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Objective: Analyze the duration of symptom‐free intervals following laser wedge excision (LWE) for recurrent idiopathic subglottic stenosis (iSGS). Secondary aim includes evaluating the influence of patient‐related or disease factors. Study Design: Retrospective review. Setting: Tertiary center. Methods: Review of iSGS patients who underwent LWE between 2002 and 2021. LWE patients without prior airway surgery were labeled LWE primary (LWEP) and those with prior history of dilation were labeled LWE secondary (LWES). A conditional frailty repeated events model was used to analyze the median time to recurrence (MTR) for each nth recurrence. Secondary analysis included stratification by use of medical therapy and initial preoperative characteristics of scar (Myer‐Cotton grade, distance between the glottis and superior‐most aspect of scar, DGS; length of scar, DL). Results: Two hundred and ten iSGS patients underwent LWE (131 LWEP, 79 LWES). The proportion of patients experiencing at least 1, 3, 6, and 12 recurrences, respectively, was 68.0% (n = 143), 40.7% (n = 85), 20.0% (n = 42), and 5.2% (n = 11). There was exponential time‐shortening from the 1st to 12th recurrence (P <.0001). While MTR was 4.1 years after the first LWE, this fell to 2.8, 1.7, 1.0, and 0.7 years for the 2nd, 3rd, 6th, and 12th recurrences. Furthermore, LWEP patients experienced longer MTR than LWES counterparts within the first 6 recurrences (P <.01). There was no significant relationship between intersurgical interval and medication adherence, DL, DGS, or grade for recurrences beyond the first (P =.207, P =.20, P =.43, P =.16). Conclusion: Symptom‐free intervals in iSGS shorten with each subsequent recurrence and LWE. The difference in MTR between LWEP and LWES groups was significant within the first 6 recurrences with LWEP having longer MTR. Level of Evidence: 3. [ABSTRACT FROM AUTHOR]

Objective: To report on a series of patients with cANCA/PR3‐positive, granulomatosis with polyangiitis (GPA)‐associated subglottic stenosis (SGS) and evaluate response to medical maintenance therapy with rituximab versus other immunosuppressants following initial endoscopic laser excision. Study Design: Retrospective chart review. Setting: Tertiary academic center. Methods: A retrospective chart review of patients with SGS and cANCA/PR3‐positive GPA who received immunosuppressive maintenance therapy following endoscopic laser excision at our institution from June 1989 to March 2020 was performed. Data pertaining to patient demographics, clinical features, medications, and endoscopic laser procedures were collected. Results: A total of 27 patients (15 women) with mean age (range) of 40 (19‐59) years and mean (range) follow‐up of 12.6 years (1.5‐28.6) were identified. Sixteen patients (60%) had limited GPA. Six patients (24%) had previously received local intervention with open surgery (n = 1, 4%) or endoscopic techniques (n = 5, 20%). All patients experienced symptom improvement following initial CO2 laser excision at our institution without any procedural complications or adverse events. Following initial laser excision, 15 patients (60%) were treated with rituximab and 10 patients (40%) were treated with nonrituximab immunosuppressive agents. Patients treated with rituximab were less likely to recur (P = 0.040). Limited GPA was associated with an increased incidence of recurrence (P = 0.031). Median time (years) to recurrence (range) was 3.2 (0.3‐19.3) and was not significantly associated with treatment or GPA subtype. Conclusion: Endoscopic CO2 laser excision is a safe and effective local intervention for GPA‐associated SGS. Medical maintenance therapy with rituximab reduces risk of recurrence following initial laser excision relative to treatment with non‐rituximab agents. [ABSTRACT FROM AUTHOR]

Objectives: Many summer research programs (SRPs) for URiM students exist; however, only a few have been established by otolaryngology programs, who have a unique opportunity to provide a diverse experience. We sought to assess URiM undergraduate student perspectives on the most valuable program features that influence decision‐making and how this might be useful to otolaryngology programs seeking to establish pathway programs. Materials and Methods: An externally facing REDCap survey composed of 37 questions in scaled, multiple‐choice, and open‐ended form. The survey was delivered to applicants via email over two time periods in April 2021 and February 2022. All survey responses were analyzed using descriptive statistics and categorized according to demographic information, program features, and advertising mechanisms. Results: Seventy‐one percent of our applicants self‐identified as URiM. Over 60% experienced financial hardship, and 31% experienced educational hardship. The single most important feature when selecting a summer research program (SRP) was access to mentorship followed by clinical shadowing and research opportunities. When program features were aggregated into groups, institutional features were the most important, followed closely by funding features. Finally, students prefer to learn about SRPs through their university, followed by social media, despite many students learning about our program through other means. Conclusions: Paid programs with effective advertising, research, mentoring, and clinical shadowing are highly valued by URiM undergraduate students. Understanding student perspectives is critical for programs aiming to address the "leaky pipeline" while being deliberate in their support of underrepresented students. Level of Evidence: 5 Laryngoscope, 134:637–644, 2024 [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate visual gaze patterns and the ability to correctly identify cancer among participants of different experience levels when viewing benign and malignant vocal cord lesions. Methods: Thirty-one participants were divided into groups based on level of experience. These included novice (medical students, PGY1-2 otolaryngology residents), intermediate (PGY3-5 otolaryngology residents, gastroenterology fellow), advanced practice providers (physician assistants, nurse practitioners, and speech language pathologists), and experts (board-certified otolaryngologists). Each participant was shown 7 images of vocal cord pathology including glottic cancer, infectious laryngitis, and granuloma and asked to determine the likelihood of cancer on a scale of certain, probable, possible, and unlikely. Eye tracking data were collected and used to identify the area of interest (AOI) that each participant fixated on first, fixated on the longest, and had the greatest number of fixations. Results: No significant differences were seen among groups when comparing AOI with first fixation, AOI with longest fixation, or AOI with most fixations. Novices were significantly more likely to rate a low likelihood of cancer when viewing infectious laryngitis compared to more experienced groups (P <.001). There was no difference in likelihood of cancer rating among groups for the remaining images. Conclusions: There was no significant difference in gaze targets among participants of different experience levels evaluating vocal cord pathology. Symmetric appearance of vocal cord lesions may explain differences seen in likelihood of cancer rating among groups. Future studies with larger sample sizes will better elucidate gaze targets that lead to accurate diagnosis of vocal cord pathology. [ABSTRACT FROM AUTHOR]

Objective: To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum. Study Design: Single institution retrospective review. Setting: Tertiary care academic hospital. Methods: We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020. Results: A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure‐related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups. Conclusion: The flexible endoscopic technique was associated with the highest rate of procedure‐related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long‐term follow‐up are needed. [ABSTRACT FROM AUTHOR]

This article presents a case study of a patient who developed a life-threatening subglottic thrombus after receiving nebulized tranexamic acid (TXA) for postoperative hemoptysis following CO2 laser wedge excision of subglottic stenosis. While other factors may have contributed to the bleeding and thrombus formation, the rapid deterioration of the patient after receiving nebulized TXA suggests a direct effect. The authors recommend implementing an airway action plan for the use of TXA in patients with postoperative hemorrhage following otolaryngology procedures. This case highlights the potential risks and benefits of nebulized TXA in patients with bleeding from the larynx or trachea. [Extracted from the article]

Objective: To compare the incidence of glottic stenosis in idiopathic subglottic stenosis (iSGS) patients with no prior surgical intervention to those with a history of endoscopic dilation and characterize the incidence of glottic involvement, changes in scar length, and progression of scar toward glottis following laser wedge excision (LWE). Methods: A retrospective review of iSGS patients who underwent LWE between 2002 and 2021 was performed. Patients without prior airway surgery were labeled LWE primary (LWEP) and operative findings for LWEP patients were reviewed for glottic involvement, scar length (DL), and distance from the glottis to superior‐most aspect of scar (DGS). Rates (in mm/procedure) of DΔL, reflecting an increase in length, and D−ΔGS, reflecting proximal migration, were calculated by dividing DΔL and D−ΔGS by the number of LWE procedures. Results: 213 iSGS patients underwent LWE, with 132 being LWEP patients. LWEP had a lower incidence of baseline glottic involvement (n = 6, 4.5%) than LWE secondary (LWES; n = 6, 7.5%). Four new cases of glottic involvement were noted in LWEP patients following LWE, with only one being clinically significant resulting in permanently decreased vocal fold mobility. With each procedure, scar length increased by 1.0 mm and DGS decreased by 0.7 mm, reflecting a migration or decrease in DGS of 9.5% with each procedure with respect to initial DGS. Overall rates of glottic stenosis following operations were similar between LWEP and LWES cohorts, 7.6% and 7.5% respectively. Conclusion: There appears to be a low risk of glottic involvement resulting from the LWE procedure in iSGS patients. Level of Evidence: 4 Laryngoscope, 133:875–882, 2023 [ABSTRACT FROM AUTHOR]

Keywords: Airway stenosis/reconstruction; broncho-eEsophagology; airway stenosis Clinical; laryngology; airway reconstruction EN Airway stenosis/reconstruction broncho-eEsophagology airway stenosis Clinical laryngology airway reconstruction E1062 E1066 5 03/12/21 20210401 NES 210401 INTRODUCTION Idiopathic subglottic stenosis (iSGS) is a challenging and recurrent disease affecting Caucasian females with an unknown etiology and multiple potential contributing factors.1 The most common method of management of SGS includes endoscopic balloon or rigid dilation, often with carbon dioxide (CO2) laser radial incisions prior to dilation.1 Balloon dilation does carry some risk including tracheal laceration, cricoid fracture, and dilation of healthy trachea leading to potential disruption of normal tracheal mucosal tissue.2 First described in the literature in 2013, CO2 laser wedge excisions are an alternative to traditional balloon dilation. ERMT was associated with temporary tongue paresthesia and rare dental injury.4 DISCUSSION CO2 laser endoscopic wedge excisions can be a highly effective method of treating idiopathic subglottic stenosis with decreased recurrence rates compared to traditional endoscopic balloon dilation and improved voice outcomes compared to cricotracheal resection (CTR). The excision of scar in the subglottis is individualized, with tissue excision directed towards maximizing airway diameter and preservation of the conus elasticus and perichondrium. [Extracted from the article]

Objectives: Prognostic information about the return of vocal fold mobility in patients with iatrogenic unilateral vocal fold immobility (UVFI) can help with informed decisions about temporary and permanent treatment options. Although many variables can influence the likelihood of recovery, clinical experience suggests that cervical versus thoracic injury is a determining factor. The purpose of this study was to compare recovery rates from UVFI between cervical and thoracic injuries. Methods: A retrospective review of the medical record was performed on all adult patients diagnosed with complete iatrogenic UVFI from 2005 to 2015 (n = 923). Patients with incomplete data and etiologies of idiopathic, malignancy, or stenosis were excluded, leaving a study cohort of 502 patients who were categorized as having UVFI after cervical (n = 329) or thoracic (n = 173) injury. Data regarding site of iatrogenic injury (cervical vs thoracic), mobility status, and time interval to recovery or surgical intervention were recorded and compared using χ2 analyses. Results: Overall, 15% of patients recovered vocal fold mobility at a median of 4.1 months. Patients with cervical injury (65 of 329 [20%]) were significantly more likely to recover mobility than patients with thoracic injury (11 of 173 [6.4%]) (odds ratio, 3.63). The cervical cohort contained more women (68% vs 31%) and was younger (mean age, 60.4 ± 13.8 vs 64.1 ± 16.1 years; Cohen's D = 0.25). Conclusions: Patients with cervical injuries resulting in UVFI are 4 times more likely to recover mobility than patients with thoracic injuries. This information can be valuable in counseling patients with UVFI and may affect clinical decision making. [ABSTRACT FROM AUTHOR]

In broad strokes, referral to otolaryngology at our institution typically occurs when a patient has clear obstructive dysphagia with evidence of a cricopharyngeal (CP) bar and would be a suitable surgical candidate. In Reply: We appreciate the interest in our article demonstrating outcomes in patients with inclusion body myositis that undergo surgical intervention. [Extracted from the article]

The article presents the response of comments made by Tsai et al regarding the recently published manuscript, "Cardiothoracic Patients with Unilateral Vocal Fold Paralysis: Pneumonia Rates Following Injection Laryngoplasty" highlighting the ongoing risk of pneumonia in cardiothoracic surgery.

Objective: To evaluate the impact of age on disease recurrence in idiopathic subglottic stenosis (iSGS) patients., Methods: This was a retrospective chart review of iSGS patients treated with laser wedge excision. Patients did not have prior surgery. Survival rates free of recurrence were estimated using the Kaplan-Meier methods, and associations were evaluated using Cox Proportional Hazards models., Results: Eighty-five female patients were included in the study. Most patients (68%) were postmenopausal, had first period at or before 13 years of age, had at least one full-term pregnancy (82%), were not undergoing hormone replacement therapy (93%), were not using hormonal birth control (88%), and were either partially or completely compliant with triple therapy regime (80%). There was a statistically significant average reduction in risk of recurrence of 5% for every additional year of age (p < 0.0001). When compared to patients older than 65 years of age, patients less than 35 were nearly 10 times more likely to recur (p = 0.002), and patients 55-65 and 45-55 years of age were 8 and 5 times more likely to recur, respectively (p = 0.003 and 0.009). Additionally, females on birth control showed decreased risk of recurrence of 74% compared with their counterparts (p = 0.04)., Conclusion: This is the first study to demonstrate an inverse relationship between age and disease recurrence in patients with iSGS following surgery. Using age as a surrogate for menopausal status, these results suggest that increased age and/or birth control provide a protective effect through decreased recurrence rates, possibly mediated by decreased estrogen levels., Level of Evidence: 4 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate the impact of methotrexate and rituximab therapy on highly recurrent idiopathic subglottic stenosis (iSGS) patients with a negative antineutrophil cytoplasmic antibody titer cANCA(-)., Methods: This was a retrospective cohort study of highly recurrent iSGS patients who recurred within 1 year or less and were treated with methotrexate (MTX), and rituximab (RTX), or a combination of both at different time points (MTX/RTX). Average surgical durations before and after drug treatment were summarized, and the differences were calculated., Results: A total of 21 female patients with median age of 62 years were included. Fifteen patients were treated with MTX, three were treated with RTX, and five treated with both. Patients treated with immunosuppressants showed a trend toward longer intervals between operations (mean pre-drug interval: 338; mean post-drug interval: 697 days) (p-value = 0.25). Three patients did not recur following drug initiation with median follow-up of 1265 days. All three treatment groups demonstrated a trend toward increased post-drug recurrence intervals (MTX: 444 days, RTX: 374 days, MTX/RTX: 55 days), that was not statistically significant. Patients with prior dilations demonstrated longer post-drug recurrence intervals (mean pre-drug interval: 341 days, mean post-drug interval 978 days) (p-value = 0.17). Four patients in the cohort with the highest recurring disease improved from mean 129 days between operations to 509 days with drug therapy. The most common drug side effect was nausea (16%)., Conclusion: MTX and RTX may be treatment options for some highly recurrent iSGS patients. Initial results are variable and demonstrate a need for further research on drug candidacy., Level of Evidence: 3 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: To determine the effects of gargle phonation (GP) on self-perceived vocal improvement, vocal effort, acoustic parameters, and speech rate in patients with muscle tension dysphonia (MTD). We hypothesized that GP would improve voice, reduce phonatory effort, and alter acoustic and speech measures., Study Design: Prospective randomized, single-blind cross-over clinical trial METHODS: Thirty-four participants (26 females, 8 males; average age 53 years) who were diagnosed with MTD completed the Voice Handicap Index-10 (VHI-10) and were assigned three study conditions: Baseline (B), GP, and Water Swallow (WS; sham), presented in one of two counterbalanced orders B-WS-GP (WS 1st ) or B-GP-WS (GP 1st ). Participants recorded stimuli from the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and rated their perceived vocal effort and vocal improvement. F0, vocal intensity, cepstral peak prominence (CPP), and speaking rate were measured., Results: Average VHI-10 scores by group were 16 (min/max 2-29) for WS 1st and 15 (min/max 3-40) for GP 1st . About 73.5% reported more vocal improvement after GP, 17.65% after WS, and 8.8% noted no difference between conditions. Reduced effort was reported after GP, compared to B (P < 0.001) and WS (P = 0.005). Lower effort was also reported after the WS condition, compared to B (P = 0.011). Key acoustic findings included an increase in F0 after GP for sustained /i/ for females. CPP was significantly higher for females reading CAPE-V sentences after GP, when GP preceded WS, compared to B (P = 0.004) and WS (P = 0.003). Speech rate was faster for females after GP versus B (P = 0.029)., Conclusions: GP may be beneficial in the treatment of MTD. CPP may be a useful marker for vocal improvement after GP for women with mild MTD. Further studies would benefit from having more male participants and those with moderate and severe MTD., Competing Interests: Declaration of Competing Interest None, (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Otolaryngology continues to have one of the lowest percentages of black physicians of any surgical specialty, a number than has not improved in recent years. The history of exclusion of black students in medical education as well as ongoing bias affecting examination scores, clerkship grades and evaluations, and honors society acceptance of black students may factor into the disproportionately low number of black otolaryngology residents. In order to increase the number of black physicians in otolaryngology, intentional steps must be taken to actively recruit, mentor, and train black physicians specializing in otolaryngology., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)