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Background: Voice outcome after carbon dioxide transoral laser microsurgery (CO 2 TOLMS) for glottic cancer is of prime importance. However, a comprehensive overview according to the European Laryngological Society (ELS) classification of cordectomies is still lacking. The aim of this systematic review is to summarize data on voice outcome associated with individual types of ELS glottic cordectomy after CO 2 TOLMS., Materials and Methods: A systematic review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. The initial search identified 936 records of which 25 publications were then included. Voice outcome data (Voice Handicap Index [VHI] version 30, grade of dysphonia [G] and maximum phonation time [MPT]) were extracted per resection type. Weighted averages were calculated., Results: Data show a gradual increase in the VHI scores although they were still similar for all cordectomy types (range 14.2 to 21.5). The grade of dysphonia showed a gradual increase with increasing resection depth (range 1.0 to 1.9). There was a gradual decrease in the MPT (range 15.2 to 7.2)., Conclusion: Voice outcome is related to cordectomy type with mild dysphonia characterizing ELS type I, II and III cordectomies, while more extended cordectomies (ELS type IV, V and VI) result in moderate dysphonia and shortness of breath during phonation. The voice handicap experienced by patients is limited even in the more extended cordectomies., (Copyright © 2022. Published by Elsevier Inc.)

A variety of surgical treatment options exist for adductor spasmodic dysphonia (ADSD) with selective adductor recurrent laryngeal nerve denervation and reinnervation (SLAD-R) being one of the more popular. We present a case of bilateral vocal fold paralysis (BVFP) for SLAD-R resulting in the need for total laryngectomy. We suggest BVFP is more common than reported and that we all must insure optimal long term follow up of our surgical patients. Laryngoscope, 134:4582-4584, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Velopharyngeal insufficiency (VPI) is a form of velopharyngeal dysfunction caused by abnormal or insufficient anatomy. This process is known to be associated with dysphagia and dysphonia but surgical interventions for these complex patients have not been well studied. The current study characterized a small cohort of adult patients with acquired VPI, dysphonia, and dysphagia, as well as associated surgical interventions., Methods: A retrospective descriptive case series of 22 (N = 22) adult patients over a 6-year period with acquired VPI and varying degrees of dysphagia and dysphonia was described from a multi-disciplinary voice and swallowing clinic. Perceptual assessment, nasopharyngoscopy, fluoroscopic swallowing assessment, and patient reported outcomes were reviewed to characterize the cohort., Results: VPI etiologies included: stroke (n = 4), head and neck cancer (n = 5), brainstem lesions (n = 5), trauma (n = 5), and other/unknown (n = 3). All 22 patients underwent nasopharyngoscopy and were categorized as having unilateral (n = 13), central (n = 4), or no (n = 5) velopharyngeal deficits. Seventeen patients (77.2%) underwent modified barium swallow studies, revealing that soft palate elevation scored least impaired among patients with no VPI, and most impaired among patients with unilateral VPI deficits. All 22 patients underwent some form of surgical intervention for VPI, with 14 (63.6%) of those patients requiring additional surgical revision., Conclusion: This series is one of the first to the authors' knowledge to characterize a cohort of individuals with VPI, dysphagia, and dysphonia and associated surgical interventions., Competing Interests: Declarations of competing interest None., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Age-related vocal atrophy (ARVA) is associated with vocal fold bowing, persistent glottal gap during phonation, and dysphonia. Bilateral medialization thyroplasty is sometimes performed in patients with ARVA to improve vocal fold closure and voice. We set out to quantify stroboscopic changes in vocal fold bowing, glottal closure, and abduction angle following bilateral thyroplasty and determine how these changes affect voice quality among patients with ARVA., Methods: Fifteen individuals with ARVA who underwent bilateral medialization thyroplasty were included in this study. Two independent investigators calculated bowing index (BI), normalized glottal gap area (NGGA), and maximum abduction angle from laryngostroboscopic exams using ImageJ™. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and patient-reported measures were collected before and after thyroplasty., Results: Thyroplasty resulted in a 10-point improvement in overall CAPE-V (Mean dif -10; 95% CI -17, -3.3, p < 0.01) and VHI-10 (mean dif -3.8; 95% CI -9.8, 2.3, p = 0.19, n = 8). NGGA and BI significantly decreased following surgery (mean dif -78; 95% CI -155, -1.5, p = 0.05; and mean dif -2.1; 95% CI -2.4, -0.84, p < 0.01, respectively). BI correlated with CAPE-V scores (r = 0.66, 95% CI 0.22, 0.87, p < 0.01). When considering the normalized combined contributions of both NGGA and BI, there was a stronger correlation in CAPE-V scores (r = 0.87, 95% CI 0.50, 0.97, p < 0.01) compared with either measure alone., Conclusions: Thyroplasty resulted in a decrease in vocal fold bowing, glottal gap area, and CAPE-V scores in patients with ARVA. Correction of vocal bowing and glottal gap, following bilateral thyroplasty, improved voice measures following surgery. Quantitative evaluation of vocal fold morphology may be valuable when assessing the severity and treatment-response in patients with ARVA following bilateral thyroplasty. Laryngoscope, 134:835-841, 2024., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Spasmodic dysphonia (SD) is a debilitating neurological disorder affecting the muscles of voice production. Sudden involuntary movements of the vocal folds lead to phonatory breaks and to forced, strained, and strangled voice quality in adductor SD, or breathy breaks in abductor SD. There is currently no cure for spasmodic dysphonia, and the gold standard for treatment is the injection of botulinum toxin in small amounts to the intrinsic laryngeal musculature. 1 However, botulinum treatment requires periodic reinjection, produces vocal instability immediately after injection, lacks uniform results among patients, and patients can develop antibodies to botulinum toxin. Long-term or permanent symptom relief would be ideal. We present four patients with adductor and one patient with abductor spasmodic dysphonia who underwent neurectomy and myomectomy for treatment. The mean age was 64 years (age range 45-83). The mean duration of adductor spasmodic dysphonia was 11.8 years. The duration of abductor spasmodic was 4 years. All patients had previously been treated with voice therapy and botulinum toxin A. The mean duration of follow up was 1.7 years. Four patients had subjective and objective improvement after surgery. One patient had subjective improvement., (Copyright © 2019. Published by Elsevier Inc.)

Objectives: Injection of botulinum toxin type A (BTX) into intrinsic laryngeal muscles is the current gold standard therapy for adductor spasmodic dysphonia (AdSD). However, a surgical procedure could potentially offer more stable and long-lasting voice quality to AdSD patients. Here, we report the long-term results of type 2 thyroplasty (TP2) with TITANBRIDGE® (Nobelpharma, Tokyo, Japan) compared with those of BTX injections., Methods: In total, 73 AdSD patients visited our hospital between August 2018 and February 2022. Patients were provided the option of BTX injections or TP2. They were assessed via the Voice Handicap Index (VHI)-10 before treatments and at scheduled clinical follow-ups at 2, 4, 8, and 12 weeks for BTX and at 4, 12, 26, and 52 weeks for TP2., Results: Overall, 52 patients selected the BTX injection and had a pre-injection mean VHI-10 score of 27.3 ± 8.8. Following injections, the scores significantly improved to 21.0 ± 11.1, 18.6 ± 11.5, and 19.4 ± 11.7 at 2, 4, and 8 weeks, respectively. There were no significant differences between the pre-injection scores and the 12-week scores (21.5 ± 10.7). Alternately, 32 patients opted to be treated with TP2 and had a pre-treatment mean VHI-10 score of 27.7. All patients reported an improvement in their symptoms. Additionally, the mean VHI-10 score significantly improved to 9.9 ± 7.4 at 52 weeks following treatment. There was a significant difference between the two treatment groups at 12 weeks. Some patients received both treatments., Conclusion: These preliminary results provide important insights into the value of TP2 as a potential permanent treatment for AdSD patients., Level of Evidence: 3 Laryngoscope, 133:3443-3448, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Benign vocal fold lesions cause dysphonia by preventing vocal fold closure, causing irregular vibration and increasing compensatory muscle tension. Voice therapy delivered in addition to phonosurgery may improve voice and quality of life outcomes but the evidence base is lacking and what constitutes voice therapy for this population is not defined. The purpose of this systematic review is to critically evaluate the evidence for pre and post-operative voice therapy to inform the development of an evidence based intervention., Study Design: Systematic Review., Methods: Electronic databases were searched using key terms including dysphonia, phonosurgery, voice therapy and outcomes. Eligible articles were extracted and reviewed by the authors for risk of bias and for information regarding the content, timing and intensity of any pre and post-operative voice therapy intervention., Results: Of the 432 articles identified, 35 met the inclusion criteria and were included in the review. 5 were RCTs, 2 were individual cohort studies, 1 was a case control study and 26 were case series. There was considerable heterogeneity in participant characteristics. Information was frequently lacking regarding the content timing and intensity of the reported voice therapy intervention, and where present, interventions were highly variable., Conclusion: Reporting in relevant literature is limited in all aspects of content, timing and intensity of intervention. Further intervention development work is required to develop a robust voice therapy treatment intervention for this population, before effectiveness work can commence., (Crown Copyright © 2021. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the durability of current titanium implants (TI) used in voice improvement surgery for adductor spasmodic dysphonia (ADSD), which is type II thyroplasty (T2T), and identify the effects of their fractures on vocal functions., Methods: A total of 36 ADSD patients who underwent T2T had the following exams: The CT scans of the larynx were performed 1 year after the surgery to assess the fractures of TI. The improvement in the mean voice handicap index 10 (VHI-10) scores and the success rate between nonfractured (NFR) and fractured (FR) groups were compared., Results: It was indicated that TI was broken in 21 cases (58.3%). In one case (2.7%), a fracture on the part of the bridge that connects both sides of the plates was observed, and fractures at holes placed on the plates in the other 35 cases (55.6%). The mean VHI-10 score improved from 27.2 ± 8.1 to 11.4 ± 7.9 in the NFR group and from 26.3 ± 4.9 to 9.7 ± 7.9 in the FR group. The success rates were 66.6% in the NFR group and 71.5% in the FR group. No statistical difference was observed in the improvement in the mean VHI-10 scores, and the success rate between the two groups. However, two cases resulted in failure in the FR group, whereas no worsened case was observed in the NFR group., Conclusion: The current TI used in T2T has low durability and could result in the worsening of vocal symptoms after the surgery., Level of Evidence: 4 Laryngoscope, 133:3028-3033, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Supracricoid partial laryngectomy (SCPL) is an oncologically sound alternative to total laryngectomy that results in long-term alterations in vocal function. Little is known about long-term improvements in dysphonia and the mechanism of vocal recovery is unclear due to the lack of a standardized rating tool: The Pattern, Degree, and Vibration (PDV) Scale., Methods: Data from 24 individuals were compared over 3 post-operative timepoints after SCPL: 3 to 11, 12 to 35, and over 35 months. Voice outcomes were assessed using the Voice Handicap Index (VHI) and the GRBAS scale. Laryngeal exams were deidentified and rated using a novel rating scheme developed using literature review and consensus panel discussions., Results: There were significant improvements in VHI scores, Grade, and Strain over time. There was an increase in the Degree of Closure and a decline in Mucosal Vibration across timepoints. Pattern of Movement (P) was associated with dysphonia Grade. Better Degree of Closure (D) was associated with lower VHI scores and better Grade and Roughness. Mucosal Vibration (V) was associated with reduced Breathiness and Strain but variable Roughness. Age, T-stage, radiation treatment, surgery type, and time to feeding-tube removal were also associated with voicing characteristics., Conclusions: There is evidence of improvement in several voice parameters over time after the first post-operative year. Various subcomponents of the new PDV rating scale were associated with voice outcomes. Its utility for research and clinical practice merits further investigation.

Objective: Fat injection laryngoplasty (FIL) is a common procedure used to correct glottic insufficiency. Nevertheless, few studies have discussed potential treatments for cases with poor voice recovery after FIL., Methods: Eighteen patients with unfavorable vocal outcomes from FIL were analyzed. Each of these patients presented persistent dysphonia for more than 2 months following FIL, together with bulging vocal folds and poor mucosal wave. We applied microsurgery as the standard treatment to remove excessive fat. Vocal fold steroid injection (VFSI) was administered to patients that were hesitant or declined to undergo microsurgery. Voice outcomes were evaluated using the Voice Handicap Index-10 (VHI-10), grade-roughness-breathiness (GRB) scores, and smoothed cepstral peak prominence (CPPs)., Results: Six patients underwent microsurgery directly, 6 patients received only VFSIs as a salvage treatment, and the remaining 6 patients received 1 to 3 courses of VFSIs before the decision to undergo microsurgery. Pathology reports were available for 10 patients, and contained 5 instances of adipose tissues, 3 of fat necrosis, 1 of chronic inflammation, and 1 of fibrosis. Seventeen patients reported satisfactory or improved outcomes. We found remarkable improvements in VHI-10, GRB, and CPPs (all P  < .05) after salvage treatments for FIL. Subgroup analyses showed comparable voice outcomes for patients undergoing direct microsurgery, VFSI alone, and VFSI followed by microsurgery ( P  > .05)., Conclusions: This study demonstrated that fat overinjection and/or fibrotic change in the injected vocal folds may cause poor voice outcomes after FIL. Both microsurgery and VFSI could be applied as salvage treatments with good voice recovery profiles., Level of Evidence: Level 4.

Preoperative laryngoscopy is mandatory when there is a history of cervical or thoracic surgery, dysphonia, posteriorly developed thyroid carcinoma, or significant lymph node involvement in the central compartment. Postoperative laryngoscopy should be performed for any postoperative dysphonia, swallowing difficulties, respiratory symptoms, or loss of signal during neuromonitoring of the recurrent and/or vagus nerve. Neuromonitoring can be useful in thyroid surgery because it lowers the rate of transient recurrent palsy (RP), although no impact on permanent RP has been demonstrated. It facilitates location of the recurrent nerve. Continuous neuromonitoring of the vagus nerve can, in some situations, allow early detection of a signal drop during dissection near the recurrent nerve., (Copyright © 2023 Elsevier Masson SAS. All rights reserved.)

Objective: Some patients with subglottic stenosis (SGS) require open airway reconstruction, which traditionally involves resection of the anterior cricoid cartilage. As an alternative, we present a novel technique: cricoid-sparing high tracheal resection with excision of subglottic stenotic tissue from below. A novel set of posterior circumferential cricoid sutures is used to reline the exposed cricoid plate., Study Design: Retrospective chart review., Setting: Single tertiary care center., Methods: The surgical technique is described and illustrated. A chart review was performed for all patients who underwent surgery between January 1, 2016, and June 30, 2021., Results: Fourteen patients (100% female) underwent this airway resection and reconstruction surgery during the study time period. After a mean follow-up of 12 months, no patients required tracheostomy. Twelve of 14 patients (86%) had durable airways. Two patients (14%) have required repeated endoscopic procedures for recurrent stenosis and are considered treatment failures. None exhibited postoperative dysfunction to suggest posterior cricoarytenoid muscle injury. Thirteen patients (93%) had a postoperative normal voice or only transient dysphonia. One patient had permanent unilateral vocal fold paralysis., Conclusion: Cricoid-sparing high tracheal resection is a safe and effective alternative to cricotracheal resection, especially for predominantly posterior SGS. The cricoid cartilage and cricothyroid muscles are left undisturbed, potentially decreasing the risk of postoperative dysphonia, namely lowered fundamental frequency. This is especially meaningful in the setting of a predominantly female patient population., (© 2023 The Authors. Otolaryngology-Head and Neck Surgery published by Wiley Periodicals LLC on behalf of American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Purpose: To determine whether time interval between hemi-thyroidectomy and subsequent completion thyroidectomy impacts outcomes., Methods: Retrospective review of 68 patients having completion thyroidectomy from August 2012 to December 2019. Patients were separated into two groups based on the time interval between surgeries: early (≤10 days) or delayed (≥90 days)., Results: Patients who underwent delayed completion thyroidectomy (n = 17) had significantly higher rates of hypocalcemia and/or hypoparathyroidism ( P = .03) and higher rates of requiring postoperative hospitalization ( P =.07) compared to those who underwent early completion thyroidectomy (n = 51). Delayed completion had significantly lower risk of developing one or more of dysphonia, dysphagia, or vocal cord paresis postoperatively ( P =.02). No patients developed hematoma or wound infection., Conclusions: Delayed completion thyroidectomy is associated with increased rates of hypocalcemia, but lower rates of dysphonia and dysphagia. Given the low risk of long-term complications in both groups, it may be beneficial to perform completion thyroidectomy early in order to expedite cancer treatment.

Objective: T 1a glottic cancer can be treated with transoral laser microsurgery (TLM) or radiation therapy (RT). Dysphonia is the major disadvantage of TLM, and preservation of voice appears to be the best advantage of RT compared to TLM. Studies on voice outcomes of both options gave conflicting results, but there is a tendency toward better voice outcome after TLM compared to the past., Study Design: Nonrandomized retrospective cohort study., Setting: Tertiary referral center., Methods: In total, 172 patients with a cancer lesion involving more than two-thirds of 1 membranous vocal fold underwent cordectomy type I (n = 56) (C1 group) or type II (n = 59) (C2 group) or RT (n = 57) (RT group). GRBASI (grade, roughness, breathiness, asthenia, strain, instability), videolaryngostroboscopy, Voice Handicap Index-30, acoustic analysis including F0, jitter, shimmer, noise to harmonic ratio, cepstral peak prominence, and cepstral spectral index of dysphonia using running speech, and aerodynamic analysis were performed before treatment and 6 and 24 months after treatment., Results: Study groups did not differ significantly on pretreatment voice outcomes (P > .05). The RT group had significantly better voice outcomes at 6 months posttreatment compared to the C1 and C2 groups (P < .05). The C1 group had significantly better voice outcomes at 6 months posttreatment compared to the C2 group (P < .05). The C1 group had significantly better voice outcomes at 24 months posttreatment compared to the RT and C2 groups (P < .05). The RT and C2 groups did not differ significantly at 24 months posttreatment (P > .05)., Conclusion: Voice outcomes after C2 are equal to RT. C1 has better voice outcomes than RT. C1 and C2 can be the treatment of choice for large T 1a glottic cancers., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Introduction: We compare long-term voice outcomes in patients treated with European Laryngeal Society (ELS) classification Type I, Type II, or Type V cordectomy. The aim is to understand the impact of Type V cordectomy on voice outcomes in relation to Type I and Type II cordectomy., Methods: A retrospective review of patients treated with Type I, Type II, or Type V cordectomy by a single surgeon over a 20-year period was performed. Voice Handicap Index-10 (VHI-10) scores, Cepstral Spectral Index of Dysphonia (CSID) measures from CAPE-V sentences, and two-rater GRBAS scores were analyzed., Results: Sixty-two patients were identified with a mean follow-up of 52 months. Of these, there were 43 Type I and 19 Type II cordectomies, including 8 in each group with Type V resections. Significant differences in all parameters were noted between the Type I (VHI 5.7, CSID 20.6, Grade 1.3) and the Type II cohorts (VHI 12.6, CSID 36.3, Grade 1.8) who did not undergo Type V cordectomy. Patients undergoing Type V cordectomy demonstrated voice outcomes (VHI 9.4, CSID 35.6, Grade 1.7) which fell between those of Type I and Type II cordectomies., Conclusions: Better long-term subjective, objective, and computer-analyzed voice outcomes are noted for patients undergoing Type I rather than Type II cordectomy. When Type V cordectomy is performed, voice outcomes are comparable to those of both Type I and Type II cordectomy, a surprising finding given the expectation of worsened dysphonia in longer resections. Further work is needed to explain this finding and define voice outcomes after Type V cordectomy.

Objective: To investigate the long-term outcomes of patients with unilateral vocal fold paralysis resulting in dysphonia treated with lateral vocal fold autologous fat injection. To analyze the factors that may affect the long-term efficacy of the procedure. Methods: From July 2003 to June 2020, 163 patients (86 males and 77 females), aged 9-73 years (mean (34.50±12.94) years) with unilateral vocal fold paralysis resulting in dysphonia underwent transoral laryngoscopic injection of autologous fat into the lateral vocal folds. Subjective auditory perception assessment (GRBAS scale), objective acoustic assessment, voice handicap index (VHI) evaluation and stroboscopic laryngoscopy were compared before and after the surgery. Patients were followed up for 1 to 18 years, with median follow-up time of 6 years. SPSS 22.0 software was used for statistical analysis. Results: Of 163 patients, 17 patients (10.4%) had mild hoarseness (G1) and 146 patients (89.6%) had moderate to severe hoarseness (G2-3). Stroboscopic laryngoscopy revealed an arch-shaped vocal fold on the affected side, fixed in the paramedian position or abduction position, with obvious glottic closure fissure. Postoperatively, voice recovered to normal (G0) in 139 patients (85.3%), mild hoarseness (G1) in 18 patients (11.0%) and moderate hoarseness (G2) in 6 patients (3.7%). Of these, 131 patients (80.4%) showed significant improvement in hoarseness, 29 patients (17.8%) showed mild improvement and 3 patients (1.8%) showed no significant improvement in hoarseness. Objective acoustic parameters of Jitter, Shimmer, NHR and MPT improved significantly, as did VHI scores. Stroboscopic laryngoscopy showed medialization of the affected vocal folds, improved vocal fold closure and normal or nearly normal vocal fold mucosal waves. With a fat injection volume of 3.0-4.5 ml, the patient's subjective auditory perception scores of G, R, B and A improved more significantly within 3 months after surgery, and both VHI and MPT were significantly better since 1 year after surgery. With bilateral vocal fold injection, the B and A scores improved significantly from 1 month postoperatively compared to unilateral injections(unilateral vs. bilateral injection 1 month post-operation, t B scores =1.42, t A scores =1.51, P <0.05). Conclusions: The long-term efficacy of autologous fat injection in the paraglottic space for the treatment of unilateral vocal fold paralysis was stable. The efficacy of the surgery was related to the amount of fat injected, unilateral or bilateral of the injection.

Spasmodic dysphonia (SD) is a chronic voice disorder characterized by excessive or inappropriate contraction of laryngeal muscles during speech. SD manifests as excessive glottic closure (adductor type) or sudden opening of the vocal folds (abductor type). Strained or strangled voice is the main symptom of adductor type SD, while abductor type SD presents with a breathy or absent voice. Adductor type SD accounts for 97% of all SD cases and 70% display abnormal contractions of extra laryngeal muscles. SD is currently understood to be a focal dystonia of inner laryngeal muscle during speech. Injection of botulinum toxin into laryngeal muscles is the primary treatment for SD, similar to other dystonia diseases. As the effects of botulinum toxin last for around three months, patients need repeated injections. There are two kind of surgical procedures which aim to achieve permanent emission, namely type 2 thyroplasty (TP2) and bilateral thyroarytenoid muscle myectomy (TAM). Both of these are effective and over 50% of patients can become symptom-free. However, in some cases, patient voices can become breathy and pitch ranges are reduced. For abductor type SD, there are no effective treatments apart from botulinum toxin injections into posterior cricoarytenoid muscles which open the vocal folds.

Introduction: Vocal cord vibration after transoral CO 2 LASER-guided thyroarytenoid (TA) myoneurectomy in adductor spasmodic dysphonia (AdSD) patients is unclear to date. The precise vibratory patterns in AdSD patients are difficult to evaluate with routine videolaryngostroboscopy. High-speed videolaryngoscopy (HSV) is an ideal choice to evaluate such patients. This study was performed to compare pre- and postoperative, after 6 months, vocal fold vibratory onset delay (VFVOD) and closed phase glottal cycle (CPGC) in AdSD patients following transoral CO 2 LASER-guided TA myoneurectomy using the HSV., Materials and Methods: Retrospective study, conducted from January, 2016 to January, 2019, of the AdSD patients who underwent transoral CO 2 LASER-guided TA myoneurectomy using the HSV. Patient data were acquired from the hospital database to evaluate VFVOD and CPGC from HSV recordings of the patients. VFVOD was calculated as sum of prephonatory delay (PPD) and steady-state delay (SSD). The PPD and SSD were evaluated and compared separately for each patient. The MedCal Version 19.2.6 was used for data analysis. Paired sample t test was performed to compute the significance of the difference between the mean of the dataset. A P value less than 0.05 was considered significant., Results: A total of nine patients were included in the study, out of which three were females and six were males. The average age was 45.5 ± 6.9 years. The mean of postoperative PPD (166.8 ± 22.1), SSD (76.5 ± 8.6), and CPGC (62.6 ± 4.8) were significantly less than mean of preoperative PPD (222.6 ± 22.1), SSD (97.7 ± 9.5), and CPGC (71.6 ± 5 %), with P values of 0.0007, 0.0001, and 0.0001, respectively., Conclusions: There was a significant decrease in VFVOD and CPGC posttransoral CO 2 LASER-guided TA myoneurectomy in AdSD patients after 6 months follow-up. This study also establishes efficiency of the HSV to measure the vocal cord vibration in the patients with AdSD. The primary limitations of the study were the small sample size and its retrospective nature. Future prospective studies with increased sample size can further substantiate the findings of the work performed here., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: The voice is an important marker of the transition process to the new gender identity of the transgender person. For 20% of patients seeking voice feminization, voice therapy is not completely satisfactory, and surgery should be considered, with endoscopic glottoplasty being the current practice. While the increase in fundamental frequency (F0) after glottoplasty has been well described, no systematic review of the literature or meta-analysis regarding other acoustic parameters and quality of voice has been performed yet., Objective: To define the effect of endoscopic glottoplasty on acoustic measures and quality of voice by assessing F0, maximum phonation time (MPT), frequency range, and grade of dysphonia., Methods: A literature review was performed in Medline/PubMed, Cochrane, Science Direct, LILACS, and Google Scholar, following PRISMA guidelines, with no constraints on publication date. We included studies in English, Portuguese or Spanish that assessed transgender women who underwent endoscopic glottoplasty. All the included articles were measured in terms of their methodological quality., Results: The PRISMA approach yielded 14 studies, totaling 566 patients. There was significant heterogeneity between studies regarding follow-up time, surgical technique and perioperative care. Thirteen studies were submitted to meta-analysis. The results showed significant changes in pre- to postglottoplasty mean differences of F0 = 78.49 Hz (95%CI: 75.69-81.30), MPT = -1.11 seconds (95%CI -1.67 to -0.54), frequency range = -3.55 semitones (95%CI -5.74 to -1.36) and grade of dysphonia on the GRBAS scale = 0.44 (95%CI 0.27-0.61)., Conclusion: Glottoplasty is effective in significantly increasing fundamental frequency, but slightly decreases MPT, frequency range and vocal quality measured by the grade of dysphonia on the GRBAS scale., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Mucosal Bridges (MBs) are defined as benign connective tissue abnormalities of unclear etiology that extend over the free surface of the vocal fold, are attached to the front and back of the vocal fold but are not attached to its free surface, and are histologically covered by stratified squamous epithelium. In order to overcome these drawbacks, we aimed to retrospectively evaluate and present the preoperative and postoperative results of patients with MB, who were applied the method we call "Mucosal Bridge Reconstruction" (MBR), which we apply as suturing rather than resection of the MB., Methods: Between January 2016 and February 2020, 5 patients who applied to the voice clinic due to dysphonia and were diagnosed with MB via laryngostroboscopic examination and direct laryngoscopy under general anesthesia were included in the study. Dr Speech software was used for acoustic analysis; mean fundamental frequency (fo), jitter %, shimmer %, and noise to harmonic ratio (NHR) were objectively measured and recorded. Voice Handicap Index-10 (VHI-10) was used for positive self-reporting of the severity of vocal symptoms. GRBAS scale (G: Grade, R: Roughness, B: Breathiness, A: Asthenia, and S: Strain) was also used (by the same clinician) for clinic subjective evaluation., Results: Patient age ranged from 33 to 55 years and mean patient age was 42 years. Mean duration of symptoms was 22 months (range 16-30). Mean postoperative follow-up time was 14 months (range 6-24). Unilateral MB was observed in all patients (2 left, 3 right). There was a significant improvement in objective and subjective assessment methods in all our patients after surgery., Conclusions: According to the results of our few patients, MBR offers a physiological and anatomical approach to the treatment of patients with MB. The outcomes of delicate microlaryngeal surgery are promising.

Objectives: Arytenoid adduction (AA) and injection laryngoplasty (IL) are major surgical options for the treatment of unilateral vocal fold paralysis (UVFP). AA is a laryngeal framework surgery and IL is a soft-tissue augmentation procedure. Therefore, the effect of each intervention will not be substitutive but complementary to the other., Methods: Patients who received AA and IL were enrolled (N = 43). Mean age was 60.1 ± 12.7 years. Objective and subjective voice parameters including maximum phonation time (MPT), jitter, shimmer, noise to harmonic ratio (NHR), grade of dysphonia (G), and voice handicap index (VHI)-30 were collected preoperatively and 6 months postoperatively. AA and IL were sequentially performed with time interval; 28 (65.1%) patients received IL first followed by AA (IL+AA group) and 15 (34.9%) had AA followed by IL (AA+IL group). Time interval between first and second procedures was 9.9 ± 14.6 months., Results: MPT, jitter, shimmer, NHR, G and VHI-30 significantly improved by both first and second procedures (P < 0.001). When we evaluated IL+AA group and AA+IL group separately, the final outcomes of MPT, jitter, G, and VHI-30 between the two groups were not significantly different. When the overall effects of IL and AA were compared, MPT significantly improved with AA than with IL (P < 0.001)., Conclusion: In patients with unilateral vocal fold paralysis, sequential AA and IL (or IL and AA) provided additional improvement of subjective and objective voice parameters. Final outcomes of the two combined procedures resulted in similar degree of voice improvement regardless of the order of procedure., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Goal: To document the first case of Montgomery® implant extrusion after type I thyroplasty for unilateral laryngeal nerve paralysis in adults., Case: Three years after onset of right idiopathic unilateral laryngeal nerve paralysis resulting in severe dysphonia not improved by speech therapy, a 45-year-old Caucasian woman consulted to improve her voice. Maximum phonation time (MPT) was 5seconds. Voice Handicap Index (VHI) was 64. Type I thyroplasty with n°10 Montgomery® implant was performed without difficulties. Immediate postoperative course was uneventful. One month after thyroplasty, the patient considered her voice normal, with 8sec MPT and VHI of 23. At 4 months, there was implant extrusion through the cervical skin, with 9sec MPT and VHI of 18., Conclusion: When performing type I thyroplasty with Montgomery® implant, the otorhinolaryngologist must not only take care to position the implant properly within the thyroid lamina but also ensure that the inner flanges of the implant are well deployed, to achieve proper retention., (Copyright © 2022 Elsevier Masson SAS. All rights reserved.)

Purpose: Spasmodic dysphonia (SD) or laryngeal dystonia is as a rare vocal disorder characterized by involuntary action-induced endolaryngeal contraction. In the last decade, botulin toxin injection has become the standard treatment in adductor spasmodic dysphonia necessitating repetitive injections. The purpose of this study is to analyze retrospectively data from patients treated with the minimal-invasive transoral radiofrequency-induced thermotherapy (RFITT) of the terminal branches of the recurrent nerve., Methods: Between 2009 and 2015, 11 patients (six females and five males aged from 32 to 91 years) with adductor SD were treated with RFITT. Pre-operative and post-operative vocal assessments (VHI-30, GRBASI, and acoustic-aerodynamics measurements), number of surgical revisions, delay between procedures, and post-operative complications were recorded. Statistical analyses were carried out on the first vocal assessment performed 2-8 weeks after the first procedure., Results: Based on available data from ten patients, voice handicap index (VHI) showed improvement with a mean value of -17.7 points (p-value (pval) = 0.014, adjusted p-value (adj pval) = 0.21); instability has also revealed improvement in six patients (pval = 0.05, adj pval = 0.31). Four patients underwent only one procedure including one patient showing still long-term beneficial results after 5 years of follow-up. Other patients required one to three new procedures with an average time between procedures of 15.3 months. Over 24 surgeries performed on a total of 11 patients, one definitive treatment-related severe adverse event was reported., Conclusion: Thanks to long-lasting effect, repetitive treatments are less frequent compared to botulin toxin therapy. In our opinion, RFITT is a promising alternative to botulin toxin as a second-step procedure in case of toxin resistance or patient's lack of compliance., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Spasmodic dysphonia (SD) is a rare neurological disorder that impairs phonatory function by triggering involuntary and intermittent contractions of the intrinsic laryngeal muscles. SD is classified into three types: adductor SD (AdSD), abductor SD (AbSD), and mixed SD. Of these, AdSD accounts for 90-95% of disease; younger females are predominantly affected. Botulinum toxin injection into the laryngeal muscles is safe, minimally invasive, and very effective. Here, we review the history of clinical research for SD conducted in Japan. The first use of botulinum toxin injection therapy to treat SD in Japan was by Kobayashi et al. in 1989. The group developed an objective mora (syllable) method to evaluate SD severity. Recently, we conducted a placebo-controlled, randomized, double-blinded clinical trial of botulinum toxin therapy for AdSD and an open-label trial for AbSD to obtain the approval of such therapy by the Japanese medical insurance system. The mora method revealed significant voice improvement and the evidence was of high quality. Additionally, a clinical trial of type 2 thyroplasty using titanium bridges confirmed the efficacy and safety of such therapy. These studies broadened the SD treatment options and have significantly benefited patients.

Purpose: Anterior cervical discectomy and fusion (ACDF) surgery is commonly performed to treat cervical degenerative disc disease (CDDD). The lost of range of motion (ROM) is also found after ACDF, which contributes to degenerate in adjacent segment disease (ASD). Artificial cervical disc replacement (ACDR), an alternative to ACDF, is developed to preserve the ROM and reduce ASD. This article aims to compare the outcomes between ACDR and ACDF in the short-, mid-, and long-term., Methods: Databases including Cochrane, Embase, PubMed, and Web of Science were searched. Only RCTs were included in this meta-analysis, and the search strategy followed the requirements of the Cochrane Handbook. The strength of evidence was assessed using GRADE. Two reviewers independently assessed the methodological quality of each included study and extracted the relevant data., Results: Thirty prospective RCTs were included. Prolonged operative duration, better overall success, neurological success, and NDI success rates were found in ACDR group in all follow-up periods, with lower dysphagia/dysphonia during short-term follow-up. Moreover, a lower ASD was found in ACDR group during long-term follow-up and overall analysis, with lower reoperation rates in all follow-up periods. Comparable length of hospital stay and blood loss were found in both groups. Moreover, ASD was similar in short- and mid-term follow-ups, while dysphagia/dysphonia incidence was similar in mid- and long-term follow-ups. The incidence of implant events was comparable in all follow-up periods (p > 0.05)., Conclusions: ACDR is as effective as ACDF and superior for some success rates. Disc replacement can reduce the risk of dysphagia/dysphonia, ASD, and re-operation., (© 2022. The Author(s) under exclusive licence to SICOT aisbl.)

Objectives/hypothesis: Cricotracheal resection (CTR) is an effective treatment for refractory idiopathic subglottic stenosis (iSGS) but is associated with persistent dysphonia. Outcomes were measured longitudinally to characterize how patients' voices and self-perceived voice handicaps changed after CTR., Study Design: Retrospective case-series., Methods: We conducted a retrospective cohort study of patients with refractory iSGS treated by CTR from 2006 to 2017. Voice Handicap Index (VHI), Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V), and acoustic analysis were prospectively collected preoperatively and postoperatively at 1, 3, 6, 12, and 24-month intervals. A linear mixed model was used to evaluate temporal change., Results: Thirty-three patients (97% female) were included. VHI scores increased significantly from baseline preoperative score (27.2 ± 22.7) to a mean value of 44.3 ± 25.6 (P < .001) 1-month postoperatively but decreased below preoperative scores after 2 years (18.8 ± 11.9, P = .795). Mean fundamental frequency (F0) values in speech decreased significantly from 192.0 ± 24.9 Hz preoperatively to 167.1 ± 19.8 Hz at a 2-year follow-up (P = .002), with a nadir value at 1-month postoperatively (148.4 ± 20.5, P < .001). CAPE-V scores increased significantly from preoperative to 1-month postoperative (3.0 ± 2.3 vs. 21.9 ± 17.3, P < .001) but returned toward baseline values at 24 months after CTR (6.9 ± 4.8, P = .027). CAPE-V measurements postoperatively were correlated with VHI and F0 (Pearson coefficient = 0.54 (VHI), -0.46 (F0), P < .001)., Conclusions: Following CTR, mean F0 values were significantly and consistently lower but did increase over time, correlating with patients' improving VHI and CAPE-V scores. VHI values indicate that patient's perception of their voice is not significantly impacted in long term. These results provide a framework to counsel patients about long term voice expectations., Level of Evidence: 4 Laryngoscope, 132:1054-1060, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Dysphonia in children is a common symptom, its prevalence varies between 6% and 23%. There is a broad differential diagnosis and the recommendation is to evaluate dysphonic children with an adequate laryngeal visualization method to achieve an accurate diagnosis and treatment., Objective: To describe the experience in the diagnosis of dysphonia in children in the voice unit at Universidad Católica Clinical Hospital Santiago, Chile., Methods and Materials: A retrospective chart review was conducted of all new pediatric patients treated in the voice unit at Universidad Católica Clinical Hospital between 2012 and 2019. Demographic data, diagnosis, and in-office laryngoscopies were reviewed. All patients were evaluated by the same work team consisting of two Otolaryngologists specialized in vocal pathology and a speech voice therapist., Results: A total of 126 new pediatric patients between the ages of 0 to 18 years were evaluated in the voice unit at Universidad Católica Clinical Hospital Santiago, Chile. The majority were males (54%) with an average age of 9 years. 40% of the diagnosis corresponded to vocal nodules, 26% to vocal cord cysts, the remaining to a group of less frequent diagnosis. Two different groups were studied, the first group evaluated during the years 2012-2015 with flexible fibre-optic laryngoscopy and rigid videolaryngostroboscopy (VLS); the second group evaluated between the years 2015-2019 with distal chip flexible videolaryngoscopy, distal chip flexible VLS and rigid VLS. In the second group, the diagnosis of vocal nodules decreased, and the diagnosis of vocal cord cysts increased in comparison to the first group., Conclusion: Pediatric patients with dysphonia must be evaluated by a multidisciplinary team of experts and adequate equipment. VLS should be considered the gold standard in the diagnosis of vocal cord pathology in pediatric population., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: We report a posterior laryngeal rating system and measures of voice disability in pediatric patients undergoing phonosurgery for vocal fold paralysis. Posterior glottic deficiency may account for persistent voice disability., Study Design: Retrospective Study., Methods: Retrospective analyses of 66 subjects with primary unilateral vocal fold paralysis were reviewed for the status of posterior glottis and voice disability (Pediatric Voice Handicap Index [pVHI]). Gestation age (GA), weight, and medical/surgical history were reviewed. The width, length, and depth of the larynx were analyzed to create a reproducible rating scale., Results: Mean GA was 29 weeks, with an intubation history for all subjects, with 90% having a left vocal fold immobility. Cardiac surgery was performed in 92% of subjects. A progressive rating (type 0-3) Benjamin Defect Severity Scale (BDSS) was developed to rate the absence or presence of a posterior abnormality. BDSS-2 and BDSS-3 subjects were more likely to have low birth weight. Extremely preterm GA was more likely to be associated with BDSS-1 (mild) or BDSS-2. History of multiple and prolonged intubations were seen more frequently in BDSS-2 or BDSS-3. Post-op pVHI reduced an average of 15 points for BDSS-0 to BDSS-2, but only 3 points for BDSS-3. Post-op pVHI matched normal values for preintervention dysphonic children., Conclusions: The presence of a persistent breathy voice after intervention for unilateral vocal fold immobility is potentially associated with posterior glottic defects. Low birth weight with multiple/prolonged intubation is more likely to be present with higher-grade BDs, whereas low GA is more likely to be associated with BDSS-1 to BDSS-2., Level of Evidence: 4 Laryngoscope, 131:2550-2557, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Unilateral vocal fold paralysis (UVFP) often leads to significant morbidity that may include dysphonia, swallowing problems and aspiration. The best timing for medialization procedures is still controversial. Published data suggest that early intracordal injection positively affects long-term outcomes., Objectives: To critically review current literature in order to determine if early treatment of acute UVFP influences clinical outcomes of the patients., Type of Review: Nonsystematic literature review., Methods: A literature review was performed, using the Pubmed database. All relevant articles published in English addressing the effect of early treatment in acute unilateral focal fold paralysis were analyzed. Twenty-six articles were included due to their scientific interest., Results: Published literature suggests that early intracordal injection in patients with UVFP reduces pulmonary infections, hospital length of stay and improves voice parameters. Also, patients who receive early intracordal injection seem to be less likely to undergo subsequent medialization thyroplasty., Conclusions: Early intracordal injection should be offered to patients with newly diagnosed UVFP since it promotes a satisfactory position of the vocal fold and seems to improve clinical outcomes. More investigation, with long-term follow up data and treatment randomization, is necessary to develop clinical consensus for these patients., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective/hypothesis: Adenotonsillar problems might affect the voices of patients with pediatric dysphonia, which is very common. This study aimed to evaluate the prevalence of dysphonia in patients with adenotonsillar problems and to demonstrate the impact of tonsillectomy and adenoidectomy (T & A) on their voice postoperatively., Study Design: Single-institution retrospective study., Methods: Subjects were recruited from those children admitted for the purpose of T & A, and all underwent the auditory-perceptual assessment by speech therapists preoperatively. If children demonstrated scores >2 in the G parameter, we performed subjective (pediatric voice handicap index [pVHI], severity, talkativeness scale) and objective (Multi-Dimensional Voice Program) voice analyses preoperatively and 1 and 3 months postoperatively., Results: Among the 1,197 patients, 91 (7.6%) patients showed dysphonia with a score >2 in the G parameter preoperatively. The follow-up voice analysis was completed in 51 and 22 patients after 1 and 3 months, respectively. Although there were no significant differences in the amount of speech preoperatively and postoperatively, the average visual analog scale score for dysphonia severity was significantly decreased at postoperative 1 month and postoperative 3 months. The average total pVHI score, jitter, shimmer, noise-to-harmonic ratio, and soft phonation index were significantly decreased at 1 and 3 months postoperatively. Subjective scores given by parents did not correlate with the acoustic parameters; however, the postoperative subjective parameters were significantly correlated with objective parameters., Conclusions: Voice problems were significantly improved after T & A in the short term and long term. In those with pediatric dysphonia, decreased mouth breathing and compliance with vocal hygiene would be helpful for voice improvement., Level of Evidence: 4 Laryngoscope, 131:2369-2375, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

A 77-year-old male underwent open reduction and internal fixation with placement of odontoid screws after sustaining C1 arch and odontoid fractures in a fall 14 months prior to presentation to the laryngology clinic for combined surgery with orthopedics. Serial imaging after the initial surgery demonstrated loosening of a screw and its entry into the pharyngeal lumen. The patient reported odynophagia, dysphagia, and dysphonia. He reported taking small bites and using liquid assist, vocal fatigue, and difficulty with pitch control. A surgical screw entering the pharynx just inferior to the level of the tip of the epiglottis was seen on flexible laryngoscopy. On phonation, the screw made intermittent contact with the right arytenoid resulting in restriction of full abduction of the right vocal fold. On flexible endoscopic evaluation of swallowing, there was pharyngeal and vallecular residue, and residue around the screw itself. The patient was taken to the operating room with orthopedic surgery, the screw was visualized with a combination of mouth gag and endoscopes. It was gently rocked with an orthopedic screw grabber and tapped toward the caudal pharynx. After successful removal, the mucosal defect was sutured. The patient reported improvement in swallowing postoperatively. Dysphagia is a described sequela of cervical spine surgery. We describe the presentation and treatment of a patient with a history of cervical spine surgery and subsequent exposure of an orthopedic screw in the pharynx. Laryngoscope, 131:1078-1080, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Spasmodic dysphonia (SD) is a rare disease and its epidemiological status is unclear. This review aimed to explore the current prevalence and clinical features of SD in Japan., Methods: We reviewed Japanese surveys of SD and compared them to surveys reported from other countries. We focused on SD prevalence, clinical features (SD type, sex and age), and treatment modalities., Results: The SD prevalence in Japan was 3.5-7.0/100,000, similar to that in Rochester (NY, USA) and Iceland. Adductor SD predominated (90-95%) and females were four-fold more likely to be affected than males. Mean age at onset was approximately 30 years in Japan. Several years elapsed from onset to diagnosis. The most frequent treatment was botulinum toxin injection, and surgical intervention, particularly type 2 thyroplasty is becoming more popular., Conclusions: Our review demonstrated some differences of clinical features of SD in Japan compared with other countries, such as a greater female predominance and younger age of onset. Many physicians and patients may be unfamiliar with the clinical features of SD leading to delayed of diagnosis. Therefore, we proposed diagnostic criteria to facilitate early diagnosis and an appropriate choice of treatment modalities., Competing Interests: Declaration of Competing Interest The authors have no conflict of interest relevant to the content of this article., (Copyright © 2020. Published by Elsevier B.V.)

Objective: To evaluate outcomes of injection laryngoplasty (IL) and laryngeal reinnervation for the treatment of pediatric Unilateral Vocal Fold Paralysis (UVFP), especially on swallowing and quality of voice., Methods: A literature review was performed in Medline/PubMed and Cochrane Library, following PRISMA guidelines, with no constraints on publication date. We included studies in English, Portuguese or Spanish about surgical treatment for UVFP on the pediatric population (0-21 years) that documented outcomes for one of the following techniques: IL or laryngeal reinnervation. Study characteristics, patient demographics, technical aspects of each procedure, complications, and outcomes for voice and swallowing were extracted. A meta-analysis with inverse variance, random-effects model was performed., Results: The PRISMA approach yielded 22 studies, totaling 267 patients. Seven reinnervation articles were included in meta-analysis for maximum phonation time (MPT) and quality of voice measured by Grade, Roughness, Breathiness, Asthenia and Strain (GRBAS) scale. Cardiac surgery had caused UVFP in 62.8% (142/226) of the cases. The main indication for IL was aspiration and for reinnervation was dysphonia. For IL, there was an improvement of 84.5% (confidence interval [CI] 82.6-88.4%) in swallowing and 81.4% (CI 74.6-88.1%) in voice. For reinnervation, there was an improvement of 91.6% (CI 88.2-94.9%) in swallowing and 96.8% (CI 95.5-98.0%) in voice. We found an increase of 6.19 s (CI 1.00 to 11.38) in MPT and a mean difference in GRBAS sum of -3.53 points (CI -6.15 to -0.91) after reinnervation., Conclusion: Retrospective cohort studies suggest that injection laryngoplasty and reinnervation are both effective in improving swallowing and voice in children with UVFP. There was clinical evidence of improvement in the MPT and GRBAS scale meta-analysis in patients undergoing reinnervation., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Purpose: To estimate the incidence of "innocent" arytenoid adduction asymmetry (AAA) among patients presenting at a laryngology clinic, identify its association with demographic characteristics, symptomatology and various clinical/pathological conditions and thereby determine its clinical significance., Methods: A prospective comparative observational clinical study was conducted. Group 1 included patients presenting at the Department of Laryngology, identified with a primary diagnosis and coexisting "innocent" AAA i.e., an overriding arytenoid with normal vocal fold mobility on laryngoscopy. Group 2 included an equal number of randomly selected patients fulfilling the same criteria, without AAA. Demographic and clinical details were recorded and analyzed., Results: 110 cases were included in each group. The incidence of innocent AAA was 12.7%. Males were predominant in both Groups, with the gender difference significant in Group 1. Patients in Group 1 were significantly younger than in Group 2. Professional voice users, namely singers, were significantly greater in Group 1. Symptoms associated with Group 1 (i.e. AAA) were high pitch strain while singing (p = 0.01) and unilateral throat pain (p = 0.01), and the associated diagnoses were Singing Voice Dysphonia (p = 0.005), Vocal Process Granuloma (p = 0.04) and Ventricular Band Dysphonia (p = 0.047). As a definitive diagnosis was made in all patients, the presenting complaints were not attributed to AAA. Right sided preponderance of AAA was significant. Among the diagnoses with a laterality (e.g. vocal process granuloma), AAA was observed contralateral to the pathology in 70.7% and ipsilaterally in 29.3% (p = 0.0058)., Conclusion: Innocent AAA is common among males in the 3rd-4th decades, in singers among professional voice users, and in those with the muscle tension dysphonia spectrum and vocal process granuloma, thereby suggesting that it is an acquired habit/response to greater vocal demand. The observation of AAA contralateral to laryngeal lesions, highlights its compensatory nature, attempting to optimize glottic closure.

Objective: To review the results of a series of patients with glottic insufficiency caused by scarred vocal folds who underwent injection laryngoplasty with centrifuged and emulsified autologous fat., Study Design: Prospective cohort., Setting: Single center, tertiary institution., Subjects and Methods: Examination of the medical records of 21 patients operated on through injection laryngoplasty with fat grafts for the treatment of dysphonia was performed. All patients were operated on between January of 2015 and September of 2019. The voice variables measured were the GRABS (Grade, Roughness, Breathiness, Asthenia, Strain) scale, the Voice Handicap Index-10 (VHI-10), maximum phonation time, jitter, shimmer, and harmonic/noise ratio before surgery and 8 months later., Results: Twenty-six injection laryngoplasties were performed in 21 patients during the reviewed period. Seventeen were men, and 4 were women. Mean age was 57.2 (range, 18-80) years. Mean (SD) follow-up time was 20.7 (9.3) months. Etiology of dysphonia was scarring after tumor resection in 17 patients and sulcus vocalis in 4. Five patients received an additional injection laryngoplasty. Statistically significant improvements were observed in all the parameters evaluated ( P < .05)., Conclusions: Injection laryngoplasty with fat grafts processed through centrifugation and emulsification is an effective technique for the treatment of dysphonia caused by glottic insufficiency related to scarred vocal folds, with minimal complication rates.

Purpose: This study was performed to evaluate the characteristics of the Voice Handicap Index (VHI), a self-assessment measure, for patients with unilateral vocal fold paralysis (UVFP) who underwent arytenoid adduction (AA), in comparison with postoperative vocal function examinations., Methods: A retrospective chart review was conducted for patients who underwent AA at Tohoku University Hospital during the period between 2014 and 2017. VHI was compared before and after surgery; moreover, correlations were assessed between the VHI and other voice measurements, including perceptual assessment of voice, as well as aerodynamic and acoustic measures. Factors involved in the VHI score were explored by multivariate analysis., Results: Forty-three UVFP patients (28 males, age 32-81 years; 15 females, age 34-80 years) were enrolled in the study; the average age of all patients was 61.5 years (32-81 years). Among the enrolled patients, 33 (76.7%) left and 10 (23.3%) right vocal folds were impaired. After surgery, nearly all of the patients exhibited significantly improved VHI score; each of the three subscales (functional, physical, and emotional) was also improved. The postoperative VHI correlated mildly with several values of the other voice measurements, with the exception of the mean flow rate. Multivariate analysis showed that the sole variable associated with postoperative VHI score was preoperative VHI., Conclusions: The postoperative VHI likely reflects improvement in the voices of the patients with UVFP. Although there were weak correlations with other voice measures, postoperative VHI is a relatively independent measurement parameter for patients with UVFP who underwent AA., (Copyright © 2018. Published by Elsevier Inc.)

Degenerative lesions with hyperostosis on the anterior surface of cervical spine are common in clinical practice. In addition to pain being an effect of spinal dysfunction, they sometimes cause difficulties in swallowing or speaking as well as breathing disorders. A 52-year-old farmer with 4-year history of gradually intensifying dysphagia was admitted to hospital due to inability to intake a solid food, significant weight loss, and because of the appearance of a new symptom - dysphonia. Previous conservative treatment for swallow difficulties was ineffective. CT revealed a bone excrescence on the anterior surface of two cervical vertebrae which caused an oesophageal obstruction and compression of the vocal folds. Structural abnormalities of cervical spine should be considered in differential diagnosis of symptoms from the oesophagus and upper respiratory tract, especially when a first-line conservative treatment is not effective. In these cases, surgical removal of the osteophyte is an effective way of treatment.

Objectives: This study examined the effectiveness of injection laryngoplasty (IL) in muscle tension dysphonia (MTD) patients who did not fully respond to voice therapy. It was hypothesized that IL would improve voice quality and voice-related quality of life measures in MTD., Methods: A retrospective review was conducted on 37 patients with a primary diagnosis of MTD who underwent IL following a suboptimal response to voice therapy (mean age = 43.0 years; standard deviation [SD] = 13.4; range = 23 to 71). Outcome measures included laryngoscopic signs of supraglottic constriction, Voice Handicap Index-10 (VHI-10) scores, maximal phonation time, vowel fundamental frequency (F0), standard deviation of F0 (F0SD), harmonics-to-noise ratio (HNR), and smoothed cepstral peak prominence. These were compared between baseline and within 3 months following the IL procedure., Results: There was significant decrease in supraglottic constriction. Mean (SD) of VHI-10 scores decreased from 25.4 (5.7) at baseline to 15.3 (9.3) following IL. This improvement in VHI-10 was observed in patients with and without baseline glottal insufficiency (GI). Mean (SD) of HNR (decibels) increased from 21.1 (5.4) at baseline to 22.8 (4.3) after IL. Only patients with GI demonstrated a significant improvement in HNR from baseline to post-IL. No statistically significant differences in other acoustic measures were observed., Conclusions: IL resulted in positive changes in voice-related quality of life in MTD patients with and without GI. Acoustically, only those with GI demonstrated an increase in HNR following IL. Further studies are needed to examine the effects of IL in MTD., Level of Evidence: 4 Laryngoscope, 130:980-985, 2020., (© 2019 The Authors. The Laryngoscope published by Wiley Periodicals, Inc. on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The current gold standard of therapy for adductor spasmodic dysphonia (AdSD) is injection of botulinum toxin A (BTX) in the adductor musculature. A surgical procedure could potentially offer more stable and long-lasting voice quality. In this study, we report the long-term results of endoscopic laser thyroarytenoid (TA) myoneurectomy versus BTX treatment in the same patients with AdSD., Study Design: Retrospective case series., Methods: Between July 2013 and September 2016, a total of 22 patients with AdSD were included. Voice outcomes were measured using the Voice Handicap Index and a Likert-scale patient-reported voice questionnaire. Data were obtained for each patient at four time points: preoperatively with and without BTX and twice postoperatively at 3 months (short term) and 12 months (long term)., Results: No statistically significant differences were found between voice outcome after BTX injection and the short- and long-term postoperative voice outcomes for the group as a whole. During postoperative follow-up, 10 of the 22 patients (45%) needed a second procedure after an average of 18 months (interquartile range, 13-22 months) due to recurrence of their original voice problem., Conclusions: The TA myoneurectomy showed encouraging results, comparable to BTX after follow-up of 12 months for the group as a whole. However, after good results initially, voice deterioration was seen in 45% of the patients who all underwent a second procedure. These preliminary results provide important insights into the value of TA myoneurectomy as a potential definite treatment for a select group of patients with AdSD. Further research might explore long-term results after revision surgery., Level of Evidence: 4 Laryngoscope, 130:741-746, 2020., (© 2019 The Authors. The Laryngoscope published by Wiley Periodicals, Inc. on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Adduction arytenopexy is a surgical procedure that allows the surgeon to position the arytenoid cartilage in a vocally favorable position with a suture. It is not needed in most cases of vocal paralysis when there is favorable synkinesis and good positioning of the arytenoid body. When there is a large posterior gap (intercartilaginous region), height discrepancy, or an anteriorly displaced arytenoid, adduction arytenopexy is used to suture the arytenoid cartilage into the posterior and medial aspect of the cricoarytenoid joint facet, bringing the medial bodies of the arytenoid cartilages together allowing increased closure resulting in higher dynamic range in postoperative voices. It increases the tension in the vocal fold, allowing for improved vocal quality. Adduction arytenopexy is typically combined with medialization laryngoplasty to support the vocal fold and increase the subglottic pressure that can be achieved. Cricothyroid subluxation is performed to allow the surgeon to select the degree of tension to match the opposite, working vocal fold. When there is accumulation of secretions and food in the ipsilateral dilated pyriform sinus, a hypopharyngoplasty is added to decrease the volume of the pyriform sinus and improve swallowing., (© 2020 S. Karger AG, Basel.)

Introduction: Vocal nodules and cysts are frequent causes of infantile dysphonia. Vocal therapy is the first treatment. Microsurgery has restricted indications, especially for nodules., Objective: To describe our experience with microsurgery for nodules and cysts in children., Methods: Dysphonic children (aged 4-18 years) with the diagnosis of nodules and vocal cysts were initially selected. Of these children, only those were included who had undergone microsurgery. For nodules and cysts, the microsurgery was indicated in cases of failure of vocal therapy and in cases of voice worsening or doubts about the diagnosis. All children were submitted to auditory perceptual vocal analysis and videolaryngostroboscopy (before and after surgery, after 6 months). Surgical outcomes were: total improvement (disappearance of vocal symptoms and of the laryngeal lesions); partial improvement (partial improvement of symptoms and/or maintenance of lesions); no improvement (maintenance or worsening of the symptoms and/or persistence of the lesions). -Results: There were 78 children with vocal nodules and 27 children with vocal cysts. Surgery was indicated for 12 children with vocal nodules (15.4%) and 12 children with cysts (44.4%). Total improvement registered for nodules and cysts was 75 and 83.4%, respectively. Partial improvement for both lesions was 25 and 16.6%, respectively., Conclusion: The best outcome for laryngeal microsurgery in dysphonic children was for vocal cysts. So, we encourage laryngologists for this conduct in vocal cysts. The success of microsurgery for vocal nodules was lower, and in these cases voice therapy seems to be the best treatment., (© 2019 S. Karger AG, Basel.)

Objectives/hypothesis: Medialization thyroplasty (MT) has become a prominent method for treating glottal insufficiency. This study aimed to visualize the biomechanical influence of a medialization implant on arytenoid cartilage, particularly on the length and level of paralyzation in the vocal fold, in patients with unilateral vocal fold paralysis., Study Design: Prospective study., Methods: We recruited 15 patients (10 men, 5 women) with unilateral vocal fold paralysis that underwent MT with a Montgomery® thyroplasty implant. We performed high-resolution computed tomography of the arytenoid cartilage before and after MT and analyzed the three-dimensional images. To visualize the movement of the arytenoid and to measure the lengthening of the vocal fold, we superimposed pre- and postoperative 3D images with MIMICS software., Results: On the affected side, the implant pushed the arytenoid backwards. In addition, the vocal process of the arytenoid was inwardly rotated. These movements resulted in an elongated, augmented vocal fold on the affected side., Conclusion: MT led to an elongated, medialized vocal fold on the treated side. After the intervention, the vocal folds on both sides were the same length in the phonatory position., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Importance: Adipose-derived mesenchymal stem cells (ASCs) have been used commonly in regenerative medicine and increasingly for head and neck surgical procedures. Lipoaspiration with centrifugation is purported to be a mild method for the extraction of ASCs used for autologous transplants to restore tissue defects or induce wound healing. The content of ASCs, their paracrine potential, and cellular potential in wound healing have not been explored for this method to our knowledge., Objective: To evaluate the characteristics of lipoaspirates used in reconstructive head and neck surgical procedures with respect to wound healing., Design, Setting, and Participants: This case series study included 15 patients who received autologous fat injections in the head and neck during surgical procedures at a tertiary referral center. The study was performed from October 2017 to November 2018, and data were analyzed from October 2017 to February 2019., Main Outcomes and Measures: Excessive material of lipoaspirates from subcutaneous abdominal fatty tissue was examined. Cellular composition was analyzed using immunohistochemistry (IHC) and flow cytometry, and functionality was assessed through adipose, osteous, and chondral differentiation in vitro. Supernatants were tested for paracrine ASC functions in fibroblast wound-healing assays. Enzyme-linked immunosorbent assay measurement of tumor necrosis factor (TNF), vascular endothelial growth factor (VEGF), stromal-derived factor 1α (SDF-1α), and transforming growth factor β3 (TGF-β3) was performed., Results: Among the 15 study patients (8 [53.3%] male; mean [SD] age at the time of surgery, 63.0 [2.8] years), the stromal vascular fraction (mean [SE], 53.3% [4.2%]) represented the largest fraction within the native lipoaspirates. The cultivated cells were positive for CD73 (mean [SE], 99.90% [0.07%]), CD90 (99.40% [0.32%]), and CD105 (88.54% [2.74%]); negative for CD34 (2.70% [0.45%]) and CD45 (1.74% [0.28%]) in flow cytometry; and negative for CD14 (10.56 [2.81] per 300 IHC score) and HLA-DR (6.89 [2.97] per 300 IHC score) in IHC staining; they differentiated into osteoblasts, adipocytes, and chondrocytes. The cultivated cells showed high expression of CD44 (mean [SE], 99.78% [0.08%]) and CD273 (82.56% [5.83%]). The supernatants were negative for TNF (not detectable) and SDF-1α (not detectable) and were positive for VEGF (mean [SE], 526.74 [149.84] pg/mL for explant supernatants; 528.26 [131.79] pg/106 per day for cell culture supernatants) and TGF-β3 (mean [SE], 22.79 [3.49] pg/mL for explant supernatants; 7.97 [3.15] pg/106 per day for cell culture supernatants). Compared with control (25% or 50% mesenchymal stem cell medium), fibroblasts treated with ASC supernatant healed the scratch-induced wound faster (mean [SE]: control, 1.000 [0.160]; explant supernatant, 1.369 [0.070]; and passage 6 supernatant, 1.492 [0.094])., Conclusions and Relevance: The cells fulfilled the international accepted criteria for mesenchymal stem cells. The lipoaspirates contained ASCs that had the potential to multidifferentiate with proliferative and immune-modulating properties. The cytokine profile of the isolated ASCs had wound healing-promoting features. Lipoaspirates may have a regenerative potential and an application in head and neck surgery., Level of Evidence: NA.

Objectives/hypothesis: We analyzed the results of 10 patients treated by unilateral autologous temporal fascia graft, comparing the pre and post surgery results, as well as the appearance of the wave and the intervals until the re-appearance of it., Study Design: Retrospective, clinical case series., Methods: Subjective and objective evaluation was preoperatively and postoperatively performed, using laryngovideostroboscopy, the Voice Handicap Index-10, GRBAS (grade, roughness, breathiness, asthenia, and strain), harmonics to noise ratio, Jitter, Shimmer, phonatory range, maximum phonation time, and S/Z ratio in all patients. Postoperative visits were scheduled after 1 week, 1 month, at 3 months, and at 6 months after the surgery., Results: After surgery, we found significant differences in the maximum phonation time and the S/Z ratio (P <0.05). Most parameters of GRBAS also improved significantly, both in general and in the subscales, except for Breathiness and Asthenia (P <0.05). There was an average decrease in Voice Handicap Index-10 of 11.2 (P <0.05). At laryngovideostroboscopy, the mucous wave reappeared in all patients treated 1 month after surgery, and increased in amplitude until 6 months postoperative., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Dynamic voice computerized tomography (DVCT) is a novel technique that provides additional information to characterize laryngeal function for patients with complex airway history that may alter surgical decisions. The goal of this study was to evaluate the impact of DVCT on decision making for reconstructive voice surgery for a cohort of post-airway reconstruction dysphonia patients., Methods: Retrospective chart review at a pediatric tertiary care center for patients with history of complex airway surgery and subsequent reconstructive voice surgery for dysphonia between 2010 and 2016. The study group had a DVCT prior to surgery while the control group underwent surgery without a DVCT. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) and pediatric Voice Handicap Index (pVHI) scores were evaluated by the voice clinic team (otolaryngologist, speech therapist) before and after voice surgery., Results: Twenty-one patients were analyzed (14 female, 67%) with a mean age (SD) of 14 (4.5) years old. Ninety percent (17/21) had a prior tracheostomy and a mean (SD) of 2.6 (1.3) airway surgeries. Twelve patients (57%) underwent DVCT prior to reconstructive voice surgery. CAPE-V baseline scores were similar between study and controls (means [SE] = 49 [4.6] and 57 [6.0], P = .72). However, scores significantly improved for the study group after voice surgery (mean [SE] = 31 (4.7), P < .0001) while controls did not improve (58 [5.7], P = .99). Baseline VHI scores were similar between both groups: mean (SE) = 54 (5.4) versus 52 (6.2), respectively, P = .99. Postsurgically, VHI scores were also similar between both groups (means [SE]: 46 [7.1] vs 47 [4.5], P = .99). Reconstructive voice surgery for study patients included posterior cricoid reduction (46%), vocal fold medialization/augmentation (46%), and laryngeal reinnervation (7.7%) while all controls underwent a single treatment (vocal fold medialization/augmentation)., Conclusion: Patients with preoperative DVCT were more likely to have improvement. DVCT appeared to have altered surgical decision making and has allowed tailoring of reconstructive surgery to specific patients' needs. DVCT could represent an important tool prior to reconstructive surgery to guide the choice of surgical procedures for complex airway patients.