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Objectives/hypothesis: The aim of this study was to define the coprevalence of tremor with spasmodic dysphonia (SD).Study Design: A single-institution, prospective, case-control study was performed from May 2010 to July 2010.Methods: Consecutive patients with SD (cases) and other voice disorders (controls) were enrolled prospectively. Each participant underwent a voice evaluation and an evaluation for tremor.Results: There were 146 voice disorder controls and 128 patients with SD enrolled. Of patients with SD 26% had vocal tremor, 21% had nonvocal tremor. Patients with SD were 2.8 times more likely to have coprevalent tremor than the control group (odds ratio = 2.81; 95% confidence interval, 1.55-5.08), and only 35% of patients with SD had been seen by a neurologist for the evaluation of dystonia and tremor.Conclusions: Tremor is highly prevalent in patients with SD. It is important for each patient diagnosed with SD to undergo an evaluation for tremor, and this is especially important in patients diagnosed with vocal tremor. [ABSTRACT FROM AUTHOR]

SUMMARY: The purpose of this study was to investigate the correlation between the Voice Handicap Index (VHI) and the Voice-Related Quality of Life Measure (V-RQOL), and to test conversion of scores between the two instruments. Understanding the relationship between instruments will facilitate comparison of voice outcome studies using different measures. A retrospective medical chart review of 140 consecutive patients with a chief complaint related to their voice presenting for speech pathology voice evaluation following laryngology evaluation and diagnosis was adopted. Each patient who filled out the VHI and V-RQOL within a 2-week period with no intervening treatment was included in the study. Correlation analysis for total scores was performed for the patients meeting inclusion criteria (n=132). Correlations were also performed as a function of diagnosis. Calculated VHI score based on measured V-RQOL score was compared to measured VHI score. Pearson correlation between scores on the VHI and V-RQOL was -0.82. There was no significant difference between the mean measured and mean calculated VHI scores. For individual scores, however, regression analysis did reveal a significant difference between calculated and measured VHI. The VHI and V-RQOL are highly correlated; however, this study suggests that the two instruments are not interchangeable for individuals. [ABSTRACT FROM AUTHOR]

Although outcomes account for 45% of the total ranking score in otolaryngology in the 2023-2024 U.S. News Best Hospitals rankings, little attention has been paid to the representativeness of their outcomes or volume analyses. Through retrospective review of finance data from an academic otolaryngology department, we found the overall 2023-2024 USNWR volume estimate accounted for only 10.0% (n = 2, usw 024/20,334) of all adult admissions and outpatient procedures and did not adequately represent the overall case mix or caseload., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Vocal fold scar and sulcus pose significant treatment challenges with no current optimal treatment. Platelet-rich plasma (PRP), an autologous concentration of growth factors, holds promise for regenerating the superficial lamina propria. This study aims to evaluate the potential benefits of serial PRP injections on mucosal wave restoration and vocal function., Methods: In a prospective clinical trial across two institutions, patients with vocal fold scar underwent four serial PRP injections, one month apart. Blinded independent laryngologists and expert listeners used pretreatment and one-month post-fourth injection videostroboscopy and CAPE-V assessments to evaluate mucosal wave and voice quality changes, respectively. Additionally, patient reported outcome measures (PROMs) were evaluated., Results: In the study, 15 patients received 55 PRP injections without adverse effects. Eight patients (53.3%) had mild, three patients (20%) had moderate, and four patients (26.7%) had severe scar. There was an average reduction of 8.7 points in post-treatment VHI-10 scores (p = 0.007). The raters observed an improvement in post-treatment voice in 73.4% of cases, and CAPE-V scores showed a reduction of 18.8 points on average (p = 0.036). The videostroboscopic VALI ratings showed an improvement in mucosal wave rating from 2.0 to 4.0. On average, the raters perceived the post-PRP exams to be better in 56.7% of cases., Conclusions: PRP has been validated as a safe autologous option for treatment of vocal fold scar. While results for mucosal wave and voice quality varied, there was a consistent improvement in PROMs., Level of Evidence: Level 3: Prospective cohort study, with blinded analysis Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Vocal fold injection medialization (VFIM) is widely used as an initial treatment for unilateral vocal fold paralysis (UVFP). Current practices employ materials that share the limitation of temporary clinical effect from variable resorption rates. A novel silk protein microparticle-hyaluronic acid-based material (silk-HA) has demonstrated cellular infiltration and tissue deposition that may portend a durable medialization effect. We report on ≥12 months outcomes after VFIM with silk-HA., Methods: Prospective open-label study of patients with UVFP that elected treatment with VFIM with silk-HA. Blinded experts rated laryngeal stroboscopic exams., Results: Seventeen patients with UVFP underwent VFIM with silk-HA. Twelve of the 17 patients have ≥12 months follow-up. Seven patients demonstrated durable treatment benefit ≥12 months after injection with median improvement of 19 (p = 0.0156) in VHI-10. There was no significant change in VHI-10 between 1 and 12 months for these patients. Blinded ratings indicated that 5/7 patients with sustained improvements in VHI-10 exhibited complete or touch glottal closure at 12 months. Two of the seven patients exhibited a small (<1 mm) glottal gap at 12 months. Seven patients experienced initial benefit with later regression 3-4 months after injection., Conclusion: VFIM with silk-HA can offer durable improvement in voice-related outcomes for UVFP past 12 months. A subset of patients treated with silk-HA experienced early loss of effect around 3-4 months postinjection. Clinical factors predictive of sustained treatment response to silk-HA injection require further exploration., Level of Evidence: 3 Laryngoscope, 134:3679-3685, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Safe home tracheostomy care requires engagement and troubleshooting by patients, who may turn to online, AI-generated information sources. This study assessed the quality of ChatGPT responses to such queries., Methods: In this cross-sectional study, ChatGPT was prompted with 10 hypothetical tracheostomy care questions in three domains (complication management, self-care advice, and lifestyle adjustment). Responses were graded by four otolaryngologists for appropriateness, accuracy, and overall score. The readability of responses was evaluated using the Flesch Reading Ease (FRE) and Flesch-Kincaid Reading Grade Level (FKRGL). Descriptive statistics and ANOVA testing were performed with statistical significance set to p  < .05., Results: On a scale of 1-5, with 5 representing the greatest appropriateness or overall score and a 4-point scale with 4 representing the highest accuracy, the responses exhibited moderately high appropriateness (mean = 4.10, SD = 0.90), high accuracy (mean = 3.55, SD = 0.50), and moderately high overall scores (mean = 4.02, SD = 0.86). Scoring between response categories (self-care recommendations, complication recommendations, lifestyle adjustments, and special device considerations) revealed no significant scoring differences. Suboptimal responses lacked nuance and contained incorrect information and recommendations. Readability indicated college and advanced levels for FRE (Mean = 39.5, SD = 7.17) and FKRGL (Mean = 13.1, SD = 1.47), higher than the sixth-grade level recommended for patient-targeted resources by the NIH., Conclusion: While ChatGPT-generated tracheostomy care responses may exhibit acceptable appropriateness, incomplete or misleading information may have dire clinical consequences. Further, inappropriately high reading levels may limit patient comprehension and accessibility. At this point in its technological infancy, AI-generated information should not be solely relied upon as a direct patient care resource., Competing Interests: None., (© 2024 The Author(s). Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: Decision-making regarding behavioral versus procedural intervention in the treatment of presbyphonia has not been well defined. The study objective was to survey laryngologists' reported practice patterns and decision-making in presbyphonia., Methods: All laryngology faculty in U.S. academic medical centers with residency programs were recruited to complete an anonymous 29-item survey regarding decision-making in presbyphonia treatment. The survey included 5 sections: demographics, first-line treatment distribution, factors that drive decision-making toward procedural intervention, treatment progression if first-line treatment is insufficient, durable treatment., Results: Of 153 laryngologists surveyed, 89 responded (58%). Voice therapy (VT) was the most often reported first-line treatment, with 57% of respondents indicating the majority of their patients receive VT initially. Most respondents (83%) indicated they occasionally use procedural intervention as first-line treatment. Factors driving first-line procedural intervention were severe glottal insufficiency (87%), high occupational/social voice demands (76%), voice not stimulable for change (73%), difficulty attending VT (70%), severe dysphonia (65%), and dysphagia (61%). The majority of respondents indicated the following do not affect their decision to pursue procedural intervention: patient age (88%); medical comorbidities (63%); patient's desire for a "quick fix" (55%); patient-reported outcome measures (51%). Most respondents (81%) use trial injection augmentation before durable treatment. Of durable treatments, bilateral thyroplasty was preferred (71%), followed by CaHA (15%) and lipoinjection (11%)., Conclusions: This study is the first to our knowledge to examine factors that influence decision-making in presbyphonia treatment. While VT remains the most frequent first-line treatment, study results better inform decision-making regarding first-line procedural intervention., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Idiopathic subglottic stenosis (iSGS) is a rare condition involving the subglottic larynx and upper trachea, commonly affecting Caucasian females between 30 and 50 years of age. Despite its homogeneous presentation, clinical management for iSGS is yet to be standardized, leading to variability in outcomes between predominant interventions. In recognition of the heterogenicity in iSGS treatment and the need to improve patient outcomes, this study aimed to survey laryngologists to understand the factors influencing clinical decision-making and the incorporation of new treatment modalities for iSGS., Methods: An online survey was sent to 145 academic laryngologists. The survey assessed respondents' professional backgrounds, experience treating iSGS, treatment algorithms, and how various patient factors affect management., Results: Of the 87 (60%) laryngologists who responded to the survey, the most common clinical assessments were tracheoscopy/bronchoscopy (96.8%) and pulmonary function tests (43.6%). Endoscopic dilation (ED) was the most common primary treatment offered (97.5%): 28.7% of surveyed laryngologists offer SISI as a primary treatment, and 74.7% perform SISI as a planned postoperative treatment. The most common SISI protocol was repeated injections every 4-6 weeks for a series of 1-3 total injections. Notably, 9.2% perform the Maddern procedure. Routine algorithms of care involving surgery were most often based on prior experience and prior patient outcomes (75.9%) and conversations with colleagues (64.4%). Only 31% report using the same protocol learned during their fellowship training., Conclusion: This survey highlights significant variation in the management of patients with iSGS. Understanding the factors that influence decision-making may lead to potential standardization in heterogeneous treatment approaches and may improve clinical outcomes., Level of Evidence: 5 Laryngoscope, 134:865-872, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To compare the effect of virtual and in-person head and neck physical examination training events on medical student confidence in performing examination maneuvers and seeking mentorship from otolaryngology faculty and residents., Methods: Training events were held with first-year medical student volunteers in 2020 (in-person) and 2021 (virtual). Participants in both cohorts were given didactics on head and neck cancer, trained to perform a head and neck physical examination, and demonstrated their clinical skills to otolaryngology faculty and residents. Pre- and post-training surveys were utilized to assess the following outcomes: participant head and neck cancer knowledge, confidence in performing examination maneuvers, and confidence in seeking mentorship in otolaryngology. Differences in outcomes between training settings were assessed by comparing participant survey responses pre- and post- training., Results: Both in-person and virtual training modalities improved participant confidence in performing the physical examination. There was no significant difference in the degree of improvement between training types. In-person training significantly increased participant confidence in seeking mentorship from otolaryngology faculty and residents ( P  = .003), while virtual training did not ( P  = .194)., Conclusion: Virtual training modalities are feasible methods of teaching the head and neck physical examination. Instruction through a video conferencing platform has the potential to be incorporated into traditional in-person medical education in a permanent fashion. This pilot study can inform future studies directly comparing in-person and virtual physical examination training modalities.

Background: Vocal fold injection augmentation (VFI) is a common procedure for the treatment of glottic insufficiency. Material options for VFI and decisions regarding material selection are not standardized and often based on clinician preference., Objective: This study aims to understand the variations in provider preference and utilization of injectable materials for VFI., Methods: A 40-question survey was sent to 158 academic laryngologists. Questions pertained to the type of injectable materials used including brand preferences and rationale for preferences., Results: Ninety-seven of the 158 laryngologists contacted participated in the survey (61.4%). The most frequently used injectable materials were Hyaluronic Acid (HA)-based products. Carboxymethylcellulose (CMC)-based products were preferred for trial augmentation (57.2%), HA-based products were preferred for acute/subacute vocal fold paralysis, presbyphonia, and sulcus/scar (54.2%, 61.5%, 44.7%, 41.7% respectively), and Calcium Hydroxyapatite (CaHA)-based products were preferred for long-term paralysis (28.1%). CMC-based products were discontinued by 21.8% of participants, largely due to quick material resorption. 17.8% of participants discontinued HA-based products largely due to adverse events and 26.0% abandoned CaHA-based products mostly due to inflammatory properties causing vocal fold stiffness and material unpredictability. Over 30% of respondents reported wanting to reinitiate micronized alloderm Cymetra® as an available injectable., Conclusion: Our survey demonstrated that there are significant variations in practice and preferences in regard to injectable material selection for VFI. As there is limited data on the direct material comparison, understanding the rationale behind these variations is crucial to guide new providers in material selection and provide information to patients undergoing these procedures., Level of Evidence: 5 Laryngoscope, 133:1176-1183, 2023., (© 2022 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: This state of the art review aims to examine contemporary advances in applications of artificial intelligence (AI) to the screening, detection, management, and prognostication of laryngeal cancer (LC)., Data Sources: Four bibliographic databases were searched: PubMed, EMBASE, Cochrane, and IEEE., Review Methods: A structured review of the current literature (up to January 2022) was performed. Search terms related to topics of AI in LC were identified and queried by 2 independent reviewers. Citations of selected studies and review articles were also evaluated to ensure comprehensiveness., Conclusions: AI applications in LC have encompassed a variety of data modalities, including radiomics, genomics, acoustics, clinical data, and videomics, to support screening, diagnosis, therapeutic decision making, and prognosis. However, most studies remain at the proof-of-concept level, as AI algorithms are trained on single-institution databases with limited data sets and a single data modality., Implications for Practice: AI algorithms in LC will need to be trained on large multi-institutional data sets and integrate multimodal data for optimal performance and clinical utility from screening to prognosis. Out of the data types reviewed, genomics has the most potential to provide generalizable models thanks to available large multi-institutional open access genomic data sets. Voice acoustic data represent an inexpensive and accurate biomarker, which is easy and noninvasive to capture, offering a unique opportunity for screening and monitoring of LA, especially in low-resource settings., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: To demonstrate the safety profile of platelet-rich plasma (PRP) as an injectable therapeutic for the treatment of vocal fold scarring and atrophy., Methods: Preliminary report on a prospective clinical trial of patients with vocal fold scar or atrophy undergoing unilateral vocal fold subepithelial infusion with autologous PRP. Enrolled patients underwent four subepithelial injections spaced 1 month apart. Adverse events were assessed peri and post-injection at each session. Patient-reported outcomes were collected at every visit using the Voice Handicap Index-10 (VHI-10) and Vocal Fatigue Index (VFI) questionnaires., Results: Twelve patients underwent unilateral vocal fold injection with autologous PRP prepared according to Eclipse PRP® system protocol. Forty-three injections were performed using a peroral or percutaneous approach. An average of 1.57 ± 0.4 cc (range 0.6-2.0 cc) injectate was used. All patients tolerated the procedure without difficulty or peri-procedural complications. The average duration of follow-up was 3.6 ± 1.8 months. No significant inflammatory reactions or adverse events were seen to date. There was statistically significant improvement in patient-reported outcomes at the 3 month follow up (n = 9) follow-up (mean ΔVHI-10 = 10.8, p < 0.001, mean ΔVFI = 18.9, p = 0.01, t test, paired two sample for means, two-tail). All nine patients who completed the series of four injections subjectively (yes/no) reported they were satisfied with the results., Conclusion: This prospective study cohort demonstrated a favorable safety profile, with no adverse events or peri-procedural complications. Subjective improvements in vocal quality and reduction in vocal fatigue need to be clinically correlated with further study., Level of Evidence: 4 Laryngoscope, 133:647-653, 2023., (© 2022 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: Vocal fold atrophy and scar can lead to loss of normal superficial lamina propria, negatively affecting the vibratory function of the vocal fold. These changes can lead to dysphonia, vocal fatigue, decreased volume, and altered pitch. Treatment options for these conditions are limited. Platelet-rich plasma (PRP) consists of platelets, growth factors, and cytokines derived from the patient's own blood and is believed to activate tissue regeneration. The purpose of this study was to review the technical aspects of collecting PRP and injecting it into the vocal fold injection - based on our initial experience with this procedure., Case: A patient with vocal fold scar was identified and enrolled in an ongoing prospective clinical trial study of a series of 4 monthly subepithelial vocal fold PRP injections, which was temporarily halted due to the COVID-19 pandemic. Patient underwent a single injection of autologous PRP into the left vocal fold. There were no adverse events during the study period. Subjective improvement in voice was noted at 1 month after injection with subsequent return to baseline over the next 4 months. Videostroboscopy performed on postinjection day 1 and day 7 and demonstrated no concerning exam changes. Compared to the preinjection baseline, the patient-reported voice-handicap index-10 (VHI-10) and voice catastrophization index were similar at 4 months following injection (20 to 20 and 4 to 3, respectively). Independent perceptual analysis of voice showed improvement at 4 months postinjection, compared to baseline consensus auditory-perceptual evaluation of voice 60 to 44., Conclusions: This preliminary report was part of a prospective trial investigating the use of PRP to treat vocal fold atrophy and scar. This work highlights the technical considerations for injecting PRP into the vocal fold. Planned prospective enrollment in this study will help to validate the safety and efficacy of PRP injections., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Medical podcasts are becoming increasingly available; however, it is unclear how these new resources are being used by trainees or whether they influence clinical practice. This study explores the preferences and experiences of otolaryngology residents with otolaryngology-specific podcasts, and the impact of these podcasts on resident education and clinical practice., Methods: An 18-question survey was distributed anonymously to a representative junior (up to post-graduate year 3) and senior (post-graduate year 4 or greater) otolaryngology residents at most programs across the US. Along with demographic information, the survey was designed to explore the preferences of educational materials, podcast listening habits and motivations, and influence of podcasts on medical practice. Descriptive statistics and student t -tests were used to analyze the results., Results: The survey was distributed to 198 current otolaryngology residents representing 94% of eligible residency programs and was completed by 73 residents (37% response rate). Nearly 3-quarters of respondents reported previous use of otolaryngology podcasts, among which 83% listen at least monthly. Over half of residents changed their overall clinical (53%) and consult (51%) practice based on podcast use. Residents rank-ordered listening to podcasts last among traditional options for asynchronous learning, including reading textbooks and watching online videos., Conclusions: While other asynchronous learning tools remain popular, most residents responding to this survey use podcasts and report that podcasts influence their clinical practice. This study reveals how podcasts are currently used as a supplement to formal otolaryngology education. Results from the survey may inform how medical podcasts could be implemented into resident education in the future.

Introduction: SARS-CoV-2 is transmitted via respiratory particles. Respiratory particle emission is impacted by manner of breathing and voicing, as well as intersubject variability. Assessment and treatment of voice disorders may include tasks that increase respiratory particle emission beyond typical breathing and speaking. This could increase the risk of disease transmission via respiratory particles., Methods: Respiratory particle emission was measured during a single-subject, repeated measures clinical simulation of acoustic and aerodynamic assessment and voice therapy tasks. An optical particle sizer was used to measure particle count (1-10 μm in diameter). Assessment and therapy tasks were completed in three conditions: (1) 15 cm from the device, (2) 1 m from the device, and (3) 1 m from the device with the subject wearing a surgical mask., Results: Condition 1 generated the highest particle count, with a median of 5.1 (13) additional particles above baseline, which was statistically significant (U = 381.5, P= 0.002). In condition 1, therapy and acoustic tasks combined produced more particles compared to the baseline and speech tasks, with a median difference of 6.5 additional particles per time point (U = 309.0, P= 0.002). This difference was not significant for conditions 2 and 3. Peak particle generation occurred in specific phonatory tasks, which was most pronounced in condition 1. Voice therapy tasks during condition 1 generated the highest peaks of normalized total particles with classical singing and expiratory muscle strength training. There was a significant difference in the amount of particle generation between condition 1 and 2, with a median difference of 5.2 particles (U = 461.0, P= 0.002). The particle count difference between conditions 2 and 3 was 2.1 (U = 282.0, P= 0.292), and this difference was not significant. The normalized total particles were assessed over time for each condition. For all conditions, there was no significant accumulation of particles., Conclusions: For a single subject, production of voice assessment and therapy tasks combined resulted in an increased number of respiratory particles compared to speech and baseline (1-10 μm). EMST and classical singing generated the greatest concentration of particles. Respiratory particle counts were higher at 15 cm from the particle sizer compared to 1 m from the particle sizer, suggesting that physical distancing may reduce immediate clinician exposure to respiratory particles. Particle concentration did not accumulate over time., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: Over the past 30 years laryngology fellowships have grown in number and diversity. This study investigated the career trajectories of recent laryngology fellowship graduates with the purpose of informing residents considering fellowship., Study Design: Cross-sectional survey., Setting: Academic medical center., Methods: The directors of all 27 US laryngology fellowships that graduated/recruited fellows from 2010 to 2019 were contacted, and a list of former fellows was compiled. A short survey was administered in person or via email or phone. Additional data was gathered through internet searches., Results: One hundred eighty-three fellows were identified having completed American laryngology fellowships between 2010 and 2019 (100M:83F). Fifteen percent now practice internationally and 68% are in academic practice. A higher proportion of women than men enter laryngology fellowship after otolaryngology residency. One hundred twenty-nine fellows responded to our survey. Two-thirds of former fellows report current participation in laryngology research. Seventy-two percent of former fellows are still in their first job after fellowship and 53% believe they have their ideal practice. Women were more likely to enter academics than men after laryngology fellowship. Responders were overwhelmingly satisfied with their fellowship experience, with 95% saying they would choose to pursue fellowship training again., Conclusions: Most former laryngology fellows enter academia, contribute to laryngology research, practice away from their training institution, and believe they have found their ideal practice. The results of this study may be useful to residents considering fellowship training, centers considering establishing laryngology fellowships, and practices recruiting fellowship graduates.

Objective: Patients with subglottic stenosis (SGS) present with varied degree of breathing complaints. The dyspnea index (DI) is a 10-question patient-reported outcome measure designed to measure the severity of upper airway obstruction. We set out to determine whether pulmonary function tests or clinician-reported degree of stenosis best predicted DI scores., Methods: Thirty patients with SGS were retrospectively reviewed over a 6-year period. One visit from each patient was included. Data including peak expiratory flow rate (PEFR), body-mass index (BMI), clinician-reported degree of stenosis, and DI scores were reviewed. Multiple linear regression was performed to determine how degree of stenosis and PEFR % predicted the variation in DI score., Results: PEFR % better predicted DI scores compared to degree of stenosis (partial correlation -0.32 vs 0.17). After stepwise elimination, PEFR % remained in the regression and was significantly associated with DI scores ( F [1, 29] = 9.38, P  = .005). BMI did not demonstrate a linear relationship with DI scores and was not included in the regression ( r  = -.02). The PEFR % unstandardized coefficient was -0.25 (95% CI: -0.42 to -0.08, P  = .005). The model predicts that a 4% increase in the PEFR % results in a 1-point decrease in the DI score (95% CI: -1.68 to -0.32)., Conclusion: This study suggests that pulmonary function tests may be a better in-office measure to substantiate the severity of symptoms in patients with SGS.

Objectives: Idiopathic ulcerative laryngitis (IUL) is a rare disorder characterized by ulceration in the mid-membranous portions of the vocal folds. The etiology and optimal management of this condition are poorly understood. We aimed to survey laryngologists on their experiences with managing IUL in order to better understand the diagnosis and treatment of this unusual condition., Methods: An online survey was sent to 149 laryngologists practicing at academic institutions in the United States. Survey questions assessed respondents' professional backgrounds and clinical experiences with IUL. Individual responses were tallied and calculated as percentages of total responses., Results: A total of 96 out of 149 academic laryngologists completed the survey, leading to an overall response rate of 64.4%. All respondents reported that they had encountered IUL in practice, including 56.3% who reported having seen 1-10 cases, 22.9% reporting 11-20 cases, and 20.8% reporting greater than 20 cases over their careers. Dysphonia (99.0%) and cough (84.4%) were the two co-occurring primary presenting symptoms reported. Most base diagnosis on laryngeal videostroboscopy (93.8%). Fungal/bacterial cultures and operative biopsy had been performed by approximately 30% of respondents with occasional candidiasis reported but otherwise negative or nonspecific results. Common therapies used were empiric: antireflux therapy (91.7%), modified voice rest (91.7%), and oral steroids (80.2%). Among survey respondents with experience managing more than 10 cases of IUL, many found complete voice rest (60.0%), oral steroids (55.9%), behavioral cough suppression (46.7%), and modified voice rest (46.3%) to be at least moderately effective treatment options. Resolution of symptoms was most commonly reported to occur over the course of 1-3 months (59.4%) and recurrences were seen not very often or never (85.4%). However, permanent sequelae were common, including vocal fold stiffness (89.6%) and dysphonia (81.3%)., Conclusions: IUL is a rare disorder of unknown etiology. Diagnosis is typically made with laryngeal videostroboscopy and spontaneous resolution occurs over 1-3 months. Laryngologists commonly treat empirically with antireflux therapy, voice rest, antimicrobials, and oral steroids. While no empiric treatment appears to be highly effective for the management of IUL, complete or modified voice rest, oral steroids, and behavioral cough suppression may be the most effective of the currently available options. Further research is necessary to improve the understanding and optimal management of IUL., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Community-based health fairs can help identify at-risk populations, improve health literacy, and facilitate access to medical services. No community-based screenings specifically targeting vocal health were identified in the literature. The purpose of this study is to compare the results of community-based vocal health screenings across two populations: a group of community members with unknown risk of voice problems, and a group of actors belonging to a profession with a known increased risk of voice problems., Methods: Vocal health screenings were conducted at two free, community-based health fair events in the Los Angeles area. One was open to the public, and one was organized specifically for actors who are members of the Screen Actors Guild-American Federation of Television and Radio Artists. A total of 142 community members (94 nonactors and 48 actors) were administered a questionnaire on current vocal health and voice-related quality of life indices (Vocal Handicap Index-10, Vocal Fatigue Index), followed by review and discussion with a laryngologist or a speech pathologist trained in assessment and treatment of voice disorders., Results: A significantly higher percentage of actors (55.1%) reported current voice problems than nonactors (33.0%; χ 2  = 7.122, df = 1, P = 0.008). Additionally, as measured by the Vocal Fatigue Index 2 subscale, actors reported a greater amount of perceived pain with phonation than the nonactors. Despite over half of the actors reporting current voice concerns, only 7% reported having sought medical advice regarding these concerns., Conclusions: The results of this study suggest that vocal health screenings can help identify persons with voice complaints. However, in order to determine if vocal health screenings help close prevalence-presentation gap and are useful to both medical professionals and participants, more research is needed., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: In-office recurrent laryngeal nerve conduction studies (NCSs) are a technique that can potentially provide information about laryngeal innervation. NCS is essential in the management of other neuropathies including carpal tunnel syndrome and spinal cord injury. We hypothesize that laryngeal NCS may have similar utility in managing patients with vocal fold paralysis, atrophy, and neurodegenerative disease. NCSs are technically challenging because they require transcervical stimulation of the recurrent laryngeal nerve (RLN). This study combines radiographic data with cadaveric dissection to describe the anatomic parameters for optimal RLN stimulation., Study Design: Radiographic and Cadaveric Study., Methods: Fifty computed tomography scans were reviewed to determine the dimensions for ideal needle electrode placement. These values were compared to measurements from 12 fresh human cadaveric neck dissections. Ultrasound imaging was utilized in select cases. The neck was dissected to assess the accuracy of electrode placement., Results: Radiographically, the mean transcervical depth to the RLN was 33.2 mm ± 8.3 mm in males versus 29.4 mm ± 9.4 mm in females. The working space between the lateral trachea and carotid artery was 15.3 mm ± 3.6 mm on the right and 14.1 mm ± 2.9 mm on the left. After placement of stimulating electrodes into the cadaveric neck, the electrode tips were consistently within 8 mm of the RLN. Ultrasound guidance improved placement accuracy of the stimulating electrode., Conclusions: Laryngeal NCSs can provide detailed and objective information about laryngeal innervation that could dramatically improve the management of various neuropathies. In-office NCSs require technical precision, and this study describes anatomic factors that may affect the feasibility of performing this technique., Level of Evidence: NA Laryngoscope, 131:1566-1569, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Investigate the effect of a targeted wellness program on burnout in Otolaryngology residents., Methods: Residents and faculty collaboratively developed a program aimed at improving resident wellness. Program implementation began in July of 2018 and after 1 year, residents evaluated the program's effects on burnout. We used the Maslach Burnout Inventory (MBI) and a Likert scale to evaluate the effects of the program., Results: After 1 year of the resident wellness program, the MBI results showed an increase in the number of residents in the "engaged" category and a decrease in those rated as "burnout." Residents rated favorably initiatives grouped into the following themes: time away from work, faculty engaging with residents outside of the hospital environment, efforts to enhance residents' self-efficacy, fostering a positive culture among residents, and providing easy access to physical activity. The majority of initiatives were targeted to the "culture of wellness" domain, as defined by the Stanford Well MD framework. Our program targeted to a lesser extent the other 2 domains, "efficiency of practice" and "personal resilience.", Conclusion: After 1 year, the wellness program resulted in a trend toward improving burnout. Future efforts should be focused on targeting the multidimensional drivers of burnout as defined by established wellness frameworks. Realizing new stressors brought on by the COVID-19 pandemic will also be an area of active effort and research.

Importance: One-third of singers and vocal professionals report experiencing a benefit from empirical vitamin B12 injections for improvement of mild singing-related symptoms (eg, reduced stamina, vocal fatigue, and effort). However, there is no objective evidence to support or refute these claims., Objective: To assess the presence and magnitude of the effect of empirical vitamin B12 injection on the vocal performance of singers., Design, Setting, and Participants: A randomized, double-blind, placebo-controlled, crossover trial was conducted from November 7, 2017, to November 30, 2018, at an academic voice center among 20 active adult singers without dysphonia but with mild vocal symptoms. Individuals with known or suspected vitamin B12 deficiency or active or recent vitamin B12 treatment were excluded. Analysis was on a per-protocol basis., Interventions: Participants were randomized to receive an intramuscular (deltoid) injection of either vitamin B12 (1000 μg of cyanocobalmin) or placebo (0.9% sodium chloride). After a washout period of at least 4 weeks, participants were crossed over to receive the opposite injection. Both the investigators and participants were blinded to the order of injections., Main Outcomes and Measures: The participants completed the Singing Voice Handicap Index-10 (SVHI-10), the Voice Fatigue Index (VFI), and the Evaluation of the Ability to Sing Easily (EASE) before each injection and at intervals of 1 hour, 3 hours, 24 hours, 72 hours, and 1 week after the injection. The primary time point assessment was 72 hours after injection, and the SVHI-10 score was the primary outcome measure., Results: Twenty singers (10 men; median age, 22 years [range, 19-42 years]) were enrolled. The improvements after either placebo or vitamin B12 injections were comparable to each other. At 72 hours after the vitamin B12 injection, the median difference in the SVHI-10 score was 1 (95% CI, -1 to 2) compared with 3 (95% CI, 0-4) after placebo. The median difference between differences at 72 hours between placebo and vitamin B12 injections were 1.5 (95% CI, -2 to 5) for the SVHI-10, 1 (95% CI, -9 to 9) for the VFI, and -1 (95% CI, -3 to 2) for the EASE. The improvements after both injections failed to reach the estimated minimal clinically important difference. Of the 20 participants, 4 (20%) reached the estimated minimal clinically important difference in their SVHI-10 score after 72 hours for both vitamin B12 and placebo injections., Conclusions and Relevance: This randomized, double-blind, placebo-controlled, crossover trial found that after empirical vitamin B12 injection to improve mild voice-related symptoms, the improvement in self-reported voice measures in singers shows no meaningful difference compared with placebo., Trial Registration: ClinicalTrials.gov Identifier: NCT03437824.

Objectives: To compare flexible distal-chip laryngoscopy (FDL) versus rigid telescopic laryngoscopy (RTL) in regard to examinees' pain level, comfort, satisfaction, and preference, and to evaluate the clinician's assessment of the examinees' experience with both exam types., Study Design: Randomized crossover study., Methods: Twenty-three normal adult subjects were recruited to undergo both FDL and RTL; the initial exam type was randomized. Subjects and clinicians completed corresponding questionnaires after each exam. Differences in participant characteristics and questionnaire scores between the two exam types were assessed via Pearson χ 2 and paired t tests, respectively., Results: Overall, participants reported that FDL was more uncomfortable than RTL (4.22 vs. 2.91, P = .003) and scored higher on the pain scale for FDL compared to RTL (2.91 vs. 1.70, P = .006). However, there was no significant difference in number of participants who preferred FDL versus RTL (10 [43%] vs. 13 [57%]). Poor correlation was seen between clinicians' assessment of participants' discomfort and actual reported discomfort for FDL (2.70 vs. 4.22, P = .001)., Conclusions: Subjects undergoing FDL experience greater discomfort and pain compared to RTL, but do not demonstrate a differential preference of exam. Overall, clinicians underestimate the discomfort of patients undergoing FDL, but participants maintain high satisfaction with both exams nonetheless., Level of Evidence: 1 Laryngoscope, 130:2663-2666, 2020., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Laryngeal squamous cell carcinoma (SCC) is strongly associated with tobacco smoking. With the rising awareness of tobacco's adverse health effects, we have witnessed a global decrease in tobacco use. Nevertheless, laryngeal SCC remains prevalent and includes a subset of patients lacking the traditional risk factors., Study Design: A two-center retrospective cohort., Methods: Medical records of patients diagnosed with laryngeal SCC between 2009 and 2016 were reviewed. Data collected included demographics, smoking status, and tumor site. Patients who have never smoked were designated as nonsmokers., Results: The study included 330 patients with laryngeal SCC, of whom 75 (22.7%) were nonsmokers; this rate was relatively similar for each of the two institutions independently (21.9% and 25%). There were 285 patients with glottic SCC and 45 with supraglottic SCC. All nonsmoking patients in this cohort had glottic SCC, representing 26.3% (75/285) of the glottic SCC cases. The rate of female patients was significantly higher among nonsmokers. Of the patients with glottic SCC, females represented 25.3% (19/75) of the nonsmokers compared with 12.4% (26/210) of the smokers (P = .008). Mean age at diagnosis was 60.2 ± 17.5 years for nonsmoking glottic SCC patients and 63.6 ± 12.4 years for smokers (P = .280). However, nonsmokers demonstrated a distinct age distribution pattern. Nonsmoking females with glottic SCC demonstrated a bimodal age distribution pattern; 73.7% (14/19) were age <40 years or >75 years at diagnosis., Conclusions: The rate of laryngeal SCC in nonsmokers is higher than what has previously been reported, representing a growing proportion, and may suggest a shift in etiology. Knowing that laryngeal SCC in nonsmokers predominantly affects the glottis, and that females and age extremities are more vulnerable, the traditional screening paradigm should be revised., Level of Evidence: 4 Laryngoscope, 130:E108-E115, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research., Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease., Design, Setting, and Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook., Main Outcomes and Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications., Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk., Conclusions and Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.

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

Importance: Diagnostic flexible laryngoscopy (DFL) is the second-most reimbursed procedure by Medicare in otolaryngology. However, the economic trends of this procedure on a population level are unknown., Objective: To describe national- and state-level DFL and videolaryngostroboscopy (VLS) utilization and payment trends from 2000 to 2016 in the Medicare population., Design, Setting, and Participants: This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that at the national level the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services, whereas total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071. Rates of DLS and VLS categorized as Current Procedural Terminology (CPT) code 31575 and 31579, respectively. Analysis was carried out between November 18, 2018 and December 18, 2018., Exposures: Diagnostic flexible laryngoscopy and VLS., Main Outcomes and Measures: The DFL and VLS utilization rates, payments, and reimbursement rate trends were analyzed by year and state. Utilization was assessed for physician characteristics, including specialty and credentials., Results: Nationally from 2000 to 2016 in the Medicare population, DFL utilization per Medicare enrollee increased 30% from 0.0087 to 0.0110 and payment per enrollee decreased 2% from $0.98 to $0.96, whereas VLS utilization and payment per enrollee both increased at least 300% during the same time period, with VLS procedure per enrollee and payment per enrollee increasing by 382% from 0.00028 to 0.0013 and 301% from $0.05 to $0.22, respectively. There was a weak correlation between reimbursement and utilization per enrollee for both DFL (r = 0.23; 95% CI, 0.12-0.34) and VLS (r = 0.26; 95% CI, 0.14-0.37) performed from 2012 to 2016. In 2016, the mean (SD) payment per DFL was $85.14 ($7.95), ranging from $65.45 in Puerto Rico to $104.82 in Washington, DC, a 1.6-fold difference. For VLS, there was a 2-fold difference between the lowest-reimbursing state, Maine ($92.20) and the highest, New York ($182.96). All US dollar values were uniformly adjusted for inflation to 2018 dollar values. Most DFLs in 2016 were performed by otolaryngologists (93.6%)., Conclusions and Relevance: The DFL utilization rates remained stable compared with VLS in the Medicare population from 2000 to 2016. There was a decrease in both DFL and VLS payments per procedure in the same time period and also weak correlations between reimbursement and utilization. Practice patterns and reimbursement varied geographically across the United States, though VLS exhibited significantly higher variation than DFL at the state level.

Objectives/hypothesis: Although no clear guidelines exist, protocols in the treatment of spasmodic dysphonia (SD) vary among physicians. Previously published work comes from relatively few centers., Study Design: A descriptive survey among experts (laryngologists who practice Botulinum toxin injections for SD)., Methods: An online 58-item survey was sent to all otolaryngologists who self-identify as laryngologists on the American Academy of Otolaryngology-Head and Neck Surgery website. Items surveyed included botulinum toxin injection technique, laterality, and dosage., Results: An 80% response rate was achieved (70 completed the survey). Participants collectively reported treating >4,000 SD patients in the past year (mean, 71 ± 68 patients/laryngologist). Eighty-seven percent perform injections exclusively in the office; the remainder both in the office and operating room. For adductor SD injections, 88% use electromyographic (EMG) guidance alone via cricothyroid approach. The remainder use anatomical landmarks alone (9%) or EMG with endoscopic guidance (3%). Sitting is the preferred patient position (70%; supine, 30%). A substantial majority (87%) begin with bilateral injections (starting dosage mode, 1.25 units/side). For abductor SD injections, 67% use EMG guidance alone and 31% use endoscopic guidance with or without EMG. Sitting is the preferred patient position (84%; supine, 16%). The preferred approach is anterior-translaryngeal (51%), followed by lateral-retrolaryngeal with rotation (34%). A considerable majority (79%) begin with unilateral injections (starting dosage mode, 5 units). When deciding on initial dosage, the most influential factor was balancing patients' desire/needs, followed by patients' frailty and risk of aspiration. The typical planned interval between injections is 3 to 4 months., Conclusions: Laryngologists follow fairly uniform protocols in the treatment of SD with some important and previously unpublished differences. This study documents areas of agreement and discordance among laryngologists in the United States for the treatment of SD., Level of Evidence: 4 Laryngoscope, 129:1650-1656, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction: There is a belief among vocalists that there are voice benefits from vitamin B 12 treatment. Yet there are no previous reports regarding vitamin B 12 effects on voice., Objectives: To assess the prevalence of vitamin B 12 use among singers and their beliefs regarding vitamin B 12 therapy., Methods: Anonymous online survey administered to singers, singing-teachers, speech-language pathologists, and laryngologists., Results: A total of 192 participants completed the surveys; 128 singers (68 singing-teachers, 30 speech-language pathologists) and 64 laryngologists. Among singers, 12% have perceived voice benefits from vitamin B 12 treatment taken for any reason. Four percent used vitamin B 12 for voice benefits; all perceived voice benefits as a result. The leading voice benefits were improved stamina, reduced effort, confidence, and control. Nineteen percent of the singers would recommend vitamin B 12 treatment to a friend; 15% of the singing-teachers would recommend it to a student. Among laryngologists, 33% been asked by a singer to prescribe vitamin B 12 for voice benefits; 9% have prescribed it in the past. Yet only 3% would you recommend it to a patient. When asked "Do you believe vitamin B 12 therapy improves vocal performance?" 31% of the singers responded "Yes," compared with none in the laryngologists. When asked "Do you think the singing community believes vitamin B 12 therapy improves vocal performance?" 26% of the singers responded "Yes," compared with 53% of the laryngologists (P = 0.0002)., Conclusions: There is a discrepancy between the singers' and the laryngologists' beliefs regarding vocal benefits perceived by vitamin B 12 . Blinded randomized trials are required to verify or refute this belief., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Catastrophization is a cognitive distortion that has been studied in pain patients and found to be a significant factor in their disability and response to treatment. Dysphonia patients may demonstrate a similar behavior, suggesting the existence of voice catastrophization., Objective: To establish the validity of the Voice Catastrophization Index (VCI), a new instrument estimating voice symptoms catastrophization., Methods: A prospective study. Patients with and without voice conditions were administered with the VCI, Voice-Related Quality of Life (V-RQOL), and the Generalized Anxiety Disorder-7 (GAD-7)questionnaires. Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) rating was determined for patients with voice conditions., Results: Ninety-one patients participated, 65 with voice conditions and 26 without. 61.5% were females; mean age was 49.8 ± 15.7 years. The VCI score for patients with voice conditions was significantly higher, 22.46 ± 16.56, compared with 3.96 ± 10.79, respectively (P value < 0.0001). The VCI demonstrated moderate correlation with both V-RQOL and GAD-7 scores: -0.562 and 0.560, respectively (P value < 0.000001); however, it showed no correlation with the CAPE-V. The VCI's internal consistency with each of its three dimensions and 13 items was acceptable to strong. The reproducibility and stability was demonstrated in a subgroup of 26 patients; 81% of these patients had a difference of 10 or less points between the two evaluations., Conclusions: The VCI accomplished the requirements of a scale's validity for estimation of voice symptoms catastrophization in voice patients. The potential role of voice catastrophization as a predictor of treatment response and tailoring can now be investigated using the VCI., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To establish the validity of the OMNI Vocal Effort Scale (OMNI-VES) for resistance exercise, a single-question pictorial scale, in voice-related perceived exertion. Additionally, the study aimed to assess the role of the OMNI-VES as an outcome measurement in the treatment of adductor spasmodic dysphonia (ADSD)., Methods: A prospective validation study was conducted on 226 participants. The case group was comprised of 178 patients receiving botulinum toxin (BTX) injections for ADSD and 48 controls without a voice disorder. Prior to a planned injection, the participants were asked to complete the OMNI-VES and the Voice-Related Quality-of-Life (V-RQOL) questionnaires, and the clinician completed the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). A subgroup of 17 patients were administered a repeat assessment 1 month after injection., Results: There was a weak correlation between the OMNI-VES and the V-RQOL score (Tau-b = -0.252, P < 0.001), and no significant correlation with the CAPE-V. Participants with ADSD had significantly higher OMNI-VES scores compared with normal controls, 5.07 ± 2.18 and 1.47 ± 2.28, respectively (P value < 0.0001). The average OMNI-VES score significantly improved 1 month following a BTX injection, from 6 ± 2.4 to 3.4 ± 2.8 (P value = 0.0003). Eighty-eight percent of the patients demonstrated a decrease in the OMNI-VES score following injection, whereas only 47% demonstrated an improvement in the V-RQOL score., Conclusion: The OMNI-VES is a validated tool for rating perceived voice-related exertion in people with ADSD and can be used for evaluating response to BTX injection treatment., Level of Evidence: 2b Laryngoscope, 129:448-453, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Aging adults face unique barriers to care and have unique health care needs with a high prevalence of chronic conditions. A high proportion of individuals in this group have voice disorders, in part due to age-related changes in laryngeal anatomy and physiologic features. These disorders contribute significantly to health care costs and remain poorly understood., Objective: To describe sociodemographic characteristics and response to treatment among aging adults with voice disorders., Design, Setting, and Participants: A cross-sectional study using the 2012 National Health Interview Survey was used to evaluate adults who reported voice disorders in the past 12 months. Self-reported demographics and data regarding health care visits for voice disorders were analyzed. Statistical analysis was conducted from March 1, 2017, to February 1, 2018., Main Outcomes and Measures: Self-reported voice disorders, whether or not treatment was sought, which types of professionals were seen for treatment, and whether or not the voice disorder improved after treatment., Results: Among 41.7 million adults in the United States 65 years or older, 4.20 million (10.1%; 2 683 199 women and 1 514 909 men; mean [SE] age, 74.5 [0.3] years) reported having voice disorders. Of those with voice disorders, 10.0% (95% CI, 8.3%-11.7%) sought treatment. Of individuals seeking treatment, 22.1% (95% CI, 7.9%-36.3%) saw an otolaryngologist and 24.3% (95% CI, 10.6%-38.0%) saw a speech language pathologist. By controlling for race/ethnicity, income, sex, and geography, it was found that men were less likely than women to report voice disorders (36.1% [95% CI, 31.7%-40.5%] vs 63.9% [95% CI, 59.5%-68.3%]; odds ratio, 0.70; 95% CI, 0.57-0.86). Race/ethnicity, income, and geography were not significantly associated with the likelihood that an individual 65 years or older reported voice disorders. A greater percentage of elderly adults seeking treatment than not seeking treatment reported improvement in symptoms (32.4%; 95% CI, 17.9%-47.0% vs 15.6%; 95% CI, 10.4%-20.8%). Among adults treated for a voice disorder, a lower proportion of adults 65 years or older reported improvement in symptoms with treatment compared with adults younger than 65 years (32.4%; 95% CI, 17.9%-47.0% vs 56.0%; 95% CI, 42.5%-69.6%)., Conclusions and Relevance: A small percentage of older adults with voice disorders seek treatment; even fewer are treated by an otolaryngologist or a speech language pathologist. A greater percentage of those who undergo treatment experienced symptomatic improvement compared with those who did not undergo treatment. These trends highlight the need for greater access to and awareness of services available to older adults with voice disorders.

Professional burnout is a barrier to physician wellness. Burnout is prevalent across medicine, and otolaryngology as a specialty ranks near the mean. We review burnout levels in various subgroups of otolaryngology, including academic chairs, faculty, and residents. Risk factors of burnout are discussed, which differ by subgroup. Finally, we propose measures that could help minimize burnout and promote healthy and satisfying careers.

Objectives/hypothesis: The aim of this study was to understand current protocols for voice rest implemented by laryngologists immediately after phonomicrosurgery for benign vocal fold lesions., Study Design: Cross-sectional survey., Methods: A 24-item survey was sent via electronic mail to laryngologists across the country to gather data on their recommendations of type and dosage of voice rest, factors involved in this decision, and recommendations for other behavioral modifications., Results: A majority of the laryngologists implement 7 days of complete voice rest for nodules, cysts, polyps, and Reinke's edema, 1 to 4 days for leukoplakia and papilloma, and over 8 days of relative voice rest for most lesions. A majority of the laryngologists also employ a combination of complete and relative voice rest., Conclusions: The more common recommendation for complete voice rest is 7 days for nodules, cysts, polyps, and Reinke's edema, and 1 to 4 days for leukoplakia and papilloma. Relative voice rest when recommended is typically recommended for over 8 days. Voice rest recommendations were not affected by surgery type alone, but were determined by either lesion type alone or lesion type combined with surgery type., Level of Evidence: 4. Laryngoscope, 128:1170-1175, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To assess differences in access to care and healthcare utilization among adults who reported voice problems in 2012., Study Design: Cross-sectional study., Methods: The 2012 National Health Interview Survey was utilized to evaluate adults who had a "voice problem in the past 12 months." Multivariate analyses determined the influence of sociodemographic variables on the prevalence of voice problems in adults and access to care., Results: Among 243 million adults in the United States, 17.9 ± 0.05 million adults (7.63% ± 0.21%) report experiencing voice problems. After controlling for age, education, income level, geographic region, and health insurance status, African Americans (odds ratio [OR]: 0.83, P < 0.05), Hispanics (OR: 0.61, P < 0.01), and other minorities (OR: 0.69, P < 0.01) had a lower OR for reporting voice problems in the last year relative to white adults. Among adults with voice problems, Hispanics were more likely to delay care because they could not reach a medical office by telephone (OR: 1.85, P < 0.01) and due to long wait times at the doctor's office (OR: 2.04, P < 0.01) compared to white adults. Adults with voice problems who were a racial minority, low income, or had public health insurance were more likely to postpone care because they lacked a mode of transportation., Conclusion: Targeted programs are necessary to address the health disparities and barriers to care among those who suffer from voice problems., Level of Evidence: IV. Laryngoscope, 128:915-920, 2018., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Importance: Endoscopic dilation is the mainstay treatment strategy for subglottic and proximal tracheal stenosis (SGS/PTS). Its major limitation is restenosis requiring repeated surgery. Intralesional steroid injection (ISI) is a promising adjunctive treatment aimed at prolonging the effects of dilation., Objective: To evaluate the association of serial in-office ISI after endoscopic dilation with surgery-free interval (SFI) in adults with SGS/PTS., Design, Setting, and Participants: A retrospective study of adults with SGS/PTS who underwent at least 2 consecutive in-office ISI at the University of Southern California, Keck School of Medicine, over a 3-year period was conducted., Exposure: Serial ISI with triamcinolone 40 mg/mL using topical anesthesia, spaced 3 to 6 weeks apart., Main Outcomes and Measures: Surgery-free interval, number of dilations, need for open airway surgery, decannulation rate, and adverse events. Patients with previous dilations and sufficient follow-up time were included in a comparative analysis of SFI before and after ISI. The Mann-Whitney U test was applied for comparisons., Results: Twenty-four patients met eligibility criteria. Mean (SD) age was 50.1 (15.1) years; 18 (75%) were female. Ten (42%) patients had idiopathic, 8 (33%) had traumatic, and 6 (25%) had rheumatologic-related SGS/PTS. Mean (SD) follow-up time was 32.3 (33.4) months. Patients underwent mean (SD) 4.08 (1.91) injections. Seventeen (71%) patients have not undergone further surgery after ISI. Mean (SD) SFI was 17.8 (12.8) months overall and was 15.7 (10.6) months for idiopathic, 13.8 (9.9) for traumatic, and 26.7 (16.9) for rheumatologic-related SGS/PTS. Twenty-one (88%) patients underwent dilation(s) prior to ISI. Among patients who fulfilled eligibility criteria for comparison of SFI before and after ISI, SFI improved from 10.1 months before, to 22.6 months after ISI (mean difference, 12.5 months; 95% CI, -2.1 to 27.2 months). Three of 6 patients (all with traumatic SGS/PTS) presenting with a tracheotomy were decannulated. No patients required open airway surgery after ISI. There were no adverse events associated with ISI., Conclusions and Relevance: Serial in-office ISI are safe and well-tolerated in adults with SGS/PTS. This technique can reduce the surgical burden on these patients and may obviate the need for future airway intervention.

Objective: The aim of this study was to describe the presentation of pharyngeal dystonia (PD), which can occur as a focal or segmental dystonia with a primarily pharyngeal involvement for the discussion of treatment methods for controlling consequent symptoms. PD is specific to speech-related tasks., Methods: A retrospective medical record review of four patients with PD was performed., Results: All patients were initially misdiagnosed with adductor spasmodic dysphonia and failed standard treatment with botulinum toxin type A (BTX). On laryngoscopy, the patients were discovered to have segmental or focal dystonia primarily affecting the pharyngeal musculature contributing to their vocal manifestations. A novel treatment regimen was designed, which involved directing BTX injections into the muscles involved in spasmodic valving at the oropharyngeal level. After titrating to an optimal dose, all patients showed improvement in their voice and speech with only mild dysphagia. These patients have maintained favorable results with repeat injections at 6- to 12-week intervals., Conclusions: PD, or dystonia with predominant pharyngeal involvement, is a rare entity with vocal manifestations that are not well described. It can be easily mistaken for spasmodic dysphonia. PD is specific to speech-related tasks. A novel method of BTX injections into the involved muscles results in a significant improvement in voice without significant dysphagia., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: A recently published retrospective chart review of aerodynamic profiles of women with primary muscle tension dysphonia by Gillespie et al (2013) identified various relationships between mean airflow rate (MFR) and estimated subglottal pressure (est-Psub). The current retrospective study expanded the diagnostic categories to include all voice disorders referred for voice therapy. Three research questions were proposed: (1) Are there differences in the MFR and the est-Psub compared with the normal control group? (2) Within the disordered population, are there different variations in the pairing of MFR and est-Psub? (3) If these variations exist, are they diagnosis specific?, Methods: A retrospective chart review of patients seen for acoustic and aerodynamic voice assessment at the Emory Voice Center between January 1, 2013 and December 31, 2014, were examined for aerodynamic measures of est-Psub and MFR; of these, 192 met the inclusion criteria. Simple t test, two-step cluster analysis, and analysis of variance, as well as Tukey multiple comparisons, were performed using R and SPSS., Results: Mean est-Psub was significantly greater in the group with voice disorder than in the control group (P value < 0.001). However, no statistical significance was found when comparing the MFR with the control group (P value <0.59). Nine possible pairings of MFR and est-Psub were found. Sufficient evidence was not found to detect significant differences in these pairings across diagnostic groups., Conclusion: With regard to the rate and interrelationships of MFR and est-Psub, the findings of this study are similar to those of Gillespie et al, that is, MFR and est-Psub are not determinate of diagnosis., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study aimed to identify the changes in dosing of botulinum toxin-A for adductor spasmodic dysphonia (ADSD) over a prolonged period., Study Design: This is a retrospective chart review., Methods: One hundred thirteen subjects treated for ADSD from 2003 to 2013 were identified from a clinical database. Subject age, gender, and total injection dose amount were all recorded for all subjects who had at least 10 injections., Results: Fifty-four subjects met criteria for inclusion. There were no age or gender differences in the starting dose for subjects. Dosing decreased significantly compared with the second dose (5.05 ± 1.623 Units), by the sixth dose (4.26 ± 1.698 Units), and continued through the 10th dose (4.08 ± 2.019 Units) (P < 0.005 for all)., Conclusions: Botulinum toxin-A dosing for ADSD decreases consistently over subsequent injections after the initial two dose titrations., (Copyright © 2017. Published by Elsevier Inc.)

Objective: The aim of this study was to illustrate the risk of vocal fold atrophy in patients who receive serial subepithelial steroid injections for vocal fold scar., Methods: This study is a retrospective case report of two patients who underwent a series of weekly subepithelial infusions of 10 mg/mL dexamethasone for benign vocal fold lesion. Shortly after the procedures, both patients developed a weak and breathy voice. The first patient was a 53-year-old man with radiation-induced vocal fold stiffness. Six injections were performed unilaterally, and 1 week later, he developed unilateral vocal fold atrophy with new glottal insufficiency. The second patient was a 67-year-old woman with severe vocal fold inflammation related to laryngitis and calcinosis, Raynaud's phenomenon, esophagean dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome. Five injections were performed bilaterally, and 1 week later, she developed bilateral vocal fold atrophy with a large midline glottal gap during phonation. In both cases, the steroid-induced vocal atrophy resolved spontaneously after 4 months., Outcomes & Importance: Serial subepithelial steroid infusions of the vocal folds, although safe in the majority of patients, carry the risk of causing temporary vocal fold atrophy when given at short intervals., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)