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Objective COVID-19 spreads through aerosols produced in coughing, talking, exhalation, and also in some surgical procedures. Use of CO2 laser in laryngeal surgery has been observed to generate aerosols, however, other techniques, such cold dissection and microdebrider, have not been sufficiently investigated. We aimed to assess whether aerosol generation occurs during laryngeal operations and the effect of different instruments on aerosol production. Methods We measured particle concentration generated during surgeries with an Optical Particle Sizer. Cough data collected from volunteers and aerosol concentration of an empty operating room served as references. Aerosol concentrations when using different techniques and equipment were compared with references as well as with each other. Results Thirteen laryngological surgeries were evaluated. The highest total aerosol concentrations were observed when using CO2 laser and these were significantly higher than the concentrations when using microdebrider or cold dissection (p p p p p = 0.146, p = 0.753). In comparing all three techniques, microdebrider produced the least aerosol particles. Conclusions Microdebrider and cold dissection can be regarded as aerosol-generating relative to background reference concentrations, but they should not be considered as high-risk aerosol-generating procedures, as the concentrations are low and do not exceed those of coughing. A step-down algorithm from CO2 laser to cold instruments and microdebrider is recommended to lower the risk of airborne infections among medical staff.

SARS- CoV- 2 has been detected both in air and on surfaces, but questions remain about the patient-specific and environmental factors affecting virus transmission. Additionally, more detailed information on viral sampling of the air is needed. This prospective cohort study (N= 56) presents results from 258 air and 252 surface samples from the surroundings of 23 hospitalized and eight home- treated COVID-19 index patients between July 2020 and March 2021 and compares the results between the measured environments and patient factors. Additionally, epidemiological and experimental investigations were performed. The proportions of qRT- PCR- positiveair (10.7% hospital/17.6% homes) and surface samples (8.8%/12.9%) showed statisti-cal similarity in hospital and homes. Significant SARS- CoV- 2 air contamination was observed in a large (655.25 m3) mechanically ventilated (1.67 air changes per hour, 32.4– 421 L/s/patient) patient hall even with only two patients present. All positive air samples were obtained in the absence of aerosol- generating procedures. In four cases, positive environmental samples were detected after the patients had devel-oped a neutralizing IgG response. SARS- CoV- 2 RNA was detected in the following particle sizes: 0.65– 4.7 μm , 7. 0– 12.0 μm, >10μm, and

Objective To assess whether aerosol generation occurs during otologic surgery, to define which instruments are aerosol generating, and to identify factors that enhance safety in protection against airborne pathogens, such as severe acute respiratory syndrome coronavirus 2. Study Design An observational prospective study on aerosol measurements during otologic operations recorded between August and December 2020. Setting Aerosol generation was measured with an Optical Particle Sizer as part of otologic operations with anesthesia. Particles with a size range of 0.3 to 10 mu m were quantified. Aerosol generation was measured during otologic operations to analyze aerosols during drilling in transcanal and transmastoid operations and when using the following instruments: bipolar electrocautery, laser, suction, and cold instruments. Coughing is known to produce significant concentration of aerosols and is commonly used as a reference for high-risk aerosol generation. Thus, the operating room background concentration and coughing were chosen as reference values. Patients Thirteen otologic operations were included. The average drilling time per surgery was 27.00 minutes (range, 2.00-71.80 min). Intervention Different rotation speeds during drilling and other instruments were used. Main Outcome Measures Aerosol concentrations during operations were recorded and compared with background and cough aerosol concentrations. Results Total aerosol concentrations during drilling were significantly higher than background (p < 0.0001, d = 2.02) or coughing (p < 0.0001, d = 0.50). A higher drilling rotation speed was associated with higher particle concentration (p = 0.037, eta(2) = 0.01). Aerosol generation during bipolar electrocautery, drilling, and laser was significantly higher than with cold instruments or suction (p < 0.0001, eta(2) = 0.04). Conclusion High aerosol generation is observed during otologic surgery when drill, laser, or bipolar electrocautery is used. Aerosol generation can be reduced by using cold instruments instead of electric and keeping the suction on during aerosol-generating procedures. If drilling is required, lower rotation speeds are recommended. These measures may help reduce the spread of airborne pathogens during otologic surgery.

SARS-CoV-2 cell entry starts with membrane attachment and ends with spike-protein (S) catalyzed membrane fusion depending on two cleavage steps, one usually by furin in producing cells and the second by TMPRSS2 on target cells. Endosomal cathepsins can carry out both. Using real-time 3D single virion tracking, we show fusion and genome penetration requires virion exposure to an acidic milieu of pH 6.2-6.8, even when furin and TMPRSS2 cleavages have occurred. We detect the sequential steps of S1-fragment dissociation, fusion, and content release from the cell surface in TMPRRS2 overexpressing cells only when exposed to acidic pH. We define a key role of an acidic environment for successful infection, found in endosomal compartments and at the surface of TMPRSS2 expressing cells in the acidic milieu of the nasal cavity.Significance StatementInfection by SARS-CoV-2 depends upon the S large spike protein decorating the virions and is responsible for receptor engagement and subsequent fusion of viral and cellular membranes allowing release of virion contents into the cell. Using new single particle imaging tools, to visualize and track the successive steps from virion attachment to fusion, combined with chemical and genetic perturbations of the cells, we provide the first direct evidence for the cellular uptake routes of productive infection in multiple cell types and their dependence on proteolysis of S by cell surface or endosomal proteases. We show that fusion and content release always require the acidic environment from endosomes, preceded by liberation of the S1 fragment which depends on ACE2 receptor engagement.One sentence summaryDetailed molecular snapshots of the productive infectious entry pathway of SARS-CoV-2 into cells

Funding Information: Open Access funding provided by University of Helsinki. The study has been supported by The Finnish Dental Society Apollonia (grant for MP and LL), the Helsinki and Uusimaa Hospital District (HUS, grant for LL). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The data of this study has not been presented elsewhere. Publisher Copyright: © 2022, The Author(s). We examined the usefulness of dried spot blood and saliva samples in SARS-CoV-2 antibody analyses. We analyzed 1231 self-collected dried spot blood and saliva samples from healthcare workers. Participants filled in a questionnaire on their COVID-19 exposures, infections, and vaccinations. Anti-SARS-CoV-2 IgG, IgA, and IgM levels were determined from both samples using the GSP/DELFIA method. The level of exposure was the strongest determinant of all blood antibody classes and saliva IgG, increasing as follows: (1) no exposure (healthy, non-vaccinated), (2) exposed, (3) former COVID-19 infection, (4) one vaccination, (5) two vaccinations, and (6) vaccination and former infection. While the blood IgG assay had a 99.5% sensitivity and 75.3% specificity to distinguish participants with two vaccinations from all other types of exposure, the corresponding percentages for saliva IgG were 85.3% and 65.7%. Both blood and saliva IgG-seropositivity proportions followed similar trends to the exposures reported in the questionnaires. Self-collected dry blood and saliva spot samples combined with the GSP/DELFIA technique comprise a valuable tool to investigate an individual’s immune response to SARS-CoV-2 exposure or vaccination. Saliva IgG has high potential to monitor vaccination response wane, since the sample is non-invasive and easy to collect.

Saliva is an alternative sample material to nasopharyngeal swab in SARS-CoV-2 diagnostics. We investigated possible aspects to improve the reliability of SARS-CoV-2 detection from saliva. Saliva was collected from asymptomatic healthy subjects (n=133) and COVID-19 patients (n=9). SARS-CoV-2 detection was performed with quantitative reverse-transcriptase PCR (RT-qPCR) with two viral and one host target serving as an internal control. The use of internal control revealed that in the first RT-qPCR run 25–30 % of assays failed. The failure is associated with poor RNA quality. When the amount of RNA was cut down to half from the original amount, the performance of RT-qPCR was greatly enhanced (95 % of the assays succeeded). The quality of RNA was not affected by the use of different nucleic acid stabilizing buffers. Our study showed that saliva is suitable material for RT-qPCR based SARS-CoV-2 diagnostics, but the use of internal control is essential to distinguish the true negative samples from failed assays.

Intubation, laryngoscopy, and extubation are considered highly aerosol-generating procedures, and additional safety protocols are used during COVID-19 pandemic in these procedures. However, previous studies are mainly experimental and have neither analyzed staff exposure to aerosol generation in the real-life operating room environment nor compared the exposure to aerosol concentrations generated during normal patient care. To assess operational staff exposure to potentially infectious particle generation during general anesthesia, we measured particle concentration and size distribution with patients undergoing surgery with Optical Particle Sizer.A single-center observative multidisciplinary clinical study in Helsinki University Hospital with 39 adult patients who underwent general anesthesia with tracheal intubation. Mean particle concentrations during different anesthesia procedures were statistically compared with cough control data collected from 37 volunteers to assess the differences in particle generation.This study measured 25 preoxygenations, 30 mask ventilations, 28 intubations, and 24 extubations. The highest total aerosol concentration of 1153 particles (p)/cm³ was observed during mask ventilation. Preoxygenations, mask ventilations, and extubations as well as uncomplicated intubations generated mean aerosol concentrations statistically comparable to coughing. It is noteworthy that difficult intubation generated significantly fewer aerosols than either uncomplicated intubation (p = .007) or coughing (p = 0.006).Anesthesia induction generates mainly small (1 µm) aerosol particles. Based on our results, general anesthesia procedures are not highly aerosol-generating compared with coughing. Thus, their definition as high-risk aerosol-generating procedures should be re-evaluated due to comparable exposures during normal patient care.The list of aerosol-generating procedures guides the use of protective equipments in hospitals. Intubation is listed as a high-risk aerosol-generating procedure, however, aerosol generation has not been measured thoroughly. We measured aerosol generation during general anesthesia. None of the general anesthesia procedures generated statistically more aerosols than coughing and thus should not be considered as higher risk compared to normal respiratory activities.

OBJECTIVES Given its rarity and the lack of clear clinical markers, amyotrophic lateral sclerosis (ALS) remains a diagnostic challenge. Since bulbar-onset ALS (buALS) presents with impaired speech or swallowing, patients are often primarily referred to an otolaryngologist (ORL) or phoniatrician. We analyzed the role of such specialists in ALS diagnostics and treatment. PARTICIPANTS We reviewed data for all 327 patients treated for ALS through the Hospital District of Helsinki and Uusimaa (HUS) between 2010 and 2014, focusing specifically on 110 (34%) patients presenting with bulbar nerve onset (buALS). MAIN OUTCOME MEASURES The presenting symptoms, referral to specialized care, and to a neurology clinic were assessed. Indications and findings from swallowing studies were reviewed as well as the incidence of percutaneous endoscopic gastrostomy (PEG) and tracheostomy. RESULTS Among the 110 patients with buALS, 64 (58%) were primarily referred to a neurologist, 28 (25%) to an ORL, and 5 (5%) to a phoniatrician. The most common presenting symptom was dysarthria in 89 patients, (81%), followed by dysphagia in 26 (24%). In most cases, an ORL or phoniatrician suspected a neuromuscular disease; however, in 8 (24%) cases, the neurological etiology of symptoms was missed. Overall, 49 (45%) patients underwent a swallowing study and 86 (78%) patients underwent PEG placement. CONCLUSIONS Among buALS patients, 30% initially consulted an ORL or phoniatrician and 45% underwent a swallowing study. Based on our results, swallowing studies rarely lead to immediate PEG placement. An initial visit to other specialists had no impact on diagnostic delays or survival. Five keypoints Amyotrophic lateral sclerosis (or ALS) Motor neuron disease Dysphagia Fiberoptic Endoscopic Examination of Swallowing (or FEES) Percutaneous Endoscopic Gastrostomy (or PEG) Level of Evidence: 3

The need for multidisciplinary and multiprofessional management of dysphagia is constantly increasing and creating a major challenge for healthcare professionals and society, especially in terms of professional expertise and human resources. The distribution of tasks among the dysphagia team members, which includes phoniatricians, otolaryngologists, and speech-language therapists, is flexible and overlapping. For assessing dysphagia, the (fibreoptic) flexible endoscopic evaluation of swallowing (FEES), with or without videofluoroscopy, is a pivotal diagnostic tool. This position paper aims to illustrate the phoniatrician’s role in performing a FEES, which is an indispensable component of the diagnostic workup of patients suffering from oropharyngeal dysphagia. It is based on the current collaborative expert view of the Swallowing Committee of the Union of European Phoniatricians and a literature review. A FEES is one of the core competences of phoniatricians due to their endoscopic expertise and experience in the field of dysphagia and diseases of the upper aerodigestive tract. Therefore, the phoniatrician is an important member of the dysphagia team, for the medical diagnostics of the aerodigestive tract and dysphagia as well as for FEES. Phoniatric competence is especially important for head and neck cancer patients, infants, and complex cases.

Objectives To assess malignant transformation rate, non-sinonasal malignancies, and factors contributing to recurrence in patients treated for sinonasal inverted papilloma (SNIP). Study Design Retrospective study. Methods We retrospectively reviewed medical records of all patients treated for SNIP (n = 296) between the years 1984-2014 at Helsinki University Hospital. Data from the Finnish Cancer Registry confirmed the number of those patients with sinonasal and non-sinonasal malignancies. Results Only 2 of 296 (0.7%) patients primarily diagnosed with benign SNIP developed sinonasal cancer in a mean follow-up of 5.8 years. The most common non-sinonasal cancer sites were similar to those reported for the whole Finnish population. None of the patients presented with an HPV-associated non-sinonasal malignancy. The recurrence rate among patients who underwent attachment-oriented surgery was significantly lower compared to those operated on with other approaches (40.2% vs. 56.6%, p = 0.006). Dysplasia in SNIP was associated with a higher recurrence rate (p < 0.001). Conclusions Malignant transformation of SNIP was rare. Patients with SNIP were not prone to HPV-associated non-sinonasal malignancies. Endoscopic resection and attachment-oriented surgery have become predominant approaches in the treatment of SNIP; meanwhile, the total number of SNIP recurrences has decreased. Level of Evidence 3 Laryngoscope, 2022

To compare speech symptoms of velopharyngeal insufficiency (VPI) and incidence of secondary speech surgery in 10-year-old Finnish children with unilateral cleft lip and palate (UCLP) following primary palatal surgery using 2 surgical methods.Single center analysis within the Scandcleft multicenter randomized controlled trial of primary surgery for UCLP.Patients comprised 79 nonsyndromic 10-year-old children with UCLP. Two randomized surgical methods were used in the primary palatal surgery: soft palate closure at 4 months and hard palate closure at 12 months (Arm A) and closure of both the soft and hard palate at 12 months (Arm C). Speech symptoms of VPI were analyzed from standardized video recordings by 2 experienced speech pathologists. The incidences of surgery for correcting VPI, fistula closure, and speech therapy were evaluated retrospectively from patient records.No differences in speech symptoms of VPI, need for VPI surgery or speech therapy were found between the surgical methods. Of all 79 children, 33% had had VPI surgery and 61% had speech therapy. The number of fistulas was significantly higher in Arm A (25%) than in Arm C (2%). Moderate to severe speech symptoms of VPI (hypernasality, continuous nasal air leakage, weak pressure consonants, and/or compensatory articulation) were found in 11% of the children.No differences were present between groups in speech symptoms of VPI or need for VPI surgery or speech therapy between the 2 surgical methods. One third of the children had undergone VPI surgery. Most of the children (89%) had good or relatively good speech.

Our aim was to validate a Finnish version of the Eating Assessment Tool (F-EAT-10) for clinical use and to test its reliability and validity in a multicenter nationwide study. Normative data were acquired from 180 non-dysphagic participants (median age 57.0 years, 62.2% female). Dysphagia patients (n = 117, median age 69.7 years, 53.0% female) referred to fiberoptic endoscopic evaluation of swallowing (FEES) completed F-EAT-10 before the examination and after 2 weeks. Patients underwent the 100-ml water swallow test (WST) and FEES was evaluated using the following three scales: the Yale Pharyngeal Residue Severity Rating Scale, Penetration-Aspiration Scale, and the Dysphagia Outcome Severity Scale. An operative cohort of 19 patients (median age 75.8 years, 57.9% female) underwent an endoscopic operation on Zenker’s diverticulum, tight cricopharyngeal muscle diagnosed in videofluorography, or both. Patients completed the F-EAT-10 preoperatively and 3 months postoperatively. The cut-off score for controls was p

The COVID-19 pandemic has caused unseen pressure on healthcare systems in many countries, jeopardizing the mental well-being of healthcare workers. The authors aimed to assess the mental well-being of Finnish healthcare workers from 2 hospital districts (Helsinki University Hospital [HUS] and Social and Health Services in Kymenlaakso [Kymsote]) with differing COVID-19 incidence rates during the first wave of the COVID-19 pandemic in spring 2020.A total number of 996 healthcare workers (HUS N = 862, Kymsote N = 134) participated in this prospectively conducted survey study during summer 2020. Symptom criteria of self-reported mental health symptoms followed ICD-10 classification, excluding duration criteria. Participants were divided into symptom categories "often/sometimes", and "rarely/never". These groups were compared to sociodemographic factors and factors related to work, workload, and well-being.The degree of mental health symptoms did not differ between the 2 healthcare districts despite differing COVID-19 incidences (p = 1). The authors observed a significant relationship between self-reported diagnostic mental health symptoms and experiences of insufficient instructions for protection against COVID-19 (in HUS cohort p0.001), insufficient recovery from work (p0.001), and subjective increased workload (p0.001).The authors' results show the importance of well-planned and sufficient instructions for protection from SARS-CoV-2 for healthcare workers, indicating their need to feel safe and protected at work. The workload of healthcare workers should be carefully monitored to keep it moderate and ensure sufficient recovery. Sufficient control of the epidemic to keep the burden of the healthcare system low is vital for healthcare workers' well-being.

COVID-19 has highlighted the need for indoor risk-reduction strategies. Our aim is to provide information about the virus dispersion and attempts to reduce the infection risk. Indoor transmission was studied simulating a dining situation in a restaurant. Aerosolized Phi6 viruses were detected with several methods. The aerosol dispersion was modeled by using the Large-Eddy Simulation (LES) technique. Three risk-reduction strategies were studied: (1) augmenting ventilation with air purifiers, (2) spatial partitioning with dividers, and (3) combination of 1 and 2. In all simulations infectious viruses were detected throughout the space proving the existence long-distance aerosol transmission indoors. Experimental cumulative virus numbers and LES dispersion results were qualitatively similar. The LES results were further utilized to derive the evolution of infection probability. Air purifiers augmenting the effective ventilation rate by 65% reduced the spatially averaged infection probability by 30%-32%. This relative reduction manifests with approximately 15 min lag as aerosol dispersion only gradually reaches the purifier units. Both viral findings and LES results confirm that spatial partitioning has a negligible effect on the mean infection-probability indoors, but may affect the local levels adversely. Exploitation of high-resolution LES jointly with microbiological measurements enables an informative interpretation of the experimental results and facilitates a more complete risk assessment.

BackgroundThe following position statement from the Union of the European Phoniatricians, updated on 25th May 2020 (superseding the previous statement issued on 21st April 2020), contains a series of recommendations for phoniatricians and ENT surgeons who provide and/or run voice, swallowing, speech and language, or paediatric audiology services.ObjectivesThis material specifically aims to inform clinical practices in countries where clinics and operating theatres are reopening for elective work. It endeavours to present a current European view in relation to common procedures, many of which fall under the aegis of aerosol generating procedures.ConclusionAs evidence continues to build, some of the recommended practices will undoubtedly evolve, but it is hoped that the updated position statement will offer clinicians precepts on safe clinical practice.

Introduction Maxillary advancement may affect speech in cleft patients. The aim of this study was to evaluate the effect of maxillary advancement on Finnish alveolar consonants /s/, /l/, and /r/ in cleft patients. Materials and methods Fifty-nine Finnish-speaking nonsyndromic cleft patients, who had undergone Le Fort I or bimaxillary osteotomies, were evaluated retrospectively Production of the Finnish alveolar consonants /s/, /l/, and /r/ was assessed from pre- and postoperative standardized video recordings by two experienced speech pathologists. McNemar's test was used in the statistical analyses. Kappa statistics were calculated to assess reliability. Results The patients included 35 females and 24 males with CP (n = 12), UCLP (n = 31), and BCLP (n = 16). There was a significant improvement in /s/ and /l/ sounds after maxillary advancement (p = 0.039 and p = 0.002, respectively). The preoperative mean percentage of /s/ errors was 34%; postoperatively it was 20%. /L/ was misarticulated preoperatively by 34% of the patients and postoperatively by 19%. /R/ was misarticulated preoperatively by 47% of the patients and postoperatively by 42%. The level of mild articulation errors rose from 25% to 31%, while severe articulation errors decreased from 37% to 25%. The reliabilities were good. Conclusion When planning orthognathic surgery in cleft patients with maxillary retrusion and articulation errors, advancement of the maxilla might be a means for improving articulation of /s/ and /l/.

During the COVID-19 pandemic, healthcare workers (HCWs) have faced unprecedented workloads and personal health risks leading to mental disorders and surges in sickness absence. Previous work has shown that interindividual differences in psychological resilience might explain why only some individuals are vulnerable to these consequences. However, no prognostic tools to predict individual HCW resilience during the pandemic have been developed. We deployed machine learning (ML) to predict psychological resilience during the pandemic. The models were trained in HCWs of the largest Finnish hospital, Helsinki University Hospital (HUS, N = 487), with a six-month follow-up, and prognostic generalizability was evaluated in two independent HCW validation samples (Social and Health Services in Kymenlaakso: Kymsote, N = 77 and the City of Helsinki, N = 322) with similar follow-ups never used for training the models. Using the most predictive items to predict future psychological resilience resulted in a balanced accuracy (BAC) of 72.7–74.3% in the HUS sample. Similar performances (BAC = 67–77%) were observed in the two independent validation samples. The models' predictions translated to a high probability of sickness absence during the pandemic. Our results provide the first evidence that ML techniques could be harnessed for the early detection of COVID-19-related distress among HCWs, thereby providing an avenue for potential targeted interventions.

SARS-CoV-2 has been detected both in air and on surfaces, but questions remain about the patient-specific and environmental factors affecting virus transmission to the environment. Additionally, more detailed information on viral findings in air is needed. This cross-sectional study presents results from 259 air and 252 surface samples from the surroundings of 23 hospitalized and eight home-treated COVID-19 patients between July 2020 and March 2021 and compares the results between the measured environments and patient factors. The proportions of PCR-positive air and surface samples showed statistical similarity in hospital and in the home. In four cases, positive environmental samples were detected even after the patients had developed a neutralizing IgG response. SARS-CoV-2 RNA was detected in the following particle sizes: 0.65–4.7 μm, >7 μm, >10 μm, and

Purpose Due to the coronavirus disease of 2019 (COVID-19), teachers during the pandemic have had to adapt to online teaching at short notice. This study aims to investigate the voice symptoms and their environmental risk factors as well as the work ability associated with distance teaching and to compare these with symptoms in previous contact teaching. Methods We conducted a survey of 121 primary and secondary school teachers across Finland. The survey was advertised online through social media and the replies collected from voluntarily participating teachers. Results During distance teaching vocal symptoms appeared less often than in school with 71% teachers experiencing them in regular teaching and 44% in distance teaching, VHI result decreased from 7.88 in school teaching to 4.58 in distance teaching. Acoustic conditions were reported to be more suitable in distance teaching with 73% of teachers finding them adequate during distance teaching in comparison to 46% for those in regular teaching. Background noise was the most disturbing factor for a teacher’s voice in the classroom and in distance teaching and this was even more conspicuous in the classroom. Also, subjectively experienced poor indoor air quality at school influenced the voice negatively. Further, voice problems were associated with increased subjective stress levels and reduced ability to work. Conclusion Distance teaching has affected teachers’ voices in a positive way compared with regular teaching. This difference is likely to be due to better acoustics and indoor air quality in distance teaching conditions.

AimThe purpose of the study was to determine aerosol exposure generated by coughing in operation room environments to create a quantitative limit value for high-risk aerosol-generating medical procedures.BackgroundCoughing is known to produce a significant amount of aerosols and is thus commonly used as a best reference for high-risk aerosol-generation. Accordingly, procedures during which aerosol generation exceeds the amount of aerosol generated in instances of coughing are seen as high-risk aerosol generating procedures. However, no reliable quantitative values are available for high-risk aerosol-generation.MethodsCoughing was measured from 37 healthy volunteers in the operating room environment. Aerosol particles generated during coughing within the size range of 0.3–10 µm were measured with Optical Particle Sizer from 40cm, 70cm, and 100cm distances. The distances reflected potential exposure distances where personnel are during surgeries.ResultsA total of 306 coughs were measured. Average aerosol concentration during coughing was 1.580 ± 13.774 particles/cm3 (range 0.000 – 195.528).DiscussionThe aerosol concentration measured in this study can be used as a limit for high-risk aerosol generation in the operating room environment when assessing the aerosol generating procedures and the risk of operating room staff’s exposure for aerosol particles.

Summary Background Classical singing pedagogy uses many concepts which lack precise definition and whose acoustic and physiologic correlates are unclear. This study focuses on the concepts “head resonance” and “imposto.” In singing guidebooks, head resonance has been described as causing vibratory sensations on the face and head, auditively it has been described as a bright color especially predominating in the higher pitch range. “Imposto” has been related to the sensation of “air flow” or “sympathetic resonance vibrations” on or over the upper bridge of nose, and it also has been pursued using a “closing mechanism of the upper respiratory track” (activation of nasalis muscle). Study Design Experimental cross-sectional study. Method Five subjects (three classical singers, one amateur singer, and a nonsinger) were investigated with nasofiberoscopy during phonation. The singers were instructed to sing [i:] on one comfortable self-chosen pitch in three ways: (1) without head resonance, (2) with head resonance, and (3) using imposto (exploiting the nasalis muscle). The nonsinger was investigated without phonation, while just holding his breath after inhalation first normally and then while producing imposto. The following measurements were made on the fiberoscopic images: (1) height of soft palate, (2) area of the hypopharynx, (3) area of the epilaryngeal tube inlet. Results The singers raised the soft palate and narrowed the epilaryngeal inlet during head resonance and even more during imposto. The pharynx to epilarynx ratio increased. Similar narrowing of the epilaryngeal tube inlet was observed in the nonsinger when constricting the nasalis, Conclusions The results suggest that both the head resonance and imposto are related to control of the pharyngeal space and epilaryngeal tube, and that the nasal muscles may be used as an aid in regulating the epilaryngeal tube width, which in turn, improves the voice-source -tract interaction.

Summary Background Applying measures that prioritize staff safety, while protecting patient safety and care, represents a challenge during the current pandemic. Many documents of recommendations toward safe practice have been developed for this purpose. Objective To assess adjustments that have been undertaken by phoniatricians and otolaryngologists in the delivery of health-care services during the pandemic in order to reduce staff exposure to COVID-19 and improve safety. Study design Cross-sectional. Methods An online self-administered survey was used during the first wave of the COVID-19 pandemic in June 2020 to collect data related to demographics of participants, their sources of information, administrative alterations, and changes they adopted when meeting patients for a consultation/procedure/surgery. Results The eligible 154 responses were grouped into 4 groups based on country of residence. Alterations to service delivery amongst the different groups were compared. Conclusions The majority of participants were following the suggested recommendations to service delivery adjustments, with some inconsistencies in practice across countries.

Our aim was to validate a Finnish version of the Eating Assessment Tool (F-EAT-10) for clinical use and to test its reliability and validity in a multicenter nationwide study. Normative data were acquired from 180 non-dysphagic participants (median age 57.0 years, 62.2% female). Dysphagia patients (n = 117, median age 69.7 years, 53.0% female) referred to fiberoptic endoscopic evaluation of swallowing (FEES) completed F-EAT-10 before the examination and after 2 weeks. Patients underwent the 100-ml water swallow test (WST) and FEES was evaluated using the following three scales: the Yale Pharyngeal Residue Severity Rating Scale, Penetration-Aspiration Scale, and the Dysphagia Outcome Severity Scale. An operative cohort of 19 patients (median age 75.8 years, 57.9% female) underwent an endoscopic operation on Zenker's diverticulum, tight cricopharyngeal muscle diagnosed in videofluorography, or both. Patients completed the F-EAT-10 preoperatively and 3 months postoperatively. The cut-off score for controls was 3 (sensitivity 94.0%, specificity 96.1%) suggesting that ≥ 3 is abnormal. Re-questionnaires for test-retest reliability analysis were available from 92 FEES patients and 123 controls. The intraclass correlation coefficient was excellent for the total F-EAT-10 score (0.93, 95% confidence interval 0.91-0.95). Pearson correlation coefficients were strong (p 0.001) for each of the questions and the total score. Internal consistency as assessed by Cronbach's alpha was excellent (0.95). Some correlations between findings in FEES and 100-ml WST with F-EAT-10 were observed. The change in subjective symptoms of operative patients paralleled the change in F-EAT-10. F-EAT-10 is a reliable, valid, and symptom-specific patient-reported outcome measure for assessing dysphagia among Finnish speakers.

Funding Information: This work was supported by the Helsinki University Hospital (research grant No. Y1014KN025, grant manager: Leena-Maija Aaltonen). Received: October 4, 2020. Accepted: January 28, 2021. Corresponding author: Lotta-Maria Adele Helena Oksanen, Helsinki University Hospital Department of Otorhinolaryngology and Phoniatrics – Head and Neck Surgery, Maistraatinportti 2, PO Box 250, 00029 Helsinki, Finland (e-mail: lotta.oksanen@hus.fi). Publisher Copyright: © 2021 Nofer Institute of Occupational Medicine. All rights reserved. Objectives: To evaluate the effectiveness of safety guidelines in the workplace, the authors analyzed the work-related exposure to SARS-CoV-2 and the source of COVID-19 infections among healthcare workers (HCWs), together with the use of personal protective equipment (PPE). Material and Methods: A cross-sectional prospective study was conducted in tertiary hospitals in the Uusimaa region, Finland, with 1072 volunteers being enrolled in the study from among the HCWs at the Helsinki University Hospital. Overall, 866 (80.8%) HCWs (including 588 nurses, 170 doctors, and 108 laboratory and medical imaging nurses) completed the questionnaire by July 15, 2020, with 52% of the participants taking care of COVID-19 patients. The participants answered a structured questionnaire regarding their use of PPE, the ability to follow safety guidelines, exposure to COVID-19, and the source of potential COVID-19 infections. The participants with COVID-19 symptoms were tested with the SARS-CoV-2 real-time polymerase chain reaction method. All infected participants were contacted, and their answers were confirmed regarding COVID-19 exposure. Results: In total, 41 (4.7%) participants tested positive for SARS-CoV-2, with 22 (53.6%) of infections being confirmed or likely occupational, and 12 (29.3%) originating from colleagues. In 14 cases (63.6%), occupational infections occurred while using a surgical mask, and all infections originating from patients occurred while using a surgical mask or no mask at all. No occupational infections were found while using an FFP2/3 respirator and following aerosol precautions. The combined odds ratio for working at an intensive care unit, an emergency department, or a ward was 3.4 (95% CI: 1.2-9.2, p = 0.016). Conclusions: A high infection rate was found among HCWs despite safety guidelines. Based on these findings, the authors recommend the use of FFP2/3 respirators in all patient contacts with confirmed or suspected COVID-19, along with the use of universal masking, also in personnel rooms.

Introduction: Maxillary advancement may affect speech in cleft patients. The aim of this study was to evaluate whether preoperative velopharyngeal (VP) function and cleft type can predict VP function after a Le Fort I maxillary osteotomy. Materials and methods: One hundred consecutive nonsyndromic cleft patients (54 females, 64 males) who underwent Le Fort I osteotomies were retrospectively evaluated. Pre- and postoperative VP function was assessed perceptually and instrumentally by a Nasometer. A five-point scale was used to rate velopharyngeal insufficiency symptoms (VPI 0-4). To assess reliability, 30 video recordings were re-evaluated. Results: Preoperatively, 89% of patients had normal or insignificant VPI (0-1), and only 3% had moderate VPI (3). Postoperatively, 77% of patients had VPI values of 0-1 and 14% had moderate to severe VPI values (VPI 3-4). A positive correlation was found between pre- and postoperative VPI scores, whereas the cleft type did not affect speech results. Patients with a preoperatively normal VPI (0) were not at risk for postoperative velopharyngeal incompetence. Conclusions: There was an overall significant negative change in speech after a Le Fort I osteotomy. At-risk patients presented with borderline (1) or more severe VPI (2 and 3) preoperatively. (C) 2018 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Purpose After surgery of vocal folds, almost every patient will need some voice rest. It is common to recommend total silence for some days, followed by less restricted voice use for variable periods. By now, we do not know how voice rest affects the healing process or the current practise in Europe. Methods Members of the European Laryngological Society (2012) and the Union of European Phoniatrics (2018) were sent a web-based questionnaire which included two patient cases with a short history and a still picture. The respondents were asked about the postoperative recommendation of absolute voice rest and sick leave. Results Over 90% of the respondents would recommend absolute voice rest after removing a polyp or after mucosal repair of Reinke’s oedema. For both cases, the mean length of recommended absolute voice rest among UEP members was 4 days (range 0–10 days) and among ELS members was 5 days (range 0–14 days). The recommended sick leave ranged from 0 to 35 days. The mean figures suggested by ELS members for the receptionist with Reinke’s oedema were 12 days and for the teacher with a polyp 13 days. On average, UEP members recommended 14 days of sick leave for both cases. Conclusion The present scientific evidence is scant, but does not support for prolonged (over 3 days) absolute voice rest after simple phonosurgery. So far, there are no studies that could show absolute voice rest to be superior over relative voice rest. According to the present survey, there is considerable variation in recommending voice rest and sick leave after the removal of benign mucosal lesions. Many European laryngologists suggest voice rest that is longer and stricter than the present scientific literature supports.

OBJECTIVES/HYPOTHESIS Facial functional restoration is one of the main goals in face transplantation. We report the oromyofacial function outcomes of two bimaxillary face transplantation (FT) patients in Helsinki. STUDY DESIGN Outcome Study. METHODS Two male patients, aged 34 and 59, had severe functional facial disabilities following self-inflicted gunshot injuries sustained to their mid and lower faces several years earlier. Both underwent tooth-bearing maxillomandibular face transplantation in 2016 and 2018. We collected data regarding speech, swallowing, sensory recovery, motor recovery, and olfaction prior to transplantation. Patient charts were reviewed from the follow-up period of 4 and 2 years, respectively. RESULTS Speech intelligibility, acceptability, and articulation continued to improve during follow-up for both patients. Voice quality and resonance were mainly normal at last follow-up. Swallowing improved once lip occlusion was regained, with only minor aspiration evident on videofluorography. Both patients had significant improvement in facial mimic muscle function after FT. The first patient who only had buccal sensory nerves connected has only recovered protective facial sensation, whereas our second patient with buccal, infraorbital, and alveolar nerves connected has almost complete facial two-point discrimination. CONCLUSION Both patients have regained satisfactory facial sensory and motor function. Sensory recovery seems to be faster and more precise if multiple sensory nerve coaptations are performed. Swallowing and speech have continued to improve over time although not reaching the level of the normal population. We demonstrate how speech-corrective surgery can safely be performed in a FT patient and can improve speech recovery. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E2643-E2649, 2021.

Introduction To diminish the risk of voice disorders in people who are highly dependent on their voices, such as teachers, vocal screening is important already at the beginning of such individuals’ professional studies. A reliable, specified screening tool is needed. The Acoustic Voice Quality Index (AVQI) has been found to differentiate normal voices from abnormal voices and to serve as a treatment outcome measure. This study investigated whether AVQI could be a screening tool in combination with auditory- and self-perception of the voice to discriminate normal from slightly poor voices. Type of Study Experimental. Methods Some 128 female teaching students (mean age 26.39 years, SD 9.80 years) with no diagnosed voice disorders participated in this study. They read aloud a text in Finnish, sustained the vowel /a:/, and filled the Voice Handicap Index (VHI) questionnaire. Voice samples were recorded with an AKG C544L headset microphone, iFocusrite soundcard, and Praat software using a 44100 sample rate and 16-bit amplitude quantization. Five expert voice therapists evaluated the samples to determine the grade of dysphonia (G) using a scale of 0–0.5 (=normal), 0.5–1 (=mild), 1–2 (=moderate), and 2–3 (=severe). Three medial seconds of [a:] and the first 31 syllables of the text were analyzed using AVQI script version 03.01 in Praat (5.3.55). The analysis gives one AVQI score per participant (scale 0–10). The AVQI threshold of normal and disordered voices for Finnish speakers is 1.83; a Gmean = 0.0–0.5 and VHI score Results According to the AVQI results, the area under the curve (AROC) was 0.554, which is fair. The Youden index gave a cutoff value of 0.30 with a sensitivity of 85% and a specificity of 81.1%. There were weak but significant correlations between Gmean and AVQI and two AVQI parameters, smoothed cepstral peak prominence and harmonic-to-noise ratio (r = 0.27; −-0.24; −0.20, respectively; |P Conclusions AVQI did not differentiate between voices that had been perceptually judged as normal or slightly abnormal, but a combination of perceptual assessment in the form of AVQI and VHI could better screen slightly deviant voices.

ObjectiveTo analyse the work-related exposure to SARS-CoV-2 and trace the source of COVID-19 infections in tertiary hospitals’ healthcare workers in light of the used PPE and their ability to maintain social distances and follow governmental restrictions.DesignCross-sectional studySettingTertiary hospitals in Uusimaa region, FinlandParticipantsOf 1072 enrolled, 866 HCWs (588 nurses, 170 doctors and 108 laboratory and medical imaging nurses) from the Helsinki University Hospital completed the questionnaire by July 15th, 2020. The average age of participants was 42.4 years and 772 (89.0%) were women. The participants answered a detailed questionnaire of their PPE usage, ability to follow safety restrictions, exposure to COVID-19, the source of potential COVID-19 infection and both mental and physical symptoms during the first wave of COVID-19 in Finland.Main outcome measuresAll participants with COVID-19 symptoms were tested with either RT-PCR or antibody tests. The infections were traced and categorised based on the location and source of infection. The possibility to maintain social distance and PPE usage during exposure were analyzed.ResultsOf the HCWs that participated, 41 (4.7%) tested positive for SARS-CoV-2, marking a substantially higher infection rate than that of the general population (0.3%); 22 (53.6%) of infections were confirmed or likely occupational, including 7 (31.8%) from colleagues. Additionally, 5 (26.3%) of other infections were from colleagues outside the working facilities. 14 (63.6%) of occupational infections occurred while using a surgical mask. No occupational infections were found while using an FFP2/3 respirator and aerosol precautions while treating suspected or confirmed COVID-19 patients.ConclusionsWhile treating suspected or confirmed COVID-19 patients, HCWs should wear an FFP2/3 respirator and recommended PPE. Maintaining safety distances in the workplace and controlling infections between HCWs should be priorities to ensure safe working conditions.

Purpose. The present study aimed at measuring the smoothed and non-smoothed cepstral peak prominence (CPPS and CPP) in teachers who considered themselves to have normal voice but some of them had laryngeal pathology. The changes of CPP, CPPS, sound pressure level (SPL) and perceptual ratings with different voice tasks were investigated and the influence of vocal pathology on these measures was studied. Method. Eighty-four Finnish female primary school teachers volunteered as participants. Laryngoscopically, 52.4% of these had laryngeal changes (39.3% mild, 13.1% disordered). Sound recordings were made for phonations of comfortable sustained vowel, comfortable speech, and speech produced at increased loudness level as used during teaching. CPP, CPPS and SPL values were extracted using Praat software for all three voice samples. Sound samples were also perceptually evaluated by five voice experts for overall voice quality (10 point scale from poor to excellent) and vocal firmness (10 point scale from breathy to pressed, with normal in the middle). Results. The CPP, CPPS and SPL values were significantly higher for vowels than for comfortable speech and for loud speech compared to comfortable speech (P 0.05). Conclusion. Neither the acoustic measures (CPP, CPPS, and SPL) nor the perceptual evaluations could clearly distinguish teachers with laryngeal changes from laryngeally healthy teachers. Considering no vocal complaints of the subjects, the data could be considered representative of teachers with functionally healthy voice.

Phoniatricians usually have the key role when dealing with a voice disorder, supported by logopedists/speech-language pathologists. Cooperation with other medical or non-medical disciplines may contribute when needed. Fundamentals, general goals and the structure of voice therapy are followed by a survey of specific methods and techniques. No matter what kind of technique is used, treatment strategy is inevitably based on pathophysiological mechanisms of a disorder and the patient’s state as a whole. Voice therapy is a dynamic process and not an application procedure for a stable phonatory pattern or a list of exercises for every patient. This integrative model for treatment of voice disorders includes additional skills and knowledge of mechanisms of applications, stages of behavioural treatment, phases of motor learning, stages of voice therapy and steps of a given technique. Functional disorders of the singing voice (dysodia) require additional and specific expertise, especially in emergency situations in the frame of cancellation policy regarding the opera and theatre business. Drug treatment and physiotherapy/osteopathy as more therapeutic approaches to voice disorders are presented, as well as phonosurgical procedures, i.e. functional surgical interventions aiming exclusively, or in part, at improvement, restoration or preservation of vocal function. Methods comprise of phonomicrosurgery (endoscopic microsurgery), laryngeal injection and laryngeal framework surgery that modify the cartilaginous framework of the larynx (laryngoplastic phonosurgery, open-neck surgery). Pacing and reinnervation are also discussed as alternatives in bilateral vocal fold palsies, and vocal rehabilitation after head and neck surgery, including the use of personalised computer speech synthesis for laryngectomised patients, is considered. Indications for tracheostomy and tracheostoma care refer to clinical practice. The prognosis of voice rehabilitation depends on the various factors that are included in voice production and should be considered accordingly.