium-titanyl-phosphate (KTP) treatment of vocal fold granulomas and identify any predictors of complete lesion resolution., Methods: A retrospective review of patients who underwent in-office KTP ablation of vocal fold granulomas between 2007 and 2016 was performed. Medical records were reviewed for use of acid suppression medication, prior surgical treatment, voice therapy, laser settings, number of treatments, follow-up time, and Voice Handicap Index-10 (VHI-10) scores., Results: Twenty-six patients underwent a total of 43 laser treatments. Eighty percent of patients were previously on acid suppression medication, and 42.3% had failed previous endoscopic treatments. Patients underwent a mean number of 1.65 ± 1.16 in-office treatments with decrease in size in 96.2% of cases. The VHI-10 was not significantly affected. Complete resolution occurred in 73.1% of cases with follow-up time ranging from 1 to 86 months (median = 9.5 months). No recurrences occurred in patients with complete resolution. Other than undergoing a single KTP treatment, no variable was found to be predictive of complete lesion resolution. Granuloma etiology was not predictive of lesion resolution but did correlate with symptom improvement., Conclusion: In-office pulsed KTP laser is an effective treatment option for vocal fold granulomas as the lesion resolves in the majority of cases.

Introduction: Laryngeal webs are a rare clinical entity, with those in the mid-membranous region occurring even less commonly. This is the first case series describing this condition., Case Report: We describe the clinical course of four patients with mid-glottic webs and propose the possible pathophysiology., Discussion: Trauma to the vocal folds followed by an inflammatory reaction is the likely event leading to the development of this lesion. Endoscopic division of this type of web has shown good postoperative voice outcomes without any recurrences., Conclusion: The mid-glottic web is a rare clinical entity for which there is no defined etiology. It is likely that trauma results in an inflammatory reaction and, ultimately, web formation. Further studies are needed to identify risk factors for this condition., (Published by Elsevier Inc.)

Objectives/hypothesis: To establish the rate of inflammatory reaction to hyaluronic acid (HA) in vocal fold injection augmentation, determine the most common presenting signs and symptoms, and propose an etiology., Study Design: Retrospective chart review., Methods: Patients injected with HA over a 5-year period were reviewed to identify those who had a postoperative inflammatory reaction. Medical records were reviewed for patient demographic information, subjective complaints, Voice Handicap Index-10 (VHI-10) scores, medical intervention, and resolution time. Videolaryngostroboscopy examinations were also evaluated., Results: A total of 186 patients (245 vocal folds) were injected with HA over a 5-year period, with a postoperative inflammatory reaction rate of 3.8%. The most common complaints in these patients were odynophagia, dysphonia, and dyspnea with vocal fold erythema, edema, and loss of pliability on videolaryngostroboscopy. All patients were treated with corticosteroids. Return of vocal fold vibration ranged from 3 weeks to 26 months, with VHI-10 scores normalizing in 50% of patients., Conclusions: This reaction may be a form of hypersensitivity related to small amounts of protein linked to HA. Alternatively, extravascular compression from the HA could lead to venous congestion of the vocal fold. The possibility of equipment contamination is also being investigated. Further studies are needed to determine the etiology and best treatment., Level of Evidence: 4 Laryngoscope, 2016 127:445-449, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Supraglottic injection of botulinum toxin (Botox) has been described as an effective treatment for adductor spasmodic dysphonia (ADSD). Anecdotal evidence suggests that the patients have little to no breathiness after injection, but no formal longitudinal studies have been carried out to date. The purpose of this study was to examine the voice outcomes in patients with ADSD after supraglottic Botox injection., Study Design: Retrospective case series., Methods: Patients with ADSD who were treated with supraglottic Botox injections completed a qualitative self-evaluation of voice function after injection using the percentage of normal function (PNF) scale, a validated, quantitative scale from 0% (no function) to 100% (normal function). Posttreatment voice improvement after injection was determined using a Voice Handicap Index-10 (VHI-10) questionnaire., Results: A total of 198 supraglottic injections were performed between July 2011 and October 2014. Twenty-five questionnaires were completed. Mean postinjection PNF was 95.0% ± 8.4% and was significantly increased from the preinjection mean PNF (62.5%) ± 22.6% (P < 0.001). The mean best VHI-10 for all injections was 7.23. In 19 of 25 patients (76%), there was no reduction in PNF in the early postinjection period. In the remaining six patients (24%), the decline in mean vocal function was 9.2%., Conclusions: Supraglottic Botox injection is an effective treatment for ADSD. Postinjection voice is significantly improved, and the majority of patients do not experience breathy voice/decline in vocal function after injection., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: This study aimed to assess vocal disability in patients with laryngotracheal stenosis who are managed with endoscopic surgery, comparing patients with posterior glottic stenosis (PGS) to those with subglottic or tracheal stenosis (SGS/TS)., Methods: Patients who underwent endoscopic treatment for laryngotracheal stenosis with voice outcomes data from 2005 to 2013 were studied. The mean Voice Handicap Index-10 (VHI-10) was compared over the study period. Of those with SGS/TS, the distance from the vocal folds to the proximal portion of the stenosis was obtained and compared to VHI-10., Results: Forty-four patients met inclusion criteria. The mean VHI-10 for all patients was 14.6. Fifty percent were dysphonic (VHI-10>11). The mean VHI-10 for PGS patients was 22.4, and for SGS/TS patients, 10.9 (P=.004). Of those with PGS, 78.6% were dysphonic compared to only 36.7% of those with SGS/TS. Voice Handicap Index-10 improved from 14.1 for those with proximal stenosis to 4 for those with stenosis more than 2 cm distal to the vocal folds., Conclusion: Following endoscopic management of stenosis, those with PGS have poorer voice outcomes compared to those with SGS/TS. The majority of those with SGS/TS are not dysphonic. Vocal outcomes are greatest for those with stenosis beginning at least 2 cm distal to the vocal folds., (© The Author(s) 2014.)

Objective/hypothesis: To determine the efficacy of the potassium titanyl phosphate (KTP) laser in lesion reduction, as well as preservation of mucosal wave and glottic closure in a cohort of patients with benign laryngeal pathology across multiple institutions., Study Design: Multi-institutional and retrospective., Methods: One hundred two patients who underwent in-office KTP procedures at multiple academic laryngology practices with at least a single follow-up visit were included. Image analysis was used to quantify vocal fold lesion size before and after treatment. A subset of images was analyzed by expert reviewers to determine the impact of this treatment on glottic closure and mucosal wave., Results: Statistically, when considering all lesions, KTP induced a significant reduction in lesion size. Post hoc analyses revealed some lesion specificity; all lesions decreased in size, with the exception of vocal fold scar. Mucosal wave and glottic closure were improved or unchanged in more than 90% of the patients examined. The inter- and intrarater reliabilities of the lesion quantification method were excellent., Conclusions: With great care and insight, the KTP laser appears to be a valuable tool for the treatment of various benign laryngeal lesions. Furthermore, KTP laser therapy appears to preserve or improve mucosal wave and glottic closure. The lesion measurement protocol previously described by our group appears to be reliable., (Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

Objectives/hypothesis: There is a significant lack of uniform agreement regarding nomenclature for benign vocal fold lesions (BVFLs). This confusion results in difficulty for clinicians communicating with their patients and with each other. In addition, BVFL research and comparison of treatment methods are hampered by the lack of a detailed and uniform BVFL nomenclature., Study Design: Clinical consensus conferences were held to develop an initial BVFL nomenclature paradigm. Perceptual video analysis was performed to validate the stroboscopy component of the paradigm., Methods: The culmination of the consensus conferences and the video-perceptual analysis was used to evaluate the BVFL nomenclature paradigm using a retrospective review of patients with BVFL., Results: An initial BVFL nomenclature paradigm was proposed utilizing detailed definitions relating to vocal fold lesion morphology, stroboscopy, response to voice therapy and intraoperative findings. Video-perceptual analysis of stroboscopy demonstrated that the proposed binary stroboscopy system used in the BVFL nomenclature paradigm was valid and widely applicable. Retrospective review of 45 patients with BVFL followed to the conclusion of treatment demonstrated that slight modifications of the initial BVFL nomenclature paradigm were required. With the modified BVFL nomenclature paradigm, 96% of the patients fit into the predicted pattern and definitions of the BVFL nomenclature system., Conclusions: This study has validated a multidimensional BVFL nomenclature paradigm. This vocal fold nomenclature paradigm includes nine distinct vocal fold lesions: vocal fold nodules, vocal fold polyp, pseudocyst, vocal fold cyst (subepithelial or ligament), nonspecific vocal fold lesion, vocal fold fibrous mass (subepithelial or ligament), and reactive lesion., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: The purpose of this study was to determine whether the videostroboscopic finding of vibratory asymmetry in mobile vocal folds is a reliable predictor of vocal fold paresis. In addition, the ability of experienced reviewers to predict the distribution (left/right/bilateral) of the paresis was investigated., Methods: This is a retrospective chart review of all patients who presented to our clinic during a 3-year period with symptoms suggestive of glottal insufficiency (vocal fatigue or reduced vocal projection) accompanied by the videostroboscopic findings of bilateral normal vocal fold mobility and vibratory asymmetry. Twenty-three of these patients underwent diagnostic laryngeal electromyography of the thyroarytenoid and cricothyroid muscles to determine the presence of vocal fold paresis., Results: Nineteen of the 23 patients (82.6%) were found to have electrophysiological evidence of vocal fold paresis, either unilaterally or bilaterally, when videostroboscopic asymmetry was present in mobile vocal folds. However, the three expert reviewers' ability to predict the distribution (left/right/bilateral) of the paresis was poor (26.3%, 36.8%, and 36.8%, respectively)., Conclusions: The videostroboscopic finding of vibratory asymmetry in mobile vocal folds is a reliable predictor of vocal fold paresis in most cases. However, the ability of expert reviewers to determine the distribution (left/right/bilateral) of the paresis using videostroboscopic findings is poor. This study highlights the value of laryngeal electromyography in arriving at a correct diagnosis in this clinical situation.

Objectives/hypothesis: Vocal fold augmentation with autologous fat has been widely used for the last 15 years with varying success. Autologous fat is biocompatible, readily available, and easily harvested, making it a commonly used material for vocal fold augmentation. Although felt to be a relatively safe procedure, few studies have looked at the complication rate of lipoinjection for vocal fold augmentation., Study Design: Retrospective review., Methods: Ninety-eight vocal fold injections were performed at one institution from 1997 to 2008. The charts were reviewed retrospectively, and age, diagnosis, side of procedure, concurrent procedures, length of follow-up, and complications during or subsequent to the injection were recorded in a database. Patients were excluded if data was inadequate to make a determination regarding complication during or after lipoinjection., Results: Eighty-eight patients met the criteria for review with an average age of 57.4 years. The most common indications for injection were vocal fold paresis, vocal fold scarring, and presbylaryngeus. Mean follow-up was 20.2 months with a range of 0 months to 126 months. Overall, four laryngeal complications occurred (4.5%), including three over-injections (3.4%) leading to poor voice quality and one granuloma formation (1.1%). The over-injections were managed using cordotomy with fat removal, resulting in vocal improvement in all cases., Conclusions: Although lipoinjection vocal fold augmentation is a safe procedure, over-injection of autologous fat is a risk. Lipoinjection for vocal fold augmentation can lead to over-injection with dysphonia in a small number of patients. The complications can be managed with lateral cordotomy and fat removal.

A retrospective chart review was performed at the senior author's voice disorder clinic to report the symptoms, signs, and laryngeal electromyography (LEMG) data of patients presenting with vocal fold paresis (VFP) in a tertiary laryngology academic practice over a 4-year period. Medical records of 739 patients presenting to the clinic with a chief complaint of dysphonia (for 2000-2004) were assessed. History intake forms, strobovideolaryngoscopy images, and LEMG reports were reviewed for all patients with a clinical diagnosis of VFP. Of the 739 patients presenting to the clinic with voice complaints, 195 were initially diagnosed with either vocal fold paralysis or VFP (26.4%). Only 13 out of 739 patients (1.8%) with voice complaints were diagnosed with LEMG-confirmed unilateral or bilateral VFP. The most common findings on strobovideolaryngoscopy were vocal fold bowing (70%), incomplete closure (62%), and increased vibratory amplitude (38%). Seventy percentage of the patients had unilateral VFP, predominantly isolated recurrent laryngeal nerve (RLN) disease. Only 9% had unilateral superior laryngeal nerve (SLN) involvement. The most common LEMG abnormality was reduced recruitment of motor units. In our voice center, VFP was a relatively uncommon diagnostic entity. Despite the low prevalence, VFP needs to be considered in all patients who present with dysphonia. Further study is needed to examine the prevalence of "abnormal" LEMG studies in an asymptomatic control population, and to determine the utility of LEMG in the evaluation and management of dysphonia. In the same way that strobovideolaryngoscopy has been critically evaluated in the past, there is also a need to determine how commonly LEMG contributes essential data which leads to a change in the patient's management and/or ultimate vocal outcome.

Objective: The objective of this study was to describe the management of suboptimal injection of calcium hydroxylapatite during augmentation laryngoplasty., Study Design: A retrospective review was conducted at four Voice and Swallowing centers to identify patients who had a suboptimal injection of calcium hydroxylapatite during augmentation laryngoplasty., Results: Five patients (ages 19-75) were identified with an impaired voice secondary to a superficial injection of calcium hydroxylapatite or over-medialization of the true vocal fold. All patients underwent revision surgery with all experiencing subjective and objective improvement., Conclusion: Microflap excision can lead to successful return of vibratory function after a suboptimal injection of calcium hydroxylapatite. Complete control of the initial injection is paramount to avoiding this complication.

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.

Objectives: Vocal fold injection (VFI) in the office setting and in the operating room is becoming increasingly popular. Most training programs fail to educate residents in performing these injections. In this report, we describe novel and effective teaching tools that provide real-life simulation of VFI for the education of residents and otolaryngologists in practice., Methods: Equipment was developed to allow the use of excised fresh cadaver larynges to simulate peroral VFI in a life-sized model of the human head and neck. A separate setup was also developed for use of a laryngoscope holder and cadaver larynges to simulate microlaryngoscopy VFI. Each of these VFI training setups allows the student to perform and practice VFI in a simulated setting with physical and anatomic constraints and laryngeal anatomy similar to those of real-life VFI. The use of fresh cadaver larynges allows the user to have a realistic feel of actual injection. A visual analog scale was used to measure the participants' comfort levels with the peroral and microlaryngoscopic injection techniques before and after the workshop., Results: Pre-workshop and post-workshop surveys were collected from 22 of the VFI course participants. The mean comfort levels for VFI prior to the workshop were 22 for peroral VFI and 69 for microlaryngoscopy VFI (0 = not comfortable at all and 100 = very comfortable). The post-workshop comfort levels were 52 for peroral VFI and 85 for microlaryngoscopy VFI. The differences in the pre- and post-workshop comfort level scores for each VFI technique were significant (microlaryngoscopy, p = .001; peroral, p < .0001)., Conclusions: The use of VFI simulations appears to improve surgeon comfort level with injection techniques. The described training simulations may be useful for allowing residents and practicing otolaryngologists to learn VFI before attempting these techniques on actual patients.

Objectives: Transverse cordotomy (TC) and medial arytenoidectomy (MA) are procedures performed to enlarge the glottic airway in patients with bilateral vocal fold paralysis (BVFP). Both are less destructive than total arytenoidectomy and have distinct theoretical advantages for voice preservation, but they have never been compared., Methods: The records of patients with BVFP treated with TC or MA were reviewed; information regarding the outcome measures of tracheotomy decannulation, dysphagia, Voice Handicap Index score, voice intensity, clinical course, and preoperative and postoperative voice quality was obtained., Results: Seventeen patients were available for evaluation (11 with TC, 6 with MA). All 6 patients with a preoperative tracheotomy were decannulated. Four patients in the MA group and 2 in the TC group had an increase in their postoperative Voice Handicap Index score. Two of the patients in the MA group had a decrease in phonatory sound pressure level of 3 dB, and 1 in the TC group had a decrease of 2 dB sound pressure level. Patient self-report of airway status following TC or MA showed that 62.5% (10 of 16) were significantly better and 25% (4 of 16) were somewhat better. Blinded audio perceptual analysis comparing preoperative and postoperative voice quality showed no difference between the MA and TC groups. A swallowing quality-of-life instrument confirmed a lack of swallowing difficulties postoperatively., Conclusions: Both TC and MA are good treatment options for BVFP, with a low incidence of complications in postoperative voice or of swallowing difficulties and a consistent improvement of laryngeal airway restriction symptoms.

More than 16,000 vagal nerve stimulators (VNSs) have been implanted for refractory epileptic seizures. The most commonly reported side effect is hoarseness. This study examines the effects of VNS placement on vocal fold function. Eleven patients who had undergone VNS placement at our institution were recruited. Subjective evaluation by a panel of speech and language pathologists of both connected speech and videolaryngoscopy recordings were used both at rest and during VNS activation. Additional subjective evaluation included use of the Voice Handicap Index for the study group. These results were compared to data from age- and sex-matched controls. Objective data included maximum phonation time in the study and control groups, as well as laryngeal electromyography performed on the VNS-implanted patients only. Motor unit potential morphology and recruitment, as well as spontaneous activity, were analyzed bilaterally for the cricothyroid and thyroarytenoid muscles. Significant differences were found between the study and control groups subjectively for vocal quality and videolaryngoscopy parameters. Vocal fold tension, supraglottic muscular hyperfunction, and reduced vocal fold mobility were the most common findings during VNS activation. Two of 10 patients had immobile left vocal folds in the absence of active stimulation. The maximum phonation time was generally reduced in the subject group, but this reduction did not reach statistical significance. Finally, 6 of 10 patients had abnormal electromyographic results, including large-amplitude polyphasic motor unit potentials and decreased recruitment. We conclude that implantation of a VNS can affect vocal fold function. The effects are magnified during periods of active stimulation. There is the potential for nerve degeneration after prolonged repetitive stimulation, and there may be a trend toward greater vocal fold dysfunction with higher stimulation parameters.

The article presents the case of a 71-year-old man who had been referred to our clinic for evaluation of a 2-year history of persistent vocal fold leukoplakia. The lesion was made up of hyperplastic and reactive squamous epithelium with mild dysplasia. It had recurred within 4 weeks of the previous biopsy. The initial videolaryngostroboscopy showed that the leukoplakia was confined to the anterior half of the left vocal fold. The patient was started on a twice-daily proton-pump inhibitor and was followed every month stroboscopically.