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To demonstrate the safety profile of platelet-rich plasma (PRP) as an injectable therapeutic for the treatment of vocal fold scarring and atrophy.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.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.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.4 Laryngoscope, 2022.

ImportanceThe gold-standard treatment for laryngeal dystonia (LD) and essential tremor of the vocal tract (ETVT) is botulinum toxin (BoNT) chemodenervation. Although safe and effective, it is not curative, and periodic injections are required. Some medical insurance companies only cover injections at a 3-month interval, though some patients benefit from injections more frequently.ObjectiveTo determine the proportion and characteristics of patients who receive BoNT chemodenervation treatment in intervals shorter than 90 days.Design, Setting, and ParticipantsThis retrospective cohort study across 3 quaternary care neurolaryngology specialty practices in Washington and California recruited patients who underwent at least 4 consecutive laryngeal BoNT injections for LD and/or ETVT in the past 5 years. Data were collected from March through June 2022 and analyzed from June through December 2022.ExposureLaryngeal BoNT treatment.Main Outcomes and MeasuresBiodemographic and clinical variables, injection characteristics, evolution during the 3 interinjection intervals, and lifetime laryngeal BoNT treatment data were collected from patient medical records. Logistic regression was used to assess association to the short-interval outcome, defined as an average injection interval shorter than 90 days.ResultsOf 255 patients included from the 3 institutions, 189 (74.1%) were female, and the mean (SD) age was 62.7 (14.3) years. The predominant diagnosis was adductor LD (n = 199 [78.0%]), followed by adductor dystonic voice tremor (n = 26 [10.2%]) and ETVT (n = 13 [5.1%]). Seventy patients (27.5%) received short-interval injections (Conclusions and RelevanceThis cohort study demonstrated that while insurance companies often mandate a 3-month or greater interval for BoNT chemodenervation financial coverage, there is a considerable subset of patients with LD and ETVT who receive short-interval treatment to optimize their vocal function. Short-interval chemodenervation injections demonstrate a similar adverse effect profile and do not appear to predispose to resistance through antibody formation.

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.

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.

This study aimed to compare the prevalence and incidence of vocal fold pathologies among undergraduate classical, musical theatre, and contemporary commercial music (CCM) students over two-time points.This study is part of a longitudinal investigation. Videostroboscopic examinations were rated, with consensus among three of four expert blinded raters confirming the presence of pathology. Association between genre of singer and the presence of pathology, interrater reliability, and intra-rater reliability were calculated. Prevalence and incidence of pathologies were compared across genres.During first-year evaluations, 32% of musical theatre, 18% of CCM, and 0% of classical students had vocal pathologies. The prevalence at third-year evaluations showed 22% of classical, 39% of musical theatre, and 27% of CCM participants having vocal fold pathologies. The incidence of pathologies was 67% of musical theatre students compared to 22% of classical students and 27% of CCM students. The four raters demonstrated fair to moderate interrater agreement. Singing Voice Handicap Index-10 scores were normal for CCM singers at both time points but elevated for musical theatre and classical singers.No classical singers were found to have pathology during first-year evaluations, although CCM and musical theatre singers showed evidence of vocal fold pathologies. At third-year evaluations, all three genres had an apparent increase in prevalence of pathologies. Implications of this study suggest that more time in the field and intense voice usage may lead to a greater risk of pathology for all singers, regardless of genre.2 Laryngoscope, 2022.

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).Four bibliographic databases were searched: PubMed, EMBASE, Cochrane, and IEEE.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.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.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.

OBJECTIVES/HYPOTHESIS An artificial intelligence (AI) tool was developed using audio clips of cis-male and cis-female voices based on spectral analysis to assess %probability of a voice being perceived as female (%Prob♀). This program was validated with 92% accuracy in cisgender speakers. The aim of the study was to assess the relationship of fo on %Prob♀ by a validated AI tool in a cohort of trans females who underwent intervention to feminize their voice with behavioral modification and/or surgery. STUDY DESIGN Cohort study. METHODS Fundamental frequency (fo ) from prolonged vowel sounds (fo /a/) and fo from spontaneous speech (fo -sp) were measured using the Kay Pentax Computerized Speech Lab (Montvale, NJ) in trans females postintervention. The same voice samples were analyzed by the AI tool for %Prob♀. Chi-square analysis and regression models were performed accepting >50% Prob♀ as female voice. RESULTS Forty-two patients were available for analysis after intervention. fo -sp post-treatment was positively correlated with %Prob♀ (R = 0.645 [P 50% for the speech samples and fo -sp >160 Hz (P 160 Hz. Of these, the AI program only perceived nine patients as female (>50 %Prob♀). CONCLUSION Patients with fo -sp >160 Hz after feminization treatments are not necessarily perceived as having a high probability of being female by a validated AI tool. AI may represent a useful outcome measurement tool for patients undergoing gender affirming voice care. LEVEL OF EVIDENCE 3 Laryngoscope, 131:2567-2571, 2021.

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients. Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence. Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression. Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.

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.

To compare patient, disease and treatment characteristics of patients treated for recurrent respiratory papillomatosis (RRP) at a public county versus a private hospital.A retrospective cohort study was conducted of adult patients undergoing treatment for RRP at a tertiary-care academic center (TAC, n = 48) versus public safety net hospital (PSNH, n = 14), both staffed by the same Otolaryngology providers.There was no difference between cohorts in age, gender, medical comorbidities, history of juvenile-onset presentation, or history of prior treatment at a different institution. PSNH patients were more likely to be Hispanic/Latino, primarily speak Spanish, have public or no insurance, and reside in a zip code with lower median income compared with TAC patients. Despite living significantly closer to the hospital, PSNH patients were more likely than TAC patients to present with respiratory symptoms (50% versus 20.8%, P = 0.04), and exhibit more than one involved laryngeal subsite at their first surgical intervention (78.6% versus 27.1%, P = 0.001). They also had high rates of referral for otolaryngologic care via the emergency department (42.9%) rather than outpatient specialty referral (35.7%) and were more likely than TAC patients to require urgent intervention (21.4% versus 2.1%, P = 0.03). There was no difference in time interval from first clinic visit to procedure date or total number of treatments.PSNH patients present with more severe and symptomatic RRP disease compared with TAC patients. This finding may be related to sociodemographic disparities leading to poorer access in care.

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.

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.

Oxidized low-density lipoproteins play an important role in tissue pathology. In this study, we report a sensitive novel enzyme-linked immunosorbent assay for the detection of malondialdehyde-modified low-density lipoprotein (MDA-LDL), a key component of oxidized LDL. The assay is capable of measuring a variable presence of MDA-LDL within human plasma and serum. We demonstrate the robust nature of the assay on samples stored for over 20 months, as well as high inter-operator reproducibility (r = 0.74, p &lt, 0.0001). The assay was capable of detecting dynamic changes in patient blood samples after coronary artery bypass graft surgery, indicating synthesis or release of MDA-LDL with the oxidative stress of surgery, followed by homeostatic clearance. This robust, sensitive and specific assay for circulating MDA-LDL will serve as a valuable translational tool for the improved detection of oxidative forms of LDL in response to a range of physiological or pathological stimuli, with potential clinical applicability.

OBJECTIVES/HYPOTHESIS: To investigate the concordance in diagnosis and management between initial telemedicine visits and subsequent in-person visits with laryngoscopy for laryngology-related complaints during COVID-19. STUDY DESIGN: Retrospective cohort study. METHODS: Patients who presented to a tertiary care center with laryngology-related complaints (voice, swallowing, airway, general throat complaints and others) and completed initial telemedicine visits and subsequent in-person visits with laryngoscopy between March and October 2020 were included (n = 250). Preliminary diagnoses and managements provided during initial telemedicine visits were compared with the diagnoses and managements during subsequent in-person visits with laryngoscopy. Multivariable logistic regression analysis was performed to compare concordance rates in diagnosis and management by chief complaint categories after adjusting for relevant demographic and clinical factors. RESULTS: Overall concordance rates in diagnosis and management between the initial telemedicine visit and subsequent laryngoscopy exam were 86.1% and 93.7%, respectively. Mean (standard deviation) days until laryngoscopy from the initial visit were 21.2 (23.0). Concordance rates were not associated with patient's age, gender, preferred language, provider, telemedicine visit duration, or days until laryngoscopy. Management concordance rate was relatively lower among patients with general throat complaints in comparison with voice-related complaints (odds ratio: 0.27; 95% confidence interval: 0.08-0.90). Management changes after laryngoscopy included need for further imaging, procedures, voice therapy, and referral to other specialists. CONCLUSION: Concordance rates in diagnosis and management remained high between the initial telemedicine visit and subsequent in-person visit with laryngoscopy for new patients presenting with laryngology-related complaints during the COVID-19 pandemic. While laryngoscopy is still essential to confirm diagnosis and provide appropriate management, telemedicine may be a feasible alternative to provide suitable empiric therapy until laryngoscopy can be safely performed. LEVEL OF EVIDENCE: Level IV Laryngoscope, 2021.

1. To survey how vocal fatigue manifests itself in the vocal range of a sample of professional, female opera singers. 2. To assess laryngeal videostroboscopic changes of one professional, female opera singer before and after extended operatic singing.Survey study: 296 professional, female opera singers were recruited to participate in an anonymous research survey querying the temporary impact of vocal fatigue in professional, female opera singers. 46.3% of participants described themselves as singing mainstage roles at large, A-level opera houses. Singers were asked to report where in their vocal range they experienced the effects of vocal fatigue and could choose more than one response. Single-subject study: One professional, female opera singer (the author) underwent two laryngeal videostroboscopic exams pre and post vocal loading. The exams were evaluated and compared independently by two blinded laryngologists.The results of the survey found that 42.9% of the total responses from professional, female opera singers indicated a temporary impact on the lower middle range (≈C4-F4) as a result of vocal fatigue. 36.5% of participants experienced a temporary impact on their lowest range (≈below C4) and 19.6% reported a temporary impact on their higher range due to vocal fatigue. The results of the single-subject study showed reduced glottal closure pattern in the postloading, lower middle range, head voice condition.A large proportion (64.9%) of the professional, female opera singers surveyed reported increased difficulty navigating their lower middle range and/or lowest range after extended operatic singing. These results support the single-subject study, which found that after vocal loading, there was a decrease in glottal competence while singing in head voice in the lower middle range.

Summary Introduction There is a belief among vocalists that there are voice benefits from vitamin B12 treatment. Yet there are no previous reports regarding vitamin B12 effects on voice. Objectives To assess the prevalence of vitamin B12 use among singers and their beliefs regarding vitamin B12 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 B12 treatment taken for any reason. Four percent used vitamin B12 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 B12 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 B12 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 B12 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 B12 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 B12. Blinded randomized trials are required to verify or refute this belief.

OBJECTIVE Severe acute respiratory syndrome coronavirus-2 spreads through respiratory fluids. We aim to quantify aerosolized particles during laryngology procedures to understand their potential for transmission of infectious aerosol-based diseases. STUDY DESIGN Prospective quantification of aerosol generation. METHODS Airborne particles (0.3-25 μm in diameter) were measured during live-patient laryngology surgeries using an optical particle counter positioned 60 cm from the oral cavity to the surgeon's left. Measurements taken during the procedures were compared to baseline concentrations recorded immediately before each procedure. Procedures included direct laryngoscopy with general endotracheal anesthesia (GETA), direct laryngoscopy with jet ventilation, and carbon dioxide (CO2 ) laser use with or without jet ventilation, all utilizing intermittent suction. RESULTS Greater than 99% of measured particles were 0.3 to 1.0 μm in diameter. Compared to baseline, direct laryngoscopy was associated with a significant 6.71% increase in cumulative particles, primarily 0.3 to 1.0 μm particles (P

INTRODUCTION. It is well understood that hearing plays an important role in accurate vocal production. Singers in particular rely on auditory cues and auditory feedback to reproduce specific pitch contours. Therefore, even mild hearing loss may have a detrimental effect on a singer’s ability to perform. This study investigates the effect of hearing loss on self-reported vocal production in singers, specifically in the domains of pitch matching, pitch maintenance, vowel production, and dynamic control as well as the effect of hearing loss on vocal handicap. METHODS. An 18-item electronic self-report survey was distributed to the members of the National Association of Teachers of Singing and to the Voice Foundation. Data collected included demographics, the Singing Voice Handicap Index-10 (SVHI-10), and a series of closed and open-ended questions. Demographic variables, variables related to the SVHI-10, and variables related to the newly introduced survey were included in a hierarchical regression analysis to determine significant relationships. RESULTS. Among 206 eligible participants, 37 individuals reported a voice problem, 58 reported hearing loss, and 19 reported concurrent hearing loss and a voice problem. Among males, there were no significant differences between hearing impaired and normal hearing singers in reported pitch matching, pitch maintenance, dynamic control, and vowel matching when those with voice problems were excluded and included. However, in females, when singers with voice problems were excluded, there was a significant difference between hearing impaired and normal hearing singers in pitch matching (P = 0.38). Additionally, when singers with voice problems were included in the female subset, significant differences emerged between the hearing impaired and normal hearing singers in areas of pitch matching (P = 0.01) and vowel matching (P = 0.02). Further, controlling for gender, when excluding voice problems, there was a significant difference between the SVHI-10 scores of normal hearing (mean = 9.03) and hearing impaired participants (mean = 11.30, P = 0.02). This difference continued to be significant when including those with voice problems (normal hearing mean = 9.97, hearing impaired mean=14.1, P

To compare flexible distal-chip laryngoscopy (FDL) and rigid telescopic laryngoscopy (RTL) in image quality and diagnostic ability.Prospective cohort study; blinded comparison.Eighteen normal adult subjects were recruited to undergo both FDL and RTL and normalized videos were recorded. Three blinded laryngologists compared the videos for color fidelity, illumination, resolution, and vascularity, and indicated superiority with FDL, RTL, or no difference. Raters also reported if an abnormality was seen and in which video it was better visualized. Videos for two subjects were repeated to assess intra-rater reliability, making 20 video comparisons across 3 raters for a total of 60 ratings. Differences in responses were analyzed via Mann-Whitney U and Pearson ΧRTL was rated superior in all categories of image quality (47 vs 5 vs 8, P0.01; 47 vs 7 vs 6, P0.01; 51 vs 5 vs 4, P0.01; 44 vs 9 vs 7, P0.01, respectively). An abnormality was seen 33 times with both modalities and 6 times with RTL only. When seen with both modalities, visualization was superior in RTL compared with FDL (29 vs 4, P0.01).There was significant superiority of RTL in all categories of image quality, with slight inter-rater agreement for color fidelity, resolution, and vascularity. RTL was also significantly better for visualization of abnormalities. These findings suggest superior image quality in RTL compared with FDL, but further research is required to determine if this difference is clinically significant.

OBJECTIVES/HYPOTHESIS A variety of laryngeal pathologies are increasingly being managed with in-office KTP laser (IOKTP) endoscopic procedures. The primary goal of this study was to identify patient characteristics and disease-related features that correlated with tolerance for IOKTP. STUDY DESIGN Retrospective chart review. METHODS The study was a retrospective review of adult patients undergoing office-based laryngeal laser procedures between November 2016 and December 2019 at a tertiary care center. Two blinded otolaryngologist reviewers scored videotaped recordings of IOKTP procedures and assessed severity and distribution of disease using a modified Derkay score, and evaluated procedure tolerance using a visual analog scale. RESULTS A total of 56 patients who received IOKTP procedures for laryngeal pathology were reviewed, 42 male and 14 female, with a mean age of 61 years. Gender, age, and BMI were not correlated with tolerance. There was a moderate, negative correlation between tolerance and total number of pathological anatomic laryngeal subsites (rs(56) = -0.35, P = .01). There was a weak, negative correlation between tolerance and total modified Derkay score (rs(56) = -0.29, P = .03). The median tolerance score was lower for patients with posterior lesions (Mdn = 6.4) compared with patients with non-posterior lesions (Mdn = 7.4), P = .04, and lower for current or former smokers (Mdn = 6.5) compared with never smokers (Mdn = 7.3), P = .04. CONCLUSION Patients with large disease burden or posterior lesions and patients with smoking history may exhibit poorer tolerance of IOKTP procedures, factors which can help guide pre-procedural counseling and management decisions. LEVEL OF EVIDENCE IV Laryngoscope, 131:E2292-E2297, 2021.

Summary 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.

Summary 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.

While the novel coronavirus outbreak has profoundly altered health care systems across the globe, it has also affected similar change and devastation on the social, educational, and cultural communities upon which many rely, including communities of choral singers, solo performers, conductors, voice teachers, and the professionals that collaborate with them. Even as citizens of the most heavily impacted countries took to their balconies to serenade first responders and health care workers, singers of most genres who typically perform in ensembles have been told to not carry on their beloved practice. This message, promoted by the lay media and by early reports of “super-spreading” of the virus at choral events in the United States and abroad,1 , 2 has been reinforced by expert and nonexpert opinion regarding the transmissibility of SARS-CoV-2 through droplets and aerosols, the generation of respiratory particles when singing, and concern about the interpersonal interactions that routinely accompany vocal performance, both in groups and in one-on-one teaching situations. Unfortunately, there is a paucity of data about both how SARS-CoV-2 is transmitted by singing and how to bring communities of singers back together safely. The data available about disease spread through vocalization, most of which preceded the current pandemic, address primarily transmission of disease through droplets and aerosols and are specific neither to this virus nor to singing.3, 4, 5, 6 Specifically, there is a lack of data addressing how to congregate and sing safely in choral environments such as churches, concert halls and practice spaces, as well as stages, theatres and other venues. In addition, protective measures such as safest distancing between singers, wearing masks or other personal protective equipment (PPE), using larger rehearsal or performance spaces, reducing the number of singers inside a certain enclosed space, reducing the duration of rehearsals or performances, and using real time air and surface cleaning methods such as increased ventilation, UV-C light and HEPA filtration specific to a singing environment among other topics have not been studied well enough to provide evidence on which to base advice to the singing community. Opinion on these matters is plentiful and often divergent. A recent webinar with a panel of experts in the world of voice care and singing left the audience with the message, “There is no safe way for singers to rehearse together until there is a COVID-19 vaccine and a 95% effective treatment in place.”7 , 8 Although, this may ultimately prove to be accurate, evidence-based practice (defined as an approach to health that integrates scientific research, patient preferences and values, and clinical expertise to make the best recommendations possible) does not allow for such a definitive conclusion to be made at this time.9 It must be understood, that these recommendations and decisions are made not only on what scientific information is available but on intuition and unsystematic experience that is often biased and inaccurate. We do not understand all the risks posed by COVID 19 to ourselves, friends, family and colleagues, who wish to resume educational, performance, communal and congregational singing safely. Evidence-based practice demands that we critically evaluate our current state of knowledge to come up with the best possible information to disseminate. In this article, we review the information that exists relating to singing and COVID-19. This paper is intended to provide guidance based on what we know: the best available data, analyzed and scrutinized by a panel of experts in the medical, behavioral and basic science world of voice care, of whom many are professional singers, choir directors or teachers of singing. While it may not be able to afford any definitive answers, this work will offer suggestions of best practices for those singing groups that are willing to mitigate risk knowing that the risk cannot be brought to zero. Finally, this report will hopefully stimulate the larger voice research community to study the emerging consensus on safe resumption of singing and pursue scientific understanding of COVID-19.

Summary 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.

Summary Introduction The Lombard effect (LE) is a phenomenon in which speakers adjust their vocal production by raising the volume in noisy environments. As a result, the LE can create problems of vocal strain, fatigue and potential injury. Objectives This study aims to examine the difference in vocal intensity output in subjects wearing unilateral hearing protection versus no hearing protection in the presence of background noise. Methods Each subject was seated inside a sound booth wearing a head-mounted microphone. Subjects were asked to read an excerpt from “The Rainbow Passage” while various levels of background noise were played: 50, 60, 70, and 80 dBA (Multitalker Babble). Each noise level was played while the subject was with and without unilateral ear protection (Optime 98 Earmuff [3M]) in random order. The earmuff has a noise reduction rating of 25 dB. After each reading of the text, subjects were asked to rate communication disturbance, vocal clarity, and discomfort during talking using a 10 cm visual analogue scale. Results The LE is reduced from 0.38 dB/dB to 0.29 dB/dB with unilateral ear occlusion. However, self-perception of disturbance, clarity and comfort were not affected by unilateral occlusion, only by noise level. Conclusions Unilateral hearing protection reduces the LE and may protect against phonotrauma when speaking in an environment with loud background noise.

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.

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 CO2 . 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.

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

Summary 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%; χ2 = 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.

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.

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

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?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.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 value0.59). 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.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.

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 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.

This chapter reviews the various implant options that have been utilized for medialization thyroplasty surgery over the years since it was first described. While autologous implants created from cartilage were initially used, medialization thyroplasty has evolved to employ synthetic implants. These include implants designed from silicone (Silastic, Montgomery, and Netterville Phonoform), expanded polytetrafluoroethylene (Gore-Tex), hydroxyapatite (VoCoM), and titanium (TVFMI). For each implant type, details are provided about the implant material, advantages/disadvantages, and specific technical points. Additionally, guidance is offered regarding implant selection in special scenarios such as anatomical variants, revision surgery, previously irradiated patients, post ablative cancer surgery, and medialization thyroplasty performed in conjunction with other procedures.

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 B(12) 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 B(12) 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 B(12) deficiency or active or recent vitamin B(12) treatment were excluded. Analysis was on a per-protocol basis. INTERVENTIONS: Participants were randomized to receive an intramuscular (deltoid) injection of either vitamin B(12) (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 B(12) injections were comparable to each other. At 72 hours after the vitamin B(12) 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 B(12) 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 B(12) and placebo injections. CONCLUSIONS AND RELEVANCE: This randomized, double-blind, placebo-controlled, crossover trial found that after empirical vitamin B(12) 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