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Abstract Background Bronchial thermoplasty (BT) is a bronchoscopic procedure that improves asthma control by reducing excess airway smooth muscle. Treated patients have been followed out to 5 years to evaluate long-term safety of this procedure. Methods Patients enrolled in the Asthma Intervention Research Trial were on inhaled corticosteroids ≥200 μg beclomethasone or equivalent + long-acting-beta2-agonists and demonstrated worsening of asthma on long-acting-β2-agonist withdrawal. Following initial evaluation at 1 year, subjects were invited to participate in a 4 year safety study. Adverse events (AEs) and spirometry data were used to assess long-term safety out to 5 years post-BT. Results 45 of 52 treated and 24 of 49 control group subjects participated in long-term follow-up of 5 years and 3 years respectively. The rate of respiratory adverse events (AEs/subject) was stable in years 2 to 5 following BT (1.2, 1.3, 1.2, and 1.1, respectively,). There was no increase in hospitalizations or emergency room visits for respiratory symptoms in Years 2, 3, 4, and 5 compared to Year 1. The FVC and FEV1 values showed no deterioration over the 5 year period in the BT group. Similar results were obtained for the Control group. Conclusions The absence of clinical complications (based on AE reporting) and the maintenance of stable lung function (no deterioration of FVC and FEV1) over a 5-year period post-BT in this group of patients with moderate to severe asthma support the long-term safety of the procedure out to 5 years.

Abstract Background The engineering of many-component, synthetic biological systems is being made easier by the development of collections of reusable, standard biological parts. However, the complexity of biology makes it difficult to predict the extent to which such efforts will succeed. As a first practical example, the Registry of Standard Biological Parts started at MIT now maintains and distributes thousands of BioBrick™ standard biological parts. However, BioBrick parts are only standardized in terms of how individual parts are physically assembled into multi-component systems, and most parts remain uncharacterized. Standardized tools, techniques, and units of measurement are needed to facilitate the characterization and reuse of parts by independent researchers across many laboratories. Results We found that the absolute activity of BioBrick promoters varies across experimental conditions and measurement instruments. We choose one promoter (BBa_J23101) to serve as an in vivo reference standard for promoter activity. We demonstrated that, by measuring the activity of promoters relative to BBa_J23101, we could reduce variation in reported promoter activity due to differences in test conditions and measurement instruments by ~50%. We defined a Relative Promoter Unit (RPU) in order to report promoter characterization data in compatible units and developed a measurement kit so that researchers might more easily adopt RPU as a standard unit for reporting promoter activity. We distributed a set of test promoters to multiple labs and found good agreement in the reported relative activities of promoters so measured. We also characterized the relative activities of a reference collection of BioBrick promoters in order to further support adoption of RPU-based measurement standards. Conclusion Relative activity measurements based on an in vivoreference standard enables improved measurement of promoter activity given variation in measurement conditions and instruments. These improvements are sufficient to begin to support the measurement of promoter activities across many laboratories. Additional in vivo reference standards for other types of biological functions would seem likely to have similar utility, and could thus improve research on the design, production, and reuse of standard biological parts.

The article focuses on a case of vocal fold mucosal bridge with no sulcus vocalis in a female smoker. A polypoid mass in the right vocal fold was detected through strobovideolaryngoscopy. A mucosal bridge filled with Reinke edema was confirmed when surgery was carried out. The voice of the patient improved after the operation.

Objective: Benign phonotraumatic lesions of the vocal folds (BVFLs) are typically seen in younger female patients with high vocal loads. Hemorrhagic polyps (HPs) do not fit the classic paradigm of most BVFLs, as they tend to occur in an older population, have a male predominance, and report to result from a vocal accident. We present one of the largest cohorts of HPs, to reexamine their etiology and clinical features., Methods: Retrospective cohort study, inclusive of all patients with HP managed by the senior authors between the years 2016 through 2023. Demographic data, management, phonotraumatic risk factors, pre- and post-treatment VHI-10 were reviewed. We examined patient videostroboscopy, categorized the size of the lesion, and identified any concurrent mucosal abnormality., Results: One hundred and eleven patients had confirmed HP, 84 males (75.7%). Thirty-five patients were size category 1; pinpoint (28.9%), 57 were category 2; less than 1/3rd the vocal fold (45.5%), and 26 were category 3; greater than 1/3rd the vocal fold (21.5%). Ten patients (9%) had bilateral HPs. Thirty-five patients had an additional 40 mucosal lesions in addition to the HP(s). The onset of symptoms was gradual in 60% of patients. The mean pretreatment VHI-10 was 18.0 (SD 10.7), compared to 6.0 (SD 10.5) post-treatment, ( p  < .001). 57/111 patients reported high voice demand professions or recreational activities. The average self-reported talkative scale score was 7.6/10. Patients were managed with operative microdirect laryngoscopy and microflap excision (53.1%), in-office clinic potassium titanyl phosphate (KTP) laser (24.3%), voice therapy alone (7.2%), and KTP in the operating room (6.3%)., Conclusions: In our cohort, most patients were male, had high vocal demands, reported gradual symptom onset, and almost a third of patients had additional BVFLs., Level of Evidence: Level 3: Retrospective cohort study., Competing Interests: The authors declare no conflicts of interest., (© 2024 The Author(s). Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Background: While several acoustic voice metrics are available for clinical voice assessment, there remains a significant need for reliable and ecologically valid tools. The Acoustic Voice Quality Index version 03.01 (AVQI-3) and Acoustic Breathiness Index (ABI) hold potential due to their comprehensive assessment approach, incorporating diverse voice aspects. However, these tools still need to be validated in English-speaking populations., Methods: This study assessed the discriminatory accuracy and validity of AVQI-3 and ABI in 197 participants, including 148 with voice disorders. Voice samples were collected, followed by AVQI-3 and ABI calculations. Additionally, auditory-perceptual assessments were conducted by a panel of speech-language pathologists., Results: AVQI-3 and ABI effectively identified disordered voice quality, evidenced by high accuracy (AUCs: 0.84, 0.89), sensitivity, and specificity (thresholds: AVQI-3 = 1.17, ABI = 2.35). Strong positive correlations were observed with subjective voice quality assessments (rs = 0.72, rs = 0.77, p < 0.001)., Conclusions: The study highlights AVQI-3 and ABI as promising instruments for clinically assessing voice disorders in U.S. English speakers, underscoring their utility in clinical practice and voice research.

Objective: To compare flexible distal-chip laryngoscopy (FDL) and rigid telescopic laryngoscopy (RTL) in image quality and diagnostic ability., Study Design: Prospective cohort study; blinded comparison., Methods: 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 Χ 2 . Inter-rater reliability was assessed via Fleiss' kappa, and intra-rater reliability was assessed via percent agreement., Results: RTL was rated superior in all categories of image quality (47 vs 5 vs 8, P < 0.01; 47 vs 7 vs 6, P < 0.01; 51 vs 5 vs 4, P<0.01; 44 vs 9 vs 7, P < 0.01, 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, P <0.01)., Conclusions: 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., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose: This study explores sidetone amplification (amplified playback of one's own voice) provided via bone conduction in participants with voice disorders. The effects of bone conduction feedback on acoustic voice parameters and vocal effort ratings are examined., Methods: Speech samples of 47 participants with voice disorders were recorded in three auditory feedback conditions: two with sidetone amplification delivered via bone conduction and one condition with no alteration of the feedback. After each task, the participants rated their vocal effort on a visual analog scale. The voice recordings were evaluated by a speech-language pathologist through the GRBAS scale and processed to calculate the within-participant centered sound pressure level (SPL) values, the mean pitch strength (PS), the time dose (Dt%), and cepstral peak prominence smoothed (CPPS). The effects of the feedback conditions on these acoustic parameters and vocal effort ratings were analyzed., Results: The high sidetone amplification condition resulted in a statistically significant decrease in the within-participant centered SPL values and mean pitch strength across all participants. The feedback conditions had no statistically significant effects on the vocal effort ratings, time dose (Dt%), or CPPS., Conclusions: This study provides an evidence that bone conduction sidetone amplification contributes to a consistent adaptation in the within-participant centered SPL values (ΔSPL) in patients with vocal hyperfunction, glottal insufficiency, and organic/neurological laryngeal pathologies compared to conditions with no feedback., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To investigate the relationship of throat pain and dysphonia., Study Design: Prospective cohort study., Methods: Forty-five subjects presenting with hyoid bone syndrome (HBS) and dysphonia were asked to rate their pain on a numerical rating scale and complete the 10-item Voice-Related Quality of Life (V-RQOL) questionnaire prior to and at 1-week follow-up after treatment with triamcinolone injection into the attachments to the affected greater cornu(s). Wilcoxon signed-rank tests were applied to evaluate if the overall V-RQOL scores, the physical functioning (PF) and social-emotional (SE) domain scores, and pain scores changed significantly after treatment. To evaluate how change in perceived pain affected V-RQOL, the differences in the V-RQOL, PF, and SE domain scores, and in pain scores were calculated for each subject. Three linear models were fit to the response variables, ΔV-RQOL, ΔPF, and ΔSE, using ΔPain as a predicting variable., Results: V-RQOL, PF, and SE domain scores, and pain scores all improved significantly with treatment. A bigger decrease in the pain score led to a bigger increase in V-RQOL and domain scores, with slopes varying between -1.1 and -1.4. The PF domain scores showed the greatest improvement with decrease in pain scores., Conclusions: Effective treatment of HBS led to improvement in patients' voice complaints, suggesting that throat pain may have a direct effect on voice. This may be related to compensatory perilaryngeal adjustments patients make when speaking with a "guarding" effect when they have throat pain., Level of Evidence: IV (Cohort study) Laryngoscope, 131:E2303-E2308, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

The emergence of the novel coronavirus disease 2019 (COVID-19) and the subsequent need for physical distancing have necessitated a swift change in health care delivery. Prior to the COVID-19 outbreak, many institutions utilized an interdisciplinary clinic model including both a laryngologist and a speech-language pathologist for the evaluation of patients with voice, swallowing, and upper airway disorders. To improve access, many providers are pursuing the use of interdisciplinary telemedicine to provide individualized patient-centered care while allowing for physical distancing. The purpose of this commentary is to review the current literature regarding telemedicine in laryngology and speech-language pathology as well as the current and future states of practice for interdisciplinary tele-evaluations.

Introduction: Computer analysis of voice recordings is an integral part of the evaluation and management of voice disorders. In many practices, voice samples are taken in rooms that are not sound attenuated and/or sound-proofed; further, the technology used is rarely consistent. This will likely affect the recordings, and therefore, their analyses., Objectives: The objective of this study is to compare various acoustic outcome measures taken from samples recorded in a sound-proofed booth to those recorded in more common clinic environments. Further, the effects from six different commonly used microphones will be compared., Methods: Thirty-six speakers were recorded while reading a text and producing sustained vowels in a controlled acoustic environment. The collected samples were reproduced by a Head and Torso Simulator and recorded in three clinical rooms and in a sound booth using six different microphones. Newer measures (eg, Pitch Strength, cepstral peak prominence, Acoustic Voice Quality Index), as well as more traditional measures (eg Jitter, Shimmer, harmonics-to-noise ratio and Spectrum Tilt), were calculated from the samples collected with each microphone and within each room., Results: The measures which are more robust to room acoustic differences, background noise, and microphone quality include Jitter and smooth cepstral peak prominence, followed by Shimmer, Acoustic Voice Quality Index, harmonics-to-noise ratio, Pitch Strength, and Spectrum Tilt., Conclusions: The effect of room acoustics and background noise on voice parameters appears to be stronger than the type of microphone used for the recording. Consequently, an appropriate acoustical clinical space may be more important than the quality of the microphone., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: The diagnoses of voice disorders, as well as treatment outcomes, are often tracked using visual (eg, stroboscopic images), auditory (eg, perceptual ratings), objective (eg, from acoustic or aerodynamic signals), and patient report (eg, Voice Handicap Index and Voice-Related Quality of Life) measures. However, many of these measures are known to have low to moderate sensitivity and specificity for detecting changes in vocal characteristics, including vocal quality., Objective: The objective of this study was to compare changes in estimated pitch strength (PS) with other conventionally used acoustic measures based on the cepstral peak prominence (smoothed cepstral peak prominence, cepstral spectral index of dysphonia, and acoustic voice quality index), and clinical judgments of voice quality (GRBAS [grade, roughness, breathiness, asthenia, strain] scale) following laryngeal framework surgery., Methods: This study involved post hoc analysis of recordings from 22 patients pretreatment and post treatment (thyroplasty and behavioral therapy). Sustained vowels and connected speech were analyzed using objective measures (PS, smoothed cepstral peak prominence, cepstral spectral index of dysphonia, and acoustic voice quality index), and these results were compared with mean auditory-perceptual ratings by expert clinicians using the GRBAS scale., Results: All four acoustic measures changed significantly in the direction that usually indicates improved voice quality following treatment (P < 0.005). Grade and breathiness correlated the strongest with the acoustic measures (|r| ~ 0.7) with strain being the least correlated., Conclusions: Acoustic analysis on running speech highly correlates with judged ratings. PS is a robust, easily obtained acoustic measure of voice quality that could be useful in the clinical environment to follow treatment of voice disorders., (Copyright © 2018. Published by Elsevier Inc.)

Training in care of the voice for the general otolaryngologist has improved with the presence of more fellowship-trained laryngologists within academic training programs. However, preparation for caring for the professional singer goes beyond the basic understanding of voice evaluation, laryngeal imaging, and microlaryngeal surgery. The otolaryngologist must have a deeper understanding of the demands, vocabulary, psyche, and economics of the professional singer to provide optimal care. The ramification of recommendations made or procedures undertaken by the otolaryngologist can have serious consequences in a singer's career. This article introduces the otolaryngologist to the specifics of caring for professional singers., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Measurement of treatment outcomes is critical for the spectrum of voice treatments (ie, surgical, behavioral, or pharmacological). Outcome measures typically include visual (eg, stroboscopic data), auditory (eg, Consensus Auditory-Perceptual Evaluation of Voice; Grade, Roughness, Breathiness, Asthenia, Strain), and objective correlates of vocal fold vibratory characteristics, such as acoustic signals (eg, harmonics-to-noise ratio, cepstral peak prominence) or patient self-reported questionnaires (eg, Voice Handicap Index, Voice-Related Quality of Life). Subjective measures often show high variability, whereas most acoustic measures of voice are only valid for signals where some degree of periodicity can be assumed. However, this assumption is often invalid for dysphonic voices where signal periodicity is suspect. Furthermore, many of these measures are not useful in isolation for diagnostic purposes., Objective: We evaluated a recently developed algorithm (Auditory Sawtooth Waveform Inspired Pitch Estimator-Prime [Auditory-SWIPE']) for estimating pitch and pitch strength for dysphonic voices. Whereas fundamental frequency is a physical attribute of a signal, pitch is its psychophysical correlate. As such, the perception of pitch can extend to most signals irrespective of their periodicity., Methods: Post hoc analyses were conducted for three groups of patients evaluated and treated for voice problems at a major voice center: (1) muscle tension dysphonia/functional dysphonia, (2) vocal fold mass(es), and (3) presbyphonia. All patients were recorded before and after surgical/behavioral treatment for voice disorders. Pitch and pitch strength for each speaker were computed with the Auditory-SWIPE' algorithm., Results: Comparison of pre- and posttreatment data provides support for pitch strength as a measure of treatment outcomes for dysphonic voices., (Copyright © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: Dysphagia can be the presenting symptom of autoimmune disease. The otolaryngologist should be familiar with and consider these disorders when assessing the patient with swallowing difficulties., Recent Findings: The present review gives a brief overview of Sjogren's syndrome, granulomatosis with polyangiitis, pemphigus and pemphigoid, rheumatoid arthritis, systemic lupus erythematosus, scleroderma and inflammatory myopathies, and how they affect swallowing. Diagnosis of these diseases is generally based off of clinical presentation, serology, and/or biopsy. Corticosteroids in combination with other immune modulators and symptomatic therapy are the mainstays of treatment. Treatment should be coordinated with a rheumatologist., Summary: The otolaryngologist should be able to recognize when a systemic disease may be the cause of a patient's dysphagia and guide appropriate evaluation. Furthermore, the otolaryngologist can help localize the specific nature of the swallowing problem and guide or provide treatment.

Objectives/hypothesis: To evaluate clinical indications and endoscopic findings for patients undergoing transnasal esophagoscopy (TNE)., Study Design: Prospective, multi-institutional, observational cohort study at four tertiary centers., Methods: Demographics, reflux finding score, reflux symptom index, Eating Assessment Tool (EAT-10) scores, clinical indications, and endoscopic findings were compared among patients whose TNE findings resulted in a changes in management (FCIM), defined as a referral, new medication, or surgery recommendation., Results: Of the 329 patients who were enrolled nine (3%) were unable to complete the exam. In an adjusted regression model, male gender and elevated body mass index were significantly predictive of a positive TNE (P =.013-.045); 51% (n = 162/319) had TNE with FCIM. Common FCIM were esophageal stricture (7.5%), irregular Z-line (27.4%), reflux esophagitis (12.8%), and infectious esophagitis (6.3%) (P <.001-.010). Overall, the average EAT-10 was higher for patients with FCIM (9.7 vs. 5.4) than in those without it (P =.014). Patients with a history of head and neck cancer (HNCA) had FCIM 64% of the time, which rose to 81% if they had both HNCA and dysphagia., Conclusions: In treatment-seeking patients TNE is predictive of a change in management in males and obese patients. In patients with HNCA and dysphagia, TNE is likely to yield findings that cause a change in management., Level of Evidence: 2b. Laryngoscope, 126:2667-2671, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: This report aimed to present a case of inclusion body myositis presenting with dysphagia and to review the literature., Methods: Case report and literature review., Results: Inclusion body myositis is a chronic progressive acquired myopathy, uniquely distinguished by its selective muscle involvement, normal or moderately elevated muscle enzyme concentrations, and a progressive corticosteroid-resistant course. Compared to other inflammatory myopathies, the esophagus is the most commonly involved organ. Specifically, upper esophageal sphincter dysfunction often occurs. Dysphagia may be the only symptom at the time of presentation., Conclusion: Unlike other inflammatory myopathies, dysphagia in inclusion body myositis is steroid resistant. Management can be difficult. The otolaryngologist must consider underlying neuromuscular processes when evaluating the patient presenting with oropharyngeal dysphagia., (© The Author(s) 2014.)

Spindle cell carcinoma (SPCC) is a rare, malignant variant of squamous cell carcinoma (SCC), which shows biphasic proliferation of the conventional SCC component and malignant spindle shape cells with sarcomatous appearance. We present two cases of SPCC of the true vocal fold that presented as a benign appearing subepithelial mass. We discuss the patient presentation, voice assessment, surgical treatment, and a review of the literature., (Copyright © 2014 The Voice Foundation. All rights reserved.)

Importance: Spasmodic dysphonia (SD) can be difficult to diagnose, and patients often see multiple physicians for many years before diagnosis. Improving the speed of diagnosis for individuals with SD may decrease the time to treatment and improve patient quality of life more quickly., Objective: To assess whether the diagnosis of SD can be accurately predicted through auditory cues alone without the assistance of visual cues offered by laryngoscopic examination., Design, Setting, and Participants: Single-masked, case-control study at a specialized referral center that included patients who underwent laryngoscopic examination as part of a multidisciplinary workup for dysphonia. Twenty-two patients were selected in total: 10 with SD, 5 with vocal tremor, and 7 controls without SD or vocal tremor., Interventions: The laryngoscopic examination was recorded, deidentified, and edited to make 3 media clips for each patient: video alone, audio alone, and combined video and audio. These clips were randomized and presented to 3 fellowship-trained laryngologist raters (A.D.R., A.T.H., and A.M.K.), who established the most probable diagnosis for each clip. Intrarater and interrater reliability were evaluated using repeat clips incorporated in the presentations., Main Outcomes and Measures: We measured diagnostic accuracy for video-only, audio-only, and combined multimedia clips. These measures were established before data collection. Data analysis was accomplished with analysis of variance and Tukey honestly significant differences., Results: Of patients with SD, diagnostic accuracy was 10%, 73%, and 73% for video-only, audio-only, and combined, respectively (P < .001, df = 2). Of patients with vocal tremor, diagnostic accuracy was 93%, 73%, and 100% for video-only, audio-only, and combined, respectively (P = .05, df = 2). Of the controls, diagnostic accuracy was 81%, 19%, and 62% for video-only, audio-only, and combined, respectively (P < .001, df = 2)., Conclusions and Relevance: The diagnosis of SD during examination is based primarily on auditory cues. Viewing combined audio and video clips afforded no change in diagnostic accuracy compared with audio alone. Laryngoscopy serves an important role in the diagnosis of SD by excluding other pathologic causes and identifying vocal tremor.

Objectives/hypothesis: The present study aims to evaluate the degree of anterior-posterior and medial supraglottic laryngeal compression in healthy singers of different voice classifications while singing different pitches, loudness, and phonatory tasks., Study Design: Prospective study., Methods: Thirty-six classically trained singers (11 sopranos, 11 mezzo-sopranos, six tenors, and eight baritones) with at least 5 years of voice training and absence of any voice pathology within the past year were included. Flexible endoscopic voice evaluations were recorded and edited to include samples of different pitches, levels of loudness, and phonatory tasks. Sound was removed from the video samples. Two blinded laryngologists were asked to assess medial and anterior-posterior supraglottic compression using a visual analog scale for each sample., Results: Medial compression was significantly greater in male subjects and specifically tenors during loud phonation, during high pitch, and while phonating the vowel /a/. Anterior-posterior compression was also significantly greater in males and specifically baritones during loud voice production and with phonation of the vowel /a/. No difference was noted in relation to pitch. Correlation between anterior-posterior and medial compression was demonstrated. Medial compression was less severe than anterior-posterior compression., Conclusions: Supraglottic hyperfunction is present in healthy singers. Recognizing factors that might affect supraglottic hyperfunction in the healthy voice may help us to understand when hyperfunction is truly contributing to a patient's vocal pathology., Level of Evidence: 4., (© 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: This study was performed to investigate the effectiveness of treatment of globus pharyngeus with proton pump inhibitors, gabapentin, or both., Methods: The subjects all presented with globus pharyngeus during the years 2006 to 2011. The inclusion criteria included a chief (primary) complaint of globus pharyngeus; a trial of proton pump inhibitor therapy for at least 2 months and/or a trial of gabapentin for at least 2 weeks; and at least 1 follow-up visit. We reviewed 331 charts; 87 patients met the criteria. The response to treatment was graded as none, partial, or complete., Results: Seventy-seven percent of all patients had improvement. Sixty-seven percent of patients had a partial or complete response from aggressive reflux management. Sixty-six percent of patients who had a trial of gabapentin reported improvement. Eight of 14 patients who did not improve with aggressive reflux management improved with gabapentin., Conclusions: A majority of patients with globus pharyngeus can be helped by treating reflux or neuralgia. A trial of gabapentin should be considered for patients who do not respond or only partially respond to reflux management.

Objectives: We present a cohort of patients with hyoid bone syndrome who were treated with injections of triamcinolone acetonide (40 mg/mL), in order to raise awareness of this condition, validate its existence, and demonstrate the efficacy of this treatment., Methods: We performed a retrospective chart review of patients who were given a diagnosis of and treated for hyoid bone syndrome by the senior author (A.D.R.) between 2006 and 2009., Results: Eighty-four patients met the inclusion criteria. All patients presented with throat pain and had tenderness of 1 (63%) or both (38%) greater cornua of the hyoid bone. Seventy-four percent of the patients had complete resolution of symptoms with injection of the affected side(s), 15% had a partial response, and 10% had no response. One patient had a recurrence at 3 months and chose not to receive another treatment. Forty-five of the 62 patients with a complete response required only 1 injection. Forty-three patients (51%) also complained of dysphonia, only 5 of whom had additional laryngeal disorders that accounted for the dysphonia., Conclusions: Hyoid bone syndrome should be considered in patients who present with throat pain. Injection of triamcinolone into the affected greater cornu can confirm the diagnosis and resolve symptoms. A positive response to triamcinolone injection may obviate the need for additional testing and procedures.

Introduction and Objective: The purposes of this study are to demonstrate the use of the mobile voice lab in type I thyroplasty with Gore-Tex(®) using analysis of spectrogram and fundamental frequency in the operating room, and also to show how to do this procedure., Methods: Voice samples were recorded in the operating room immediately before and during type I thyroplasty. Six-week postoperative samples were also taken in the voice laboratory. Fundamental frequency and spectral analysis were analyzed. Spectrograms were evaluated by blind panel of 4 judges on a 100mm visual analogue scale. All three time points were compared and statistical analysis performed. Pre and postoperative V-RQOL scores were also compared., Results: Significant improvement in spectrogram ratings were seen between before and during (P<.001), and before and after voice samples (P<.017). There was no significant difference between during and after scores, suggesting the persistence of the intraoperative improvement in this measure. Changes in fundamental frequency were not statistically significant, although fundamental frequency tended to increase in women and decrease in men after type I thyroplasty. Mean V-RQOL scores improved from 48.08 a 85.08 (P<.001)., Conclusions: The mobile voice laboratory may be useful during type I thyroplasty with Gore-Tex(®). It offers an opportunity for the surgeon and voice pathologist to continue to collaborate in the treatment of patients with unilateral vocal fold paralysis., (Copyright © 2012 Elsevier España, S.L. All rights reserved.)

Objectives: Vibrato is considered one of the most essential characteristics of the classical singing voice. Vibrato can be acoustically described by the rate, extent, onset, and regularity. The aim of this study was to determine the influence of emotional expression on acoustic parameters of vibrato in classically trained singers., Study Design: A prospective cohort study was performed., Methods: Thirty healthy classical singers were recruited for this study, 29 singers met inclusion criteria. Inclusion criteria for this study were as follow: 1) no history of vocal pathology in the past year, 2) to have at least 5 years of classical singing training. Each subject was asked to sing the phrase "I Love You," while expressing four different emotions (tenderness, anger, happiness, and sadness) and without emotion (neutral state). The musical tonality of the phrase was adapted to each singer's vocal classification. Subjects were also recorded at three levels of loudness (pianissimo, mezzo forte, and fortissimo), while expressing each emotion. Acoustical analysis was performed during the vowel /o/ of the word "Love" to determine rate of vibrato, the extent of vibrato, and vibrato jitter., Results: Vibrato parameters did not vary significantly when different emotions were expressed. However, vibrato jitter and extent did vary significantly between different levels of loudness. Significant differences were also noted in both rate and extent of vibrato when compared between sexes., Conclusions: Expression of emotions does not affect the acoustic parameters of vibrato, although some parameters are affected by loudness and gender., (Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

The multidisciplinary approach to treatment of amyotrophic lateral sclerosis (ALS) has improved the overall care of patients suffering from this disease ( 1 , 2 ). This approach typically has included neurologists, physiatrists, occupational therapists, respiratory therapists and speech therapists. Dysphonia, dysarthria, and dysphagia are three of the most common bulbar manifestations of ALS, and are often the presenting symptoms in bulbar-onset patients. Despite this, otolaryngologists are often not included in ALS management until a tracheostomy is considered. The otolaryngologist can play an important role in early diagnosis and subsequent management of bulbar manifestations of ALS, and would be a valuable member of the multidisciplinary team.

Objectives/hypothesis: The aims of this study were to demonstrate the ability to enhance nerve regeneration by remote delivery of a viral vector to the crushed recurrent laryngeal nerve (RLN), to demonstrate the usefulness of a crushed RLN model to test the efficacy of viral gene therapy, and to discuss future potential applications of this approach., Study Design: Animal study., Methods: Adult Sprague-Dawley rats were assigned to two groups. In the experimental group, an adeno-associated viral (AAV) vector carrying a zinc-finger transcription factor, which stimulates endogenous insulinlike growth factor I production (AAV2-TO-6876vp16), was injected into the crushed RLN. In the control group, an AAV vector carrying the gene for green fluorescent protein was injected into the crushed RLN. Unilateral RLN paralysis was confirmed endoscopically. At 1 week, laryngeal endoscopies were repeated and recorded. Larynges were cryosectioned in 15-μm sections and processed for acetylcholine histochemistry (motor endplates) followed by neurofilament immunoperoxidase (nerve fibers). Percentage nerve-endplate contact (PEC) was determined and compared. Vocal fold motion was evaluated by blinded reviewers using a visual analogue scale (VAS)., Results: The difference between PEC on the crushed and uncrushed sides was statistically less in the experimental group (0.54 ± 0.18 vs. 0.30 ± 0.26, P = .0006). The VAS score at 1 week was significantly better in the experimental group (P = .002)., Conclusions: AAV2-TO-6876vp16 demonstrated a neurotrophic effect when injected into the crushed RLN. The RLN offers a conduit for viral gene therapy to the brainstem that could be useful for the treatment of RLN injury or bulbar motor neuron disease., (Copyright © 2011 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives/hypothesis: The goal of laryngeal framework surgery in patients with unilateral vocal fold paralysis is to improve glottic closure by medializing the paralyzed vocal fold. Type I thyroplasty (Th) and arytenoid adduction (AA) are two of the most commonly performed procedures. Two of the main rationales for performing an AA are to improve closure of the posterior glottis and correct vertical height discrepancy. The purpose of this study was to evaluate if AA with Th yields better posterior glottic closure and vertical height equality than Th alone., Study Design: Retrospective., Methods: Using visual analog scales, three blinded reviewers evaluated glottic closure patterns in patients who underwent Th or Th with AA. Pre- and postoperative videostroboscopic examinations of 45 patients with unilateral vocal fold paralysis, who underwent laryngeal framework surgery, were evaluated., Results: No significant difference was identified in postoperative scores for midmembranous glottis closure (P=0.282), closure just anterior to the vocal processes (P=0.426), respiratory glottis closure (P=0.158), or vertical height discrepancy (P=0.113)., Conclusions: Although larger glottic gaps and vertical height discrepancies may lead some surgeons to predict that an AA is warranted, the usefulness of AA may not always be related to these parameters. Ultimately, voice improvement and not geometry should guide the surgeon's decision making., (Copyright © 2011 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)

The University of California, Los Angeles (UCLA) Health System seeks to align its purpose of "healing humankind" with its approaches for people and performance management. These approaches include lean process improvements initiatives, sustained by efforts to impact daily team member work flows. The electronic health record (EHR) serves as a powerful supportive instrument in improving processes and sustaining performance. For UCLA, the secret to EHR effectiveness lies in creating win-win situations, where organizational objectives are achieved and team member work flows also are improved. Recent UCLA initiatives with medication bar-coding and a stroke telemedicine network highlight such opportunities. Carried out on a national level, such efforts can significantly affect healthcare in the United States. The US Recovery and Reinvestment Act of 2009's EHR provisions provide a national impetus for broad improvements in healthcare.

Infections due to methicillin-resistant Staphylococcus aureus (MRSA) have become more prevalent, in part because of the emergence and spread of community-acquired MRSA. This trend is particularly concerning because of the significant rates of morbidity and mortality associated with MRSA infections, and because MRSA strains are often resistant to many classes of antibiotics. Reports of infections of the head and neck, including wound infections, cellulitis, sinusitis, otitis media, and otitis externa, are well documented. However, to our knowledge, there have been no reports of bacterial laryngitis due to MRSA. We report the first published case of bacterial laryngitis caused by MRSA.

The objective of this study was to determine if topical anesthesia to the larynx and pharynx affects vocal fold motion during dynamic voice evaluation with transnasal flexible endoscopy. Transnasal dynamic laryngeal examinations of 10 patients with no voice complaints were evaluated by five blinded fellowship-trained laryngologists. Each patient was examined before and after application of topical anesthetic. Reviewers rated briskness of right and left vocal fold movement and longitudinal tension on a visual analogue scale. Statistical comparisons were made between individual subject scores before and after anesthetic application. Inter-rater reliability was also assessed. No statistical difference was observed between subject scores before and after anesthetic application. Average intraclass correlation coefficients were 0.643 and 0.591 for pre- and postanesthesia scores, respectively. Application of topical anesthesia to the larynx and pharynx does not affect vocal fold motion.

We evaluate a group of patients who have mobile vocal folds, but have flexible laryngeal examinations suspicious for mild vocal fold paresis. The purpose of this retrospective study is to evaluate if electroglottography (EGG) can predict the probability of having an abnormal laryngeal electromyography (LEMG). Charts of patients evaluated and suspected of having mild vocal fold paresis between August 1, 2004 and March 30, 2006 were reviewed. We compared average EGG contact quotients (CQs), average absolute difference of recorded CQ from normal (|CQ-50%|), and EGG waveforms between patients with normal and abnormal LEMG. Waveforms were evaluated in blinded fashion. Statistical analysis was performed using chi square and t test analyses. One hundred and sixteen patients received both flexible laryngoscopy and LEMG as part of their evaluation. Forty-eight patients (41%) had confirmed paresis by LEMG and 68 patients (59%) had normal LEMGs. Only 9.1% of patients with a normal EGG waveform had an abnormal LEMG. In contrast, 40.4% of patients with an abnormal EGG waveform had abnormal LEMGs. The negative predictive value of a normal EGG waveform for an abnormal LEMG was 90.9%. No significant differences were identified between patients with normal versus abnormal LEMG in terms of average CQ (47.8% vs 46.4%) or |CQ-50%| (6.2 vs 5.6). Patients with a normal EGG waveform are unlikely to have an abnormal LEMG.

The thyroid surgeon must have a thorough understanding of laryngeal neuroanatomy and be able to recognize symptoms of vocal fold paresis and paralysis. Neuropraxia may occur even with excellent surgical technique. Patients should be counseled appropriately, particularly if they are professional voice users. Preoperative or early postoperative changes in voice, swallowing, and airway function should prompt immediate referral to an otolaryngologist. Early recognition and treatment may avoid the development of complications and improve patient quality of life.

Diagnosis and treatment of the immobile or hypomobile vocal fold are challenging for the otolaryngologist. True paralysis and paresis result from vocal fold denervation secondary to injury to the laryngeal or vagus nerve. Vocal fold paresis or paralysis may be unilateral or bilateral, central or peripheral, and it may involve the recurrent laryngeal nerve, superior laryngeal nerve, or both. The physician's first responsibility in any case of vocal fold paresis or paralysis is to confirm the diagnosis and be certain that the laryngeal motion impairment is not caused by arytenoid cartilage dislocation or subluxation, cricoarytenoid arthritis or ankylosis, neoplasm, or other mechanical causes. Strobovideolaryngoscopy, endoscopy, radiologic and laboratory studies, and electromyography are all useful diagnostic tools.

Numerous neurologic diseases affect voice production either through direct effects on the larynx or by affecting muscles involved with support or resonation of the voice. Voice changes can be the initial presenting symptoms of neurodegenerative disorders, especially in patients who have increased awareness of their vocal quality. Some patients present to the otolaryngologist before the neurologist. The otolaryngologist must have an understanding and familiarity with laryngeal manifestations of neurodegenerative diseases to make the appropriate diagnosis in a timely fashion. Moreover, the otolaryngologist can play a significant role in the care of patients who have neurodegenerative disease. Video procedures for neurolaryngologic evaluation accompany this content online.

Injury to the recurrent laryngeal nerve causes vocal fold paresis or paralysis resulting in poor voice quality, and possibly swallowing dysfunction and/or airway compromise. Injury can occur as part of a neurodegenerative disease process or can be due to direct nerve trauma or tumor invasion. Management depends upon symptoms, the cause and severity of injury, and the prognosis for recovery of nerve function. Surgical treatment techniques can improve symptoms, but do not restore physiologic motion. Gene therapy may be a useful adjunct to enhance nerve regeneration in the setting of neurodegenerative disease or trauma. Remote injection of viral vectors into the recurrent laryngeal nerve is the least invasive way to deliver neurotrophic factors to the nerve's cell bodies within the nucleus ambiguus, and in turn to promote nerve regeneration and enhance both nuclear and nerve survival. The purpose of this review is to discuss the potential role for gene therapy in treatment of the unsolved problem of vocal fold paralysis.

For years, otolaryngologists and voice therapists have warned voice patients that whispering causes more trauma to the larynx than normal speech. However, no large series of patients has ever been examined fiberoptically during whispering to test this hypothesis. As part of our routine examination, patients are asked to count from 1 to 10 in a normal voice and in a whispered voice. We reviewed recorded fiberoptic examinations of 100 patients who had voice complaints. We compared supraglottic hyperfunction and vocal fold closure during the normal and whispered phonation of each patient. Sixty-nine percent of the patients demonstrated increased supraglottic hyperfunction with whispered voice. Eighteen percent had no change, and 13% had less severe hyperfunction. The most common glottal configuration during whisper was an inverted Y, which resulted from compression of the anterior and middle thirds of the true vocal folds. However, 12 patients had no true vocal fold contact during whispered voice, despite having adequate glottic closure with normal voice. Although whispering involves more severe hyperfunction in most patients, it does not seem to do so in all patients. In some patients, it may be less traumatic than normal voice.

Summary: Arytenoid cartilage dislocation is an infrequently diagnosed cause of vocal fold immobility. Seventy-four cases have been reported in the literature to date. Intubation is the most common origin, followed by external laryngeal trauma. Decreased volume and breathiness are the most common presenting symptoms. We report on 63 patients with arytenoid cartilage dislocation treated by the senior author (RTS) since 1983. Significantly more posterior than anterior dislocations were represented. Although reestablishing joint mobility is difficult, endoscopic reduction should be considered to align the heights of the vocal processes. This process may result in significant voice improvement even long after the dislocation. Strobovideolaryngoscopy, laryngeal electromyography, and laryngeal computed tomography (CT) imaging are helpful in the evaluation of patients with vocal fold immobility to help distinguish arytenoid cartilage dislocation from vocal fold paralysis. Familiarity with signs and symptoms of arytenoid cartilage dislocation and current treatment techniques improves the chances for optimal therapeutic results.

Vocal process avulsion is a rare complication of intubation or external laryngeal trauma that can cause significant dysphonia. The vocal process develops independently from the body of the arytenoid cartilage, which results in a fusion plane that is vulnerable to trauma. The findings of vocal process avulsion may be subtle, and the relationship of the vocal process to the body of the arytenoid cartilage must be examined closely. Stroboscopy is critical in the evaluation. We describe three cases of vocal process avulsion encountered by the senior author (R.T.S.) over the last 5 years and discuss our approaches to evaluation and treatment. All cases were repaired endoscopically. However, we used three different techniques. These include chemical tenotomy with botulinum toxin, closed reduction with fat injection, and open reduction via cordotomy.

Vocal fold paresis may be present in patients with voice complaints. Identification of paresis is important so that appropriate neurolaryngologic evaluation can be ordered and the appropriate treatment can be offered. Repetitive phonatory tasks (RPTs) fatigue patients vocally and may elicit signs of subtle paresis. In this study, four laryngologists independently reviewed the RPT portions of routine fiberoptic voice examinations of 100 patients in a blinded fashion. All patients had presented with voice complaints, were suspected of having a movement disorder of the larynx, and had been referred for laryngeal electromyography (LEMG). Predictions were compared with LEMG results and with predictions made at the time of each initial evaluation. Although RPTs are useful to laryngologists, predictions based on the entire examination are more accurate. LEMG can confirm clinical suspicions or identify paresis missed on fiberoptic laryngeal examination.

Paragangliomas of the larynx are rare neuroendocrine tumors, with fewer than 70 cases reported in the literature. 1 Typically, laryngeal paragangliomas are not found in patients with multicentric or familial paragangliomas. Only 1 case of laryngeal paraganglioma has been reported in a patient with a synchronous lesion elsewhere (carotid body tumor). 2 We report an additional case of a patient with a laryngeal and multiple other paragangliomas.