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Objective: Chondrolaryngoplasty, also known as thyroid cartilage reduction, alleviates gender dysphoria by reducing the thyroid cartilage to conform to a patient's gender identity. Reduction of the thyroid cartilage prominence ("Adam's apple") is often performed with a scalpel, but in cases of cartilage calcification, rongeurs or drills are utilized. This study aims to characterize the success rate with scalpel-only excision and relate this to patient age and operative time., Methods: Billing records were screened for chondrolaryngoplasties performed between 2020 and 2023 by a single surgeon. Patient demographics, operative notes, and operation duration were recorded. Type of instrumentation was categorized as scalpel only, rongeur, or drill. All cases began with attempted scalpel excision of cartilage and were transitioned to rongeur or drill if there was calcification that prevented sharp excision. Descriptive statistics were used to describe patient and surgical factors., Results: 52 individuals underwent chondrolaryngoplasty: 30 cases (57.7%) had soft cartilage requiring only a blade, 22 (42.3%) required use of either drill or rongeur. The average age of these groups was 25.7 (SE 1.8) and 41.3 years (SE 2.2), respectively; this difference was statistically significant (p < 0.0001). Cases requiring a drill or rongeur lasted on average 78.5 min (SE 2.3), whereas those using only a blade were shorter at 66.8 min (SE 2.7); this difference was significant (p = 0.0017)., Conclusion: Cartilage calcification should be expected in a significant number of chondrolaryngoplasties, and surgeons should be prepared for this scenario. The need for alternative instrumentation is higher in older individuals and may extend procedural time., Level of Evidence: 4 Laryngoscope, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To estimate the current prevalence of voice disorders among adults in the United States; to determine the association of individual factors with voice disorders., Methods: The 2022 National Health Interview Survey (NHIS) was analyzed to identify adults reporting voice problems in the past 12 months. Demographics were assessed, as well as the duration, severity, and resolution of the voice problem. The relationship between voice problems, gender, lost workdays, and long COVID was investigated. A comparison to the 2012 NHIS was made to determine changes in voice disorder prevalence., Results: 29.9 million Americans (95%CI[28.3-31.5]) annually report a voice problem, representing 12.2% of the population (95%CI[11.7-12.8%]). Overall, 26.8% and 13.2% reported the severity of their voice problem as moderate or severe, respectively. Only 5.1% (95%CI[4.3-6.0%]) of respondents sought treatment. Most voice problems were resolved within 1 week (53.0%,95%CI[50.9-55.1%]). Females were more likely than males to report a voice problem (14.4% vs. 10.0%,95%CI[13.7-15.1] and [9.3-10.7], respectively). The 17.6 million Americans with long COVID symptoms were more likely to have voice complaints than those without (21.1% vs. 11.6%,95%CI[18.9-23.5%] and [11.1-12.1%], respectively). Lost workdays were not significantly higher for those with voice disorders compared to those without (17.1 vs. 12.9 days,95%CI[12.0-22.1] and [11.0-14.8], respectively)., Conclusions: Voice problems affect approximately 1 in 8 adults in the U.S. annually, demonstrating an alarming increased prevalence since 2012 using the same survey methodology. Relatively few individuals seek care for their voice problem, despite significant self-reported impact. Further study is required regarding the impact of COVID and changes in voice use patterns on voice disorders., Level of Evidence: 3 Laryngoscope, 134:3713-3718, 2024., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Esophageal dysphagia is a common yet difficult to diagnose condition. This article underscores the role of detailed patient history and physical examinations, including prompt endoscopic evaluation, for accurate differentiation between esophageal and oropharyngeal dysphagia. The authors discuss the heightened importance of early intervention in certain patient groups, such as elderly individuals and patients with head and neck cancer, to mitigate the risk of malnutrition and infection. The authors delve into etiologic factors highlighting the complexity of clinical presentations and the significance of tailored management strategies., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Detecting voice disorders from voice recordings could allow for frequent, remote, and low-cost screening before costly clinical visits and a more invasive laryngoscopy examination. Our goals were to detect unilateral vocal fold paralysis (UVFP) from voice recordings using machine learning, to identify which acoustic variables were important for prediction to increase trust, and to determine model performance relative to clinician performance. Patients with confirmed UVFP through endoscopic examination (N = 77) and controls with normal voices matched for age and sex (N = 77) were included. Voice samples were elicited by reading the Rainbow Passage and sustaining phonation of the vowel "a". Four machine learning models of differing complexity were used. SHapley Additive exPlanations (SHAP) was used to identify important features. The highest median bootstrapped ROC AUC score was 0.87 and beat clinician's performance (range: 0.74-0.81) based on the recordings. Recording durations were different between UVFP recordings and controls due to how that data was originally processed when storing, which we can show can classify both groups. And counterintuitively, many UVFP recordings had higher intensity than controls, when UVFP patients tend to have weaker voices, revealing a dataset-specific bias which we mitigate in an additional analysis. We demonstrate that recording biases in audio duration and intensity created dataset-specific differences between patients and controls, which models used to improve classification. Furthermore, clinician's ratings provide further evidence that patients were over-projecting their voices and being recorded at a higher amplitude signal than controls. Interestingly, after matching audio duration and removing variables associated with intensity in order to mitigate the biases, the models were able to achieve a similar high performance. We provide a set of recommendations to avoid bias when building and evaluating machine learning models for screening in laryngology., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Low et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This paper presents a study on the mechanical properties of cement-stabilized steel-slag-based materials under freeze-thaw cycles for a highway project in Xinjiang. Using 3D scanning technology the specimen model conforming to the real steel slag shape was established. The objectives of the study are as follows: to explore the sensitivity between the macro- and micro-parameters of the specimen and to establish a non-linear regression equation; and to study the changes in mechanical properties of materials under freeze-thaw cycles, fatigue loading, and coupled freeze-thaw cycle-fatigue loading. The results show that there are three stages of compression damage of the specimen, namely, linear elasticity, peak plasticity, and post-peak decline. Maximum contact forces between cracks and particles occur mainly in the shear zone region within the specimen. The compression damage of the specimen is a mixed tensile-shear damage dominated by shear damage. When freeze-thaw cycles or fatigue loads are applied alone, the flexural strength and fatigue life of the specimens show a linear relationship of decline. The decrease in flexural modulus at low stress is divided into the following: a period of rapid decline, a relatively smooth period, and a period of fracture, with a tendency to change towards linear decay with increasing stress. In the case of freeze-thaw-fatigue coupling, the flexural modulus of the specimen decreases drastically by about 50% in the first 2 years, and then enters a period of steady decrease in flexural modulus in the 3rd-5th years.

Background: Studies have shown that sleep disorders are closely related to anxiety and depression, and the quality of life (QoL) of patients with sleep disorders is generally poor., Aim: To examine the occurrence of sleep disorders in people with coronary heart disease (CHD) and their relationships with QoL, depression, and anxiety., Methods: As per the sleep condition, 240 CHD individuals were separated into two groups: non-sleep disorder group ( n = 128) and sleep disorder group ( n = 112). The self-rating anxiety scale (SAS), self-rating depression scale (SDS), and World Health Organization criteria for the Quality of Life Brief scale (WHOQOL-BREF) scores of the two groups were compared. Logistic regression method was used to analyze the independent risk factors of CHD patients with sleep disorders. Multivariate logistic regression analysis was employed to develop the risk prediction model. The association among the Pittsburgh Sleep Quality Index, SAS, and SDS was examined using Spearman's correlation analysis., Results: The incidence of sleep disorder was 46.67% in 240 patients. The scores of SAS and SDS in the sleep disorder group were higher than those in the non-sleep disorder group, and the WHOQOL-BREF scores were lower than those in the non-sleep disorder group ( P < 0.05 ). The risk prediction model of sleep disturbances in CHD patients was constructed using the outcomes of multivariate logistic regression analysis, P = 1/[1 + e (-2.160 + 0.989 × (female) + 0.001 × (new rural cooperative medical insurance) + 2.219 × (anxiety) + 2.157 × depression)]. The results of a Spearman's correlation study revealed that sleep quality was strongly adversely connected with the physiological field, psychological field, and social relation scores in QoL, and was considerably positively correlated with SAS and SDS ( P < 0.05)., Conclusion: A multivariate logistic regression model can better predict the occurrence of sleep disorders in CHD patients. Sleep disorders in CHD patients are significantly correlated with QoL, depression, and anxiety., Competing Interests: Conflict-of-interest statement: The authors have no financial relationships to disclose., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Objective: The laryngeal force sensor (LFS) measures force during suspension microlaryngoscopy (SML) procedures, and has been previously shown to predict postoperative complications. Reproducibility of its measurements has not been described., Study Design: Prospective cohort study., Setting: Academic medical center., Methods: 291 adult patients had force data collected from 2017 to 2021 during various SML procedures. 94 patients had passive LFS monitoring (surgeon blinded to intraoperative recordings) and 197 had active LFS monitoring (surgeon able to see LFS recordings). 27 of these patients had repeat procedures, with unique LFS metrics for each procedure. The 27 patients were divided into three groups. Group 1 had passive use for both procedures, group 2 had passive use for the first procedure and active use for the second, and group 3 had active use for both procedures. Force metrics from the two procedures were compared with a paired samples t-test., Results: For airway dilation procedures and cancer resection procedures, average force variances were significantly lower with active versus passive use of the LFS. Group 1-no significant changes in maximum force (procedure 1 = 163.8 N, procedure 2 = 133.8 N, p = 0.324) or average force (procedure 1 = 93.6 N, procedure 2 = 78.3 N, p = 0.617). Group 2-maximum force dropped by 35 % between procedures 1 (219.2 N) and 2 (142.5 N), p = 0.013. Average force dropped by 42.5 % between procedures 1 (147.2 N) and 2 (84.6 N), p = 0.007. Group 3-no significant changes in maximum force (procedure 1 = 158.6 N, procedure 2 = 158.2 N, p = 0.986) or average force (procedure 1 = 94.2, procedure 2 = 81.8, p = 0.419)., Conclusions: LFS measurements were reproducible for similar procedures in the same patient when the type of LFS monitoring was not a confounder., Competing Interests: Declaration of competing interest None., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To characterize the evolution of swallowing and voice in patients with X-linked dystonia parkinsonism (XDP)., Study Design: Retrospective case series., Methods: Retrospective review of 59 patients with XDP from January 2016 to January 2018. All patients underwent complete examinations and quality of life (QOL) surveys (Swallowing Quality of Life questionnaire [SWAL-QOL], Voice-Related Quality of Life [V-RQOL], and Voice Handicap Index [VHI]), and functional endoscopic examination of swallowing. We excluded patients with incomplete records or patients lost to follow-up. Univariate analysis was used to compare 2016 to 2018 Penetration-Aspiration Scale (PAS), SWAL-QOL, V-RQOL, and VHI scores., Results: Ten patients met the inclusion criteria. Nine patients had oromandibular dystonia. Voice-related measures significantly worsened with an increase in mean VHI from 81 to 109.9 (P = 0.026) and decrease in mean V-RQOL from 58 to 28 (P = 0.013). Vocal strain also significantly worsened 0.4 to 1.4 (P = 0.001). Mean PAS scores increased from 4.2 to 5.1 (P = 0.068) and mean SWAL-QOL decreased from 50.4 to 43.5 (P = 0.157). In the SWAL-QOL, the mean Eating Duration score worsened from 0.9 to 0.4 (P = 0.052) and Mental Health score declined from 10.1 to 6.1 (P = 0.077)., Conclusions: Both vocal strain and voice-related QOL measures considerably worsened over the 2-year interval in our limited group of XDP patients with no significant change in PAS scores or swallowing QOL. The findings demonstrated that the pace of disease affecting voice symptoms was different from swallowing symptoms in our study group and that changes in communication ability may be a more sensitive marker for disease progression than swallowing dysfunction., (Published by Elsevier Inc.)

We present an erratum to our Letter [Opt. Lett.47, 3688 (2022)10.1364/OL.463637]. This erratum corrects subscript errors in Eq. (1), H 1 and H 2 . These errors could confuse readers when they perform the derivation processes, but the errors do not affect our experimental results. Therefore, these corrections do not affect the results and conclusions of the original Letter.

Objectives: To develop a novel laryngoscope device capable of dynamically measuring force and torque measurements in real-time during intubation and to explore the efficacy of such a device through a face validation simulation., Methods: The torque sensor laryngoscope is designed for use during intubation and is modeled after a standard, single-use plastic laryngoscope. After device calibration, a face validation study was performed with intubation experts in the field. Quantitative data (intubation force metrics) and qualitative data (expert feedback on the device) were collected from three intubations using a Mac blade and three intubations with the Miller blade., Results: Three experts (two anesthesiologists and one otolaryngologist) participated in the study. The mean maximum force exerted with the Mac blade was 24.5 N (95% confidence interval [CI], 22.3-26.8). The average force exerted was 13.6 N (95% CI, 11.7-15.5). The average total suspension time was 13.1 s (95% CI, 10.4-15.8). The average total impulse was 164.6 N·s (95% CI, 147.9-181.4). The mean maximum force exerted with the Miller blade was 31.6 N (95% CI, 26.4-36.8). The average force exerted was 15.8 N (95% CI, 13.8-17.9). The average total suspension time was 11.3 s (95% CI, 9.9-12.6). The average total impulse was 216.2 N·s (95% CI, 186.5-245.9). The mean maximum force ( p  = .0265) and total impulse ( p  = .009) were significantly higher in the Miller blade trials than in the Mac blade trials. Survey results found that this device, while bulky, intubated similarly to standard-use models and has potential as an intubation teaching tool., Conclusion: The torque sensor laryngoscope can measure and display real-time intubation force metrics for multiple laryngoscope blades. Initial validation studies showed a significantly lower maximum force and total impulse when intubating with the Mac blade than with the Miller blade. Face validation survey results were positive and suggested the potential for this device as a teaching tool., Level of Evidence: Level 5., (© 2022 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

This Letter proposes a novel, to the best of our knowledge, intensity-modulation transmitter equipped with an optical intensity feedback (OIF) loop, which mitigates the holistic nonlinearity on both sides of intensity modulation and direct detection (IM/DD) transceivers from solely the transmitter side. In contrast to the recent effort on pre-distortion, we construct a negative feedback loop bridging the optical intensity of light-emitting diodes (LEDs) toward a sensor for nonlinearity perception to suppress the nonlinearity among all physical devices. In the meantime, we propose an analytical model for the feedback loop and an implementation scheme. The experimental results demonstrate a significant linearity improvement in the total harmonic distortion (THD) and the power gain flatness. More specifically, the average THD of the bipolar junction transistor (BJT)-based OIF transceiver is -49.4 dB (0.37%) and the minimum power gain variance is 0.0005, 0.0025% of the control group. As for the transceiver using a metal-oxide-semiconductor field-effect transistor (MOSFET), its average THD is -52.42 dB (0.25%) and the minimum power gain variance can reach 0.0026. Not only that, since the method only takes advantage of the negative feedback feature and dose not rely on any particular module, it has lower complexity and better applicability.

Objective: Laryngeal fractures are rare injuries; recent data describing these injuries and associated examination findings are limited. This study aims to describe injury etiology and outcomes associated with laryngeal fractures., Study Design: Retrospective case series., Setting: Academic tertiary center., Methods: Patients with laryngeal fractures from 2005 to 2020 were identified in a retrospective chart review. Patient demographics, injury mechanisms, management, and voice outcomes were examined. Fracture type, radiologic, and endolaryngeal examination findings were analyzed for associations between fracture etiology and examination characteristics., Results: Laryngeal fractures most commonly occurred at the thyroid cartilage. Fractures were most commonly due to sport-related injuries. Mechanism of injury was not associated with specific radiologic or endolaryngeal findings. Mechanism of injury was additionally not significantly associated with the need for intubation, surgical intervention, or tracheotomy. Fracture location was significantly associated with intubation requirement ( P = .015), with 40% of patients with concomitant thyroid and cricoid fractures requiring intubation. Mechanism of injury significantly correlated with dysphonia at follow-up ( P = .033). Mechanism of injury, fracture location, and surgical management were not associated with increased vocal fold injury or dysphonia., Conclusion: There are no significant correlations between injury mechanism and fracture location, characteristics, radiologic findings, or endolaryngeal findings. These features emphasize the importance of a thorough and comprehensive laryngeal examination., (© The Authors 2022.)

Objectives: (1) Demonstrate true vocal fold (TVF) tracking software (AGATI [Automated Glottic Action Tracking by artificial Intelligence]) as a quantitative assessment of unilateral vocal fold paralysis (UVFP) in a large patient cohort. (2) Correlate patient-reported metrics with AGATI measurements of TVF anterior glottic angles, before and after procedural intervention., Study Design: Retrospective cohort study., Setting: Academic medical center., Methods: AGATI was used to analyze videolaryngoscopy from healthy adults (n = 72) and patients with UVFP (n = 70). Minimum, 3rd percentile, 97th percentile, and maximum anterior glottic angles (AGAs) were computed for each patient. In patients with UVFP, patient-reported outcomes (Voice Handicap Index 10, Dyspnea Index, and Eating Assessment Tool 10) were assessed, before and after procedural intervention (injection or medialization laryngoplasty). A receiver operating characteristic curve for the logistic fit of paralysis vs control group was used to determine AGA cutoff values for defining UVFP., Results: Mean (SD) 3rd percentile AGA (in degrees) was 2.67 (3.21) in control and 5.64 (5.42) in patients with UVFP ( P < .001); mean (SD) 97th percentile AGA was 57.08 (11.14) in control and 42.59 (12.37) in patients with UVFP ( P < .001). For patients with UVFP who underwent procedural intervention, the mean 97th percentile AGA decreased by 5 degrees from pre- to postprocedure ( P = .026). The difference between the 97th and 3rd percentile AGA predicted UVFP with 77% sensitivity and 92% specificity ( P < .0001). There was no correlation between AGA measurements and patient-reported outcome scores., Conclusions: AGATI demonstrated a difference in AGA measurements between paralysis and control patients. AGATI can predict UVFP with 77% sensitivity and 92% specificity.

Objective: To analyze specific intralaryngeal findings associated with granulomatosis with polyangiitis (GPA)., Study Design: Retrospective chart review., Setting: Tertiary referral center., Methods: A retrospective chart review was performed on all patients diagnosed with GPA who were evaluated at the laryngology division of Massachusetts Eye and Ear Infirmary between January 2006 and September 2019., Results: Forty-four patients (14 male, 30 female) were evaluated for laryngeal pathology. The mean age at onset was 48 years. Nine patients (21%) were identified with only vocal fold disease, 11 (25%) with subglottic disease, and 8 (18%) with disease at the glottis and subglottis (transglottic). The remaining 16 patients (36%) had a normal airway upon examination although they presented with laryngeal symptoms. Patients with glottic disease had statistically significantly lower voice-related quality of life scores than patients with isolated subglottic stenosis., Conclusions: Although laryngeal manifestations of GPA is often described as a subglottic disease presenting with respiratory symptoms, subsite analysis show that only 25% of patients had subglottic disease alone, with similar rates of glottic disease alone. Laryngeal subsites have different epithelial mucosa, function, and physiology, and understanding the specific sites of involvement will determine symptoms and enable better analysis of the underlying mechanisms of disease. Glottic disease is associated with a reduction in vocal fold motion and voice changes. Subglottic involvement presents more frequently with airway symptoms. Further research is necessary to better define the specific regions of laryngeal involvement in patients diagnosed with GPA., (© The Authors 2021.)

Objectives: The laryngeal force sensor (LFS) provides real-time force data for suspension microlaryngoscopy. This study investigates whether active use of the LFS can prevent the development of complications., Study Design: Prospective controlled trial., Setting: Academic tertiary center., Methods: The LFS and custom software were developed to track intraoperative force metrics. A consecutive series of 100 patients had force data collected with operating surgeons blinded to intraoperative readings. The subsequent 100 patients had surgeons actively use the LFS monitoring system. Patients were prospectively enrolled, completing pre- and postoperative surveys to assess the development of tongue pain, paresthesia, paresis, dysgeusia, or dysphagia., Results: On univariate analysis, the active monitoring group had lower total impulse ( P < .001) and fewer extralaryngeal complications ( P < .01). On multiple logistic regression, maximum force (odds ratio [OR], 1.08; 95% CI, 1.01-1.16; P = .02) was a significant predictive variable for the development of postoperative complications. Similarly, active LFS monitoring showed a 29.1% (95% CI, 15.7%-42.4%; P < .001) decrease in the likelihood of developing postoperative complications. These effects persisted at the first postoperative visit for maximum force ( P = .04) and active LFS monitoring ( P = .01). Maximum force (OR, 1.11; 95% CI, 1.04-1.18; P < .01) and active LFS monitoring (16.6%; 95% CI, 2.7%-30.5%; P = .02) were also predictive for the development of an abnormal 10-item Eating Assessment Tool score. These effects also persisted at the first postoperative visit for maximum force ( P = .01) and active LFS monitoring ( P = .01)., Conclusion: Maximum force is predictive of the development postoperative complications. Active monitoring with the LFS is able to mitigate these forces and prevent postoperative complications., Level of Evidence: 2.

Objectives: To determine preference patterns for topical anesthesia in patients undergoing endoscopy pre-coronavirus (2019 coronavirus disease [COVID-19]) pandemic and analyze outcomes based on preference, using a decision aid format., Methods: A decision aid was developed with expert and patient input. New patients presenting to subspecialty clinics over a 2-month pre-COVID-19 period completed a pre-procedure survey about their priorities, then were asked to choose between topical oxymetazoline/lidocaine spray or none. A post-procedure outcome survey followed., Results: Of 151 patients, 90.1% patients elected to have topical anesthesia. Top patient priorities were "I want the scope to be easy for the doctor" and "I want to be as comfortable as possible." Patients who strongly wanted to avoid medication ( P  = .002) and bad taste ( P  = .003) were more likely to select no spray, whereas those who wanted to avoid pain received anesthetic ( P  = .011). According to the post-procedure assessment, 95.4% of patients were satisfied or strongly satisfied their choice, and this did not correlate with anesthetic vs none., Conclusions: Patient preferences are easily elicited and correlate with treatment choices. Most patients chose to have topical anesthetic and were willing to tolerate side effects; however, both patients with and without topical anesthetic were satisfied with their choices. This decision aid can be used to optimize shared decision making in the otolaryngology clinic. Given the aerosolizing potential of both spray and no spray conditions, this insight may be consequential when devising office protocols for post-COVID-19 practice., Level of Evidence: II., Competing Interests: The authors declare no potential conflict of interest., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: To determine the difference in force metrics measured by the laryngeal force sensor for various suspension microlaryngoscopy (SML) procedures and their perioperative narcotic requirements., Study Design: Prospective observational study., Setting: Academic tertiary center., Methods: The laryngeal force sensoris a force sensor designed for SML procedures. Prospectively enrolled patients had dynamic recordings of maximum force, average force, suspension time, and total impulse. Procedures were grouped into excision of striking zone lesions, nonstriking zone lesions, endoscopic cancer surgery with margin control, and airway dilation. Narcotic administration in the intraoperative period and postanesthesia care unit was also recorded and converted into IV morphine equivalents. Surgeons were blinded to the force recordings during surgery to prevent operator bias., Results: In total, 110 patients completed the study. There was no significant difference in average force across different procedures, however, a significant difference was seen for maximum force (P = 0.025), suspension time (P < 0.001), and total impulse (P = 0.002). The highest values were seen for endoscopic cancer surgeries with margin control with a mean maximum force of 49.4 lbf (95%CI, 37.1-61.7), mean suspension time of 60.2 minutes (95%CI, 40.5-79.9), and mean total impulse of 31.3 ton*s (95%CI, 15.2-47.3). A significant difference (P < 0.01) in perioperative narcotic requirements was also seen, with endoscopic cancer surgery cases having the highest requirements at 27.6 mg of ME (95%CI, 16.1-39.2 mg)., Conclusion: Significant differences in force metrics exist between various SML procedures. Endoscopic cancer surgery is associated with higher force metrics and perioperative narcotic requirements., (Copyright © 2019 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

By regulating the solvent used for synthesis, two porous Ni-MOFs, namely {[Ni3(BTC)2(TPT)2/3(H2O)4.08(MeOH)0.92]·2DMF·0.5H2O·0.5MeOH}n (1) and {[Ni3(BTC)2(TPT)2(H2O)6]·6DMF}n (2) (H3BTC = 1,3,5-benzenetricarboxylic acid, TPT = 2,4,6-tris(pyridin-4-yl)-1,3,5-triazine, DMF = N,N-dimethylformamide, and MeOH = methanol) were obtained. Compound 1 reveals a rigid 3D framework, while compound 2 shows a flexible 3-fold interpenetrated framework. Compound 1 exhibits a selective adsorption of CO2 due to the sieving effect of the rigid framework containing two types of cages with small apertures. Noteworthily, the flexible compound 2 displays an obviously guest-induced structural transformation. The desolvated compound 2 reveals a much higher capacity toward CO2 and n-C4H10 than those of N2 CH4, C2H6 and C3H8.

Objective: Patients consider many factors when deciding how to receive medical care. This study used best-worst scaling (BWS), a technique novel to otolaryngology, to quantitatively examine preferences among patients choosing a laryngologist. Our objective was to quantify in a pilot cohort the relative importance patients place on a variety of attributes when seeking a laryngologist., Study Design: BWS survey., Setting: Academic voice clinic., Methods: New patients were recruited to take a computerized BWS survey developed using attributes derived from patient input, expert opinion, and literature review. Attributes were grouped into 4 categories: physician reputation, physician qualifications, hospital-related factors, and other nonclinical factors. Responses were analyzed using multinomial logit regression to determine importance scores and associations with other variables., Results: Eighty-seven of 93 patients recruited participated (93.5% response rate). Physician qualifications were the most important attributes to patients, with specialty laryngology training receiving the highest importance score (20.8; 95% CI, 20.2 to 21.5; P < .0001). Recommendations from referring physicians (15.6; 95% CI, 14.3 to 16.9) and use of cutting-edge technology (11.9; 95% CI, 10.7 to 13.1) were the second and third most important, respectively. Least important were nonclinical factors, including wait time to get an appointment (4.3; 95% CI, 2.8 to 5.8) and convenience of office location (1.5; 95% CI, 0.9 to 2.1). Just over half of patients (51.2%) reported willingness to wait 4 weeks for an appointment with a laryngologist. Older patients were less concerned with convenience-related factors., Conclusion: Nonclinical factors were less important to patients than clinical factors, and laryngology-specific training was paramount. Stated preference methodologies can elucidate underlying preferences and help providers make care more patient centered., (© The Authors 2021.)

Dystonia is a common movement disorder, involving sustained muscle contractions, often resulting in twisting and repetitive movements and abnormal postures. Dystonia may be primary, as the sole feature (isolated) or in combination with other movement disorders (combined dystonia), or as one feature of another neurological process (secondary dystonia). The current hypothesis is that dystonia is a disorder of distributed brain networks, including the basal ganglia, cerebellum, thalamus and the cortex resulting in abnormal neural motor programs. In comparison, functional dystonia (FD) may resemble other forms of dystonia (OD) but has a different pathophysiology, as a subtype of functional movement disorders (FMD). FD is the second most common FMD and amongst the most diagnostically challenging FMD subtypes. Therefore, distinguishing between FD and OD is important, as the management of these disorders is distinct. There are also different pathophysiological underpinnings in FD, with for example evidence of involvement of the right temporoparietal junction in functional movement disorders that is believed to serve as a general comparator of internal predictions/motor intentions with actual motor events resulting in disturbances in self-agency. In this article, we present a comprehensive review across the spectrum of FD, including oromandibular and vocal forms and discuss the history, clinical clues, evidence for adjunctive "laboratory-based" testing, pathophysiological research and prognosis data. We also provide the approach used at the Massachusetts General Hospital Dystonia Center toward the diagnosis, management and treatment of FD. A multidisciplinary approach, including neurology, psychiatry, physical, occupational therapy and speech therapy, and cognitive behavioral psychotherapy approaches are frequently required; pharmacological approaches, including possible targeted use of botulinum toxin injections and inpatient programs are considerations in some patients. Early diagnosis and treatment may help prevent unnecessary investigations and procedures, while facilitating the appropriate management of these highly complex patients, which may help to mitigate frequently poor clinical outcomes., Competing Interests: DP has received honoraria for continuing medical education lectures in functional neurological disorder.NS received financial support from John Wiley & Sons for serving as editor in chief to Brain & Behavior. CS has provided scientific advisory for Xenon Pharmaceuticals and SwanBio Pharma and received research funding from Sanofi-Genzyme for a study of video oculography in late-onset GM2 gangliosidosis. He has received financial support from Sanofi-Genzyme, Biogen and Biohaven for the conduct of clinical trials. The remaining author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Frucht, Perez, Callahan, MacLean, Song, Sharma and Stephen.)

Objective: To describe and visually depict laryngeal complications in patients recovering from coronavirus disease 2019 (COVID-19) infection along with associated patient characteristics., Study Design: Prospective patient series., Setting: Tertiary laryngology care centers., Subjects and Methods: Twenty consecutive patients aged 18 years or older presenting with laryngological complaints following recent COVID-19 infection were included. Patient demographics, comorbid medical conditions, COVID-19 diagnosis dates, symptoms, intubation, and tracheostomy status, along with subsequent laryngological symptoms related to voice, airway, and swallowing were collected. Findings on laryngoscopy and stroboscopy were included, if performed., Results: Of the 20 patients enrolled, 65% had been intubated for an average duration of 21.8 days and 69.2% requiring prone-position mechanical ventilation. Voice-related complaints were the most common presenting symptom, followed by those related to swallowing and breathing. All patients who underwent flexible laryngoscopy demonstrated laryngeal abnormalities, most frequently in the glottis (93.8%), and those who underwent stroboscopy had abnormalities in mucosal wave (87.5%), periodicity (75%), closure (50%), and symmetry (50%). Unilateral vocal fold immobility was the most common diagnosis (40%), along with posterior glottic (15%) and subglottic (10%) stenoses. 45% of patients underwent further procedural intervention in the operating room or office. Many findings were suggestive of intubation-related injury., Conclusion: Prolonged intubation with prone-positioning commonly employed in COVID-19 respiratory failure can lead to significant laryngeal complications with associated difficulties in voice, airway, and swallowing. The high percentage of glottic injuries underscores the importance of stroboscopic examination. Otolaryngologists must be prepared to manage these complications in patients recovering from COVID-19., Level of Evidence: IV., Competing Interests: The authors declare no potential conflict of interest., (© 2020 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Objective: Injuries in professional ice hockey players are common, however significant laryngeal trauma is rare. Here, we present a case series of professional and semiprofessional ice hockey players to demonstrate the mechanism and nature of laryngeal injuries they sustain during play, and to recommend best practices for treatment, prevention, and return to the ice., Methods: A retrospective case review was done of hockey-related laryngeal injuries between 2016 and 2019 at a tertiary laryngology practice. Only semiprofessional and professional hockey players were included., Results: In total, four cases were included. All cases involved trauma from a hockey puck to the neck. No cases were the result of punching, fighting, high sticks or routine checking. Notably, 1 of 4 presented with severe airway compromise, requiring urgent intubation, whereas most presented with pain or a significant voice complaint. Two patients required operative intervention with open reduction and internal fixation of significantly displaced fractures. One patient experienced significant mucosal disruption with cartilaginous exposure at the posterior vocal complex requiring microflap. The average return to ice was 6 weeks for those who required operative intervention and 4 weeks for those who were managed conservatively. One patient had persistent mild dysphonia and all others had a return to baseline phonation. None were wearing neck guards or other protective equipment at the time of injury., Conclusion: Though voice and airway injuries are rarely sustained by ice hockey players, they may require urgent intervention. We recommend that protective equipment be worn and improved to prevent laryngeal trauma., Level of Evidence: 4., Competing Interests: The authors declare no conflicts of interest., (© 2020 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Otolaryngologists are at increased risk for exposure to suspected aerosol-generating procedures during the ongoing coronavirus disease 2019 (COVID-19) pandemic. In the present study, we sought to quantify differences in aerosol generation during common ventilation scenarios. We performed a series of 30-second ventilation experiments on porcine larynx-trachea-lung specimens. We used an optical particle sizer to quantify the number of 1- to 10-µm particles observed per 30-second period (PP30). No significant aerosols were observed with ventilation of intubated specimens (10.8 ± 2.4 PP30 vs background 9.5 ± 2.1, P = 1.0000). Simulated coughing through a tracheostomy produced 53.5 ± 25.2 PP30, significantly more than background ( P = .0121) and ventilation of an intubated specimen ( P = .0401). These data suggest that undisturbed ventilation and thus intubation without stimulation or coughing may be safer than believed. Coughing increases aerosol production, particularly via tracheostomy. Otolaryngologists who frequently manage patient airways and perform tracheostomy are at increased risk for aerosol exposure and require appropriate personal protective equipment, especially during the ongoing COVID-19 pandemic.

Objectives/hypothesis: The impact of disease states can be measured using health state utilities, which are values that reflect economic preferences for health outcomes. Utilities for dysphonia have not been studied using direct methods. The objective of this project was to establish the baseline health utilities of mild and severe dysphonia from a societal perspective., Study Design: Direct utility elicitation survey., Methods: Four health states (monocular blindness, binocular blindness, mild dysphonia, and severe dysphonia) were evaluated by a convenience sample of adults recruited from the general public with three computer-aided estimation techniques (visual analog scale [VAS], standard gamble [SG], and time trade-off [TTO]). Standardized descriptions and voice recordings from multiple dysphonic patients were employed. Perfect health was defined as a utility of 1, with death 0. Analysis of variance with post hoc pairwise comparison was used to calculate significant differences between health states., Results: Three hundred participants were surveyed, and 225 (75.0%) responses met quality thresholds. Severe dysphonia (VAS = 48.3, SG = 0.810, TTO = 0.798) was valued significantly worse than monocular blindness (VAS = 56.2, SG = 0.834, TTO = 0.839) on the VAS (P < .001) and equivalent on SG and TTO; it was preferred over binocular blindness (VAS = 25.7, SG = 0.631, TTO = 0.622; P < .001) with all methods. Mild dysphonia evaluated favorably with all methods to the other health states (VAS = 78.5, SG = 0.902, TTO = 0.908; P < .001)., Conclusions: Voice disorders may have a measurable impact on utility, with severe dysphonia valued equivalently to monocular blindness. Mild dysphonia has a utility decrement from perfect health. These estimates are critical for quality-of-life assessment and could be used to assess cost-effectiveness of treatments for voice disorders., Level of Evidence: NA Laryngoscope, 130:1256-1262, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Ventilation during microlaryngoscopy previously included jet ventilation, microlaryngeal endotracheal tubes, and extended apnea. Historically, apneic oxygenation provided a tubeless field but limited operative time. Increased utilization of high-flow nasal cannula in intensive care units and operating rooms has created new opportunities to expand tubeless microlaryngoscopy. Although few studies have described high-flow nasal cannula for microlaryngoscopy, there remains much to be explored. In this case report, we describe the unique setting of utilizing high-flow nasal cannula in a spontaneously breathing patient to create an optimal tubeless surgical field for both microlaryngoscopy and vocal cord electromyography.

Objectives: To systematically characterize and describe voice and swallowing manifestations in patients with X-linked dystonia parkinsonism (XDP) and correlate with quality-of-life (QOL) measures., Methods: Thirty-four patients with XDP with communication and swallowing difficulties underwent neurological examination, head and neck examination, nasopharyngoscopy, QOL surveys (Swallowing Quality of Life questionnaire [SWAL-QOL] and Voice Handicap Index [VHI]), and functional endoscopic evaluation of swallowing (FEES) to assess the extent of dysfunction., Results: All patients showed high rates of lingual, oromandibular, and laryngeal dysfunction, as well as severe QOL changes in swallowing and communication ability. The most common head and neck manifestations of dystonic symptoms were difficulty coordinating the mouth and tongue (79%), uncontrollable tongue thrusting (53%), and jaw opening (35%). Laryngeal symptoms including vocal strain (adductor voice breaks) or stridor (32%), as well as velopharyngeal insufficiency (20%), were also identified. Of the patients with laryngeal symptoms, 18% had respiratory dystonia. Swallowing assessments showed significant abnormalities in oral bolus control and oropharyngeal dysphagia. FEES examinations showed that 87.5% of the study group had penetration or aspiration. QOL scores showed an average VHI of 94.4 (severe dysfunction), and SWAL-QOL showed an average of 37.7 (severe dysfunction)., Conclusion: Swallowing and voice impairment in XDP is not well characterized and presents a more distinctive phenomenology than other neurological disorders, with a unique set of challenges for treatment. This is the first study to systematically evaluate laryngeal and pharyngeal dysfunction in XDP patients and correlate with QOL measures., Level of Evidence: 4 Laryngoscope, 130:171-177, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine the relationship between force metrics measured by the laryngeal force sensor (LFS) during suspension microlaryngoscopy (SML) and perioperative narcotic requirements., Study Design: Prospective observational study., Methods: Compressive tissue forces were recorded during SML using the LFS and correlated with postoperative narcotic requirements in the postanesthesia care unit (PACU) at an academic tertiary center. Patients were prospectively enrolled and had force metrics recorded throughout each procedure including maximum force, average force, suspension time, and total impulse. Narcotic administration in the intraoperative period and PACU were also recorded and converted into intravenous morphine equivalents (ME). Surgeons were blinded to the force recordings during surgery to prevent operator bias., Results: Eighty-two patients completed the study. Of these patients, the mean perioperative ME requirement was 16.96 mg (range, 0.15-79.82 mg). Univariate analysis demonstrated a positive correlation between perioperative narcotic requirements and total suspension time (P < .001) as well as total impulse (P = .007). A positive correlation was also seen with maximum force, although not significantly. On multiple linear regression, total suspension time was a significant predictive variable for perioperative narcotic use, with a marginal incremental increase of 0.273 mg of ME per minute of total suspension time (0.273 mg/min, 95% confidence interval: 0.040-0.507 mg/min, P = .022)., Conclusions: Intraoperative force metrics including total suspension time are predictive of increased perioperative narcotic requirement after SML. Total impulse during SML may also correlate with increased perioperative narcotic requirements., Level of Evidence: 2 Laryngoscope, 129:2563-2567, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives To develop a novel sensor capable of dynamically analyzing the force exerted during suspension microlaryngoscopy and to examine the relationship between force and postoperative tongue complications. Study Design Prospective observational study. Setting Academic tertiary care center. Methods The laryngeal force sensor is a designed for use during microphonosurgery. Prospectively enrolled patients completed pre- and postoperative surveys to assess the development of tongue-related symptoms (dysgeusia, pain, paresthesia, and paresis) or dysphagia (10-item Eating Assessment Tool [EAT-10]). To prevent operator bias, surgeons were blinded to the force recordings during surgery. Results Fifty-six patients completed the study. Of these, 20 (36%) developed postoperative tongue symptoms, and 12 (21%) had abnormal EAT-10 scores. The mean maximum force across all procedures was 164.7 N (95% CI, 141.0-188.4; range, 48.5-402.6), while the mean suspension time was 34.3 minutes (95% CI, 27.4-41.2; range, 7.1-108.1). Multiple logistic regression showed maximum force (odds ratio, 1.15; 95% CI, 1.02-1.29; P = .019) and female sex (30.1%; 95% CI, 22.7%-37.5%; P < .001) as significant predictors for the development of tongue-related symptoms. The only significant predictor of an abnormal postoperative EAT-10 score was an increased maximum force (odds ratio, 1.03; 95% CI, 1.00-1.06; P = .045). Conclusions The laryngeal force sensor is capable of providing dynamic force measurements throughout suspension microlaryngoscopy. An increase in maximum force during surgery may be a significant predictor for the development of tongue-related symptoms and an abnormal EAT-10 score. Female patients may also be at greater risk for developing postoperative tongue symptoms.

Although epidemiology and toxicology studies have demonstrated that exposure to ambient air particles could result in a variety of lung diseases, but the pulmonary toxicological mechanism remains obscure. In this study, the toxicity of PM 2.5 particles in different concentrations was investigated by toxicological methods, including the luminescent bacteria acute toxicity test and genotoxicity performed by SOS chromogenic reaction. The results indicated that, the acute toxicity and genotoxicity were low and negative, respectively. In addition, rats were treated with PM 2.5 suspension through intratracheal instillation, and the pathologic changes and expression of different genes in their lungs were carried out. We found that PM 2.5 exposure resulted in fibrotic changes and inflammation in the lung with the increase in PM 2.5 concentration. Pathway analysis indicated that PM 2.5 can induce pulmonary toxicity through disturbing the function of ribosomal protein, fatty acids, and cholesterol metabolism, suggesting an inflammatory reaction in the lung is caused by genetic damage and is irreversible. A gene ontology analysis revealed that abnormal expression of related genes in the immune response could be the specific pathway of lung inflammation. These findings improve our understanding of the toxicological pathway and mechanism of PM 2.5 exposure.

Objectives Subglottic stenosis can be addressed with several different surgical techniques, but patient preferences for these treatment modalities are poorly understood. Economic methods are increasingly being used to understand how patients make decisions. The objective of this pilot study was to assess preferences in subglottic stenosis treatment using patient-centric stated preference techniques. Study Design Discrete choice experiment (DCE). Setting Academic research facility. Subjects and Methods A computer-based DCE was administered in a monitored setting to volunteers from the general population. Signs and symptoms of subglottic stenosis were described, and participants were asked to imagine they had subglottic stenosis. Hypothetical treatments were offered, with 5 systematically varied attributes: need for external incision, length of hospital stay, postoperative voice quality, likelihood of repeat procedures, and risk of complication. A conditional logistic model was used to assess the relative attribute importance. Results In total, 162 participants were included. Attributes with the greatest impact on decision making included potential need for repeat procedures (importance 30.2%; P < .001), amount of operative risk (importance 28.1%; P < .001), and postoperative voice quality (importance 27.7%; P < .001), whereas presence of incision (importance 5.0%; P = .001) was less important, and hospital stay was not (importance 9.0%; P = .089). Based on aggregate responses for these attributes, the model demonstrated that most participants (80.4%) would prefer endoscopic surgery for subglottic stenosis as opposed to open tracheal resection (19.6%). Conclusion In this pilot population, most participants preferred voice-sparing, low-risk procedures as treatment for subglottic stenosis, consistent with an endoscopic approach, even if multiple procedures were required.

Objectives Patient preferences are crucial for the delivery of patient-centered care. Discrete choice experiments (DCEs) are an emerging quantitative methodology used for understanding these preferences. In this study, we employed DCE techniques to understand the preferences of patients presenting for an ear, nose, and throat clinic visit. Study Design DCE. Setting Decision science laboratory. Methods A DCE survey of 5 attributes-wait time, physician experience, physician personality, utilization of visit time, and cost/copayment-was constructed with structured qualitative interviews with patients. The DCE was administered to participants from the general population, who chose among hypothetical scenarios that varied across these attributes. A conditional logit model was used to determine relative attribute importance, with a separate logit model for determining subject effects. Results A total of 161 participants were included. Cost/copayment had the greatest impact on decision making (importance, 32.2%), followed by wait time and physician experience (26.5% and 24.7%, respectively). Physician personality mattered least (4.7%), although all attributes were significantly correlated to decision making. Participants preferred doctors who spent more time performing physical examination than listening or explaining. Participants were willing to pay $52 extra to avoid a 4-week delay in appointment time; $87 extra for a physician with 10 years of experience (vs 0 years); and $9 extra for a caring, friendly, and compassionate doctor (vs formal, efficient, and business-like). Conclusion DCEs allow for powerful economic analyses that may help physicians understand patient preferences. Our model showed that cost is an important factor to patients and that patients are willing to pay extra for timely appointments, experience, and thorough physical examination.

Objective To identify occupational groups' use of specialty voice clinic evaluation. Study Design Retrospective cohort study. Setting Tertiary subspecialty clinic. Subjects and Methods We analyzed data collected on patients presenting to the Massachusetts Eye and Ear Infirmary Voice and Speech Laboratory over a 20-year period (1993-2013). The relative risk (RR) and 99% confidence interval (CI) of presentation were calculated for each occupational category in the greater Boston population using year-matched data from the Bureau of Labor Statistics (BLS). Results The records of 12,120 new patients were reviewed. Using year- and occupation-matched BLS data from 2005 to 2013, 2726 patients were included in the cohort analysis. Several occupations had significantly higher risk of presentation. These included arts and entertainment (RR 4.98, CI 4.18-5.95), law (RR 3.24, CI 2.48-4.23), education (RR 3.08, CI 2.70-3.52), and social services (RR 2.07, CI 1.57-2.73). In contrast, many occupations had significantly reduced risk of presentation for laryngological disorders, for example, maintenance (RR 0.25, CI 0.15-0.42), food preparation (RR 0.35, CI 0.26-0.48), and administrative support (RR 0.49, CI 0.41-0.57). Conclusion Certain occupations are associated with higher use of laryngological services presumably because of their vocational voice needs. In addition to confirming findings from other studies, we identified several new occupation groups with increased or decreased risk for laryngologic disorders. Understanding what factors predispose to requiring specialty voice evaluation may help in targeting preventative efforts.

Eukaryotic N-glycosylation pathways are dependent of N-acetylglucosaminyltransferase I (GnTI), a key glycosyltransferase opening the door to the formation of complex-type N-glycans by transferring a N-acetylglucosamine residue onto the Man 5 GlcNAc 2 intermediate. In contrast, glycans N-linked to Chlamydomonas reinhardtii proteins arise from a GnTI-independent Golgi processing of oligomannosides giving rise to Man 5 GlcNAc 2 substituted eventually with one or two xylose(s). Here, complementation of C. reinhardtii with heterologous GnTI was investigated by expression of GnTI cDNAs originated from Arabidopsis and the diatom Phaeodactylum tricornutum. No modification of the N-glycans was observed in the GnTI transformed cells. Consequently, the structure of the Man 5 GlcNAc 2 synthesized by C. reinhardtii was reinvestigated. Mass spectrometry analyses combined with enzyme sequencing showed that C. reinhardtii proteins carry linear Man 5 GlcNAc 2 instead of the branched structure usually found in eukaryotes. Moreover, characterization of the lipid-linked oligosaccharide precursor demonstrated that C. reinhardtii exhibit a Glc 3 Man 5 GlcNAc 2 dolichol pyrophosphate precursor. We propose that this precursor is then trimmed into a linear Man 5 GlcNAc 2 that is not substrate for GnTI. Furthermore, cells expressing GnTI exhibited an altered phenotype with large vacuoles, increase of ROS production and accumulation of starch granules, suggesting the activation of stress responses likely due to the perturbation of the Golgi apparatus.

Purpose: There are no controlled prospective studies evaluating the effect of dominant handedness in left- and right-sided surgery in otolaryngology. Endoscopic microlaryngeal phonosurgery is an ideal procedure to assess technical aspects of handedness and laterality, due to anatomic symmetry. In this study, we analyzed (1) choice of surgical approach and (2) outcomes based on handedness and laterality in a microlaryngeal simulator., Methods: Using a validated high-fidelity phonosurgery model, a prospective cohort of 19 expert laryngologists undertook endoscopic resection of a simulated vocal fold lesion. These resections were video-recorded and scored by 2 blinded expert laryngologists using a validated global rating scale, procedure-specific rating scale, and a hand preference analysis., Results: There were 18 right-handed participants and 1 left-handed. 12 left and 7 right excisions were evaluated. Cronbach's alpha for inter-rater reliability was good (0.871, global scale; and 0.814, procedure-specific scale). Surgeons used their dominant hand 78.9% of the time for both incision and dissection. In cases where the non-dominant hand would have been preferred, surgeons used the non-dominant hand only 36.4% of the time for incision and dissection. Use of the non-dominant hand did not influence global or procedural rating (p=0.132 and p=0.459, respectively)., Conclusions: In this simulation of microlaryngeal surgery, there were measurable differences in surgical approaches based on hand dominance, with surgeons preferring to cut and perform resection with the dominant hand despite limitations in the instrumentation and exposure. Regardless of hand preference, overall outcomes based on global rating and technique specific rating scales were not significantly different., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Endoscopic management of bilateral vocal fold paralysis (BVFP) includes cordotomy and arytenoidectomy, and has become a well-accepted alternative to tracheostomy. However, the costs and quality-of-life benefits of endoscopic management have not been examined with formal economic analysis. This study undertakes a cost-effectiveness analysis of tracheostomy versus endoscopic management of BVFP., Study Design: Cost-effectiveness analysis., Methods: A literature review identified a range of costs and outcomes associated with surgical options for BVFP. Additional costs were derived from Medicare reimbursement data; all were adjusted to 2014 dollars. Cost-effectiveness analysis evaluated both therapeutic strategies in short-term and long-term scenarios. Probabilistic sensitivity analysis was used to assess confidence levels regarding the economic evaluation., Results: The incremental cost effectiveness ratio for endoscopic management versus tracheostomy is $31,600.06 per quality-adjusted life year (QALY), indicating that endoscopic management is the cost-effective short-term strategy at a willingness-to-pay (WTP) threshold of $50,000/QALY. The probability that endoscopic management is more cost-effective than tracheostomy at this WTP is 65.1%. Threshold analysis demonstrated that the model is sensitive to both utilities and cost in the short-term scenario. When costs of long-term care are included, tracheostomy is dominated by endoscopic management, indicating the cost-effectiveness of endoscopic management at any WTP., Conclusions: Endoscopic management of BVFP appears to be more cost-effective than tracheostomy. Though endoscopic cordotomy and arytenoidectomy require expertise and specialized equipment, this model demonstrates utility gains and long-term cost advantages to an endoscopic strategy. These findings are limited by the relative paucity of robust utility data and emphasize the need for further economic analysis in otolaryngology., Level of Evidence: NA Laryngoscope, 127:691-697, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The hypoglossal nerve (XII) has been used as a donor nerve in facial and laryngeal reinnervation. The purpose of this study was to investigate the neuromuscular changes that occur within the tongue following partial or complete transection of XII using a canine model., Study Design: Histopathological comparison of tongue denervation following two types of XII resection in a canine model., Methods: Ten adult canines underwent complete unilateral resection of XII or resection of only the medial terminal branch of the hypoglossal nerve (mXII). After 6 months of recovery, tongue specimens were analyzed histopathologically using whole cross-sections. Routine histologic sections were assessed by two neuropathologists blinded to the type of denervation. The cross-sectional area was calculated of both sides of the tongue, and the amount of myosin was quantified morphometrically using immunohistochemistry for myosin (antimyosin heavy chain, fast isotype). Statistical comparison between partial and complete denervation was performed using the Student t test., Results: Six months following XII transection, quantitative measures of the cross-sectional area of the tongue and content of myosin demonstrated severe muscle atrophy on the operated side of the tongue for both groups, compared to the nonoperated side. For partial transection involving only mXII, the degree of atrophy was less severe (P < .05)., Conclusions: This study provides new histological information demonstrating that partial resection of the hypoglossal nerve, sacrificing only the proximal medial branch of the hypoglossal nerve (mXII), results in less severe atrophy of the tongue than complete transection of the entire hypoglossal nerve., Level of Evidence: NA Laryngoscope, 126:2689-2693, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Spasmodic dysphonia is a focal dystonia of the larynx with heterogeneous manifestations and association with familial risk factors. There are scarce data to allow precise understanding of etiology and pathophysiology. Screening for dystonia-causing genetic mutations has the potential to allow accurate diagnosis, inform about genotype-phenotype correlations, and allow a better understanding of mechanisms of disease., Study Design: Cross-sectional study., Setting: Tertiary academic medical center., Subjects and Methods: We enrolled patients presenting with spasmodic dysphonia to the voice clinic of our academic medical center. Data included demographics, clinical features, family history, and treatments administered. The following genes with disease-causing mutations previously associated with spasmodic dysphonia were screened: TOR1A (DYT1), TUBB4 (DYT4), and THAP1 (DYT6)., Results: Eighty-six patients were recruited, comprising 77% females and 23% males. A definite family history of neurologic disorder was present in 15% (13 of 86). Average age (± standard deviation) of symptom onset was 42.1 ± 15.7 years. Most (99%; 85 of 86) were treated with botulinum toxin, and 12% (11 of 86) received oral medications. Genetic screening was negative in all patients for the GAG deletion in TOR1A (DYT1) and in the 5 exons currently associated with disease-causing mutations in TUBB4 (DYT4). Two patients tested positive for novel/rare variants in THAP1 (DYT6)., Conclusion: Genetic screening targeted at currently known disease-causing mutations in TOR1A, THAP1, and TUBB4 appears to have low diagnostic yield in sporadic spasmodic dysphonia. In our cohort, only 2 patients tested positive for novel/rare variants in THAP1. Clinicians should make use of genetic testing judiciously and in cost-effective ways., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Objectives: To describe the range of findings in patients with neurofibromatosis (NF) presenting to a laryngology clinic and to analyze the etiologic factors of vocal fold dysfunction in this cohort., Study Design: Case series with chart review., Setting: Tertiary laryngology practice., Subjects and Methods: All cases of NF presenting to an academic laryngology practice were retrospectively reviewed (August 2005 to May 2014), with a total of 34 cases. Demographic data, symptoms, and endoscopic examination findings were reviewed. Etiologic factors of laryngeal complaints were analyzed with reference to NF-associated pathologies and surgical history., Results: Thirty-four patients with NF-1 or NF-2 were evaluated, and 28 of these patients (6 NF-1 and 22 NF-2) had laryngeal pathology. The most common presenting symptoms were vocal weakness (n = 21), dysphagia (n = 5), and globus (n = 4). Three patients had NF-related vocal fold masses on examination, including 2 neurofibromas and 1 schwannoma. Unilateral vocal cord paralysis was seen in 17 patients; bilateral paralysis was observed in 5 patients. Of patients with unilateral or bilateral paralysis, 20 had intracranial masses (vestibular schwannoma, meningioma, or skull base tumors), and 16 had previously undergone surgery for these lesions. Of the patients with NF-associated intracranial tumors, 87.0% presented with vocal cord paralysis, whereas only 40.0% of those without intracranial masses had paralysis (P = .0560). Seven patients underwent medialization procedures., Conclusion: Neurofibromatosis patients may present to laryngology clinic with primary laryngeal tumors or, more commonly, unilateral or bilateral paralysis. Otolaryngologists should be keenly aware of vocal fold paralysis caused by the NF-associated tumors, with particular attention to bilateral paralysis in NF-2., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Coral bleaching is the consequence of disruption of the mutualistic Cnidaria-dinoflagellate association. Elevated seawater temperatures have been proposed as the most likely cause of coral bleaching whose severity is enhanced by a limitation in the bioavailability of iron. Iron is required by numerous organisms including the zooxanthellae residing inside the symbiosome of cnidarian cells. However, the knowledge of how symbiotic zooxanthellae obtain iron from the host cells and how elevated water temperature affects the association is very limited. Since cellular iron acquisition is known to be mediated through transferrin receptor-mediated endocytosis, a vesicular trafficking pathway specifically regulated by Rab4 and Rab5, we set out to examine the roles of these key proteins in the iron acquisition by the symbiotic Symbiodinium. Thus, we hypothesized that the iron recruitments into symbiotic zooxanthellae-housed symbiosomes may be dependent on rab4/rab5-mediated fusion with vesicles containing iron-bound transferrins and will be retarded under elevated temperature. In this study, we cloned a novel monolobal transferrin (ApTF) gene from the tropical sea anemone Aiptasia pulchella and confirmed that the association of ApTF with A. pulchella Rab4 (ApRab4) or A. pulchella Rab5 (ApRab5) vesicles is inhibited by elevated temperature through immunofluorescence analysis. We confirmed the iron-deficient phenomenon by demonstrating the induced overexpression of iron-deficiency-responsive genes, flavodoxin and high-affinity iron permease 1, and reduced intracellular iron concentration in zooxanthellae under desferrioxamine B (iron chelator) and high temperature treatment. In conclusion, our data are consistent with algal iron deficiency being a contributing factor for the thermal stress-induced bleaching of symbiotic cnidarians., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Objective: To determine the diagnostic yield of computed tomography (CT) in establishing an etiology in patients with idiopathic unilateral vocal fold paresis (IUVFP). To determine the proportion of CT scans yielding incidental findings requiring further patient management., Study Design: Case series with chart review., Setting: Tertiary laryngology practice., Subjects: Laryngology clinic patients under the care of the 2 senior authors., Methods: All clinic patients were identified who had a diagnosis of IUVFP and underwent CT of the skull base to the upper mediastinum from 2004 to 2014. Demographic, historical, examination, and investigation data were extracted. CT reports and endoscopic recordings were reviewed. Patients were excluded if there were insufficient clinical findings recorded or if there was a known neurologic disorder, complete vocal fold immobility, or bilateral involvement., Results: A total of 174 patients with IUVFP who had also undergone contrast-enhanced CT were identified. Of the 174 patients, 5 had a cause for their paresis identified on CT. This equated to a diagnostic yield of 2.9% (95% confidence interval, 0.94% to 6.6%). Of the 174 patients, 48 had other incidental lesions identified that required further follow-up, investigation, or treatment. This equated to an incidental yield of 27.6% (95% confidence interval, 21.1% to 34.9%)., Conclusion: This is the second and largest study to evaluate the diagnostic yield of CT in the evaluation of IUVFP. It demonstrates a low diagnostic yield and a high incidental yield. These findings suggest that the routine use of CT in the evaluation of idiopathic vocal fold paresis should be given careful consideration and that a tailored approach to investigation with good otolaryngologic follow-up is warranted., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Objectives/hypothesis: A precise molecular schema for classifying the different cell types of the normal human vocal fold epithelium is lacking. We hypothesize that the true vocal fold epithelium has a cellular architecture and organization similar to that of other stratified squamous epithelia including the skin, cornea, oral mucosa, and esophagus. In analogy to disorders of the skin and gastrointestinal tract, a molecular definition of the normal cell types within the human vocal fold epithelium and a description of their geometric relationships should serve as a foundation for characterizing cellular changes associated with metaplasia, dysplasia, and cancer., Study Design: Qualitative study with adult human larynges., Methods: Histologic sections of normal human laryngeal tissue were analyzed for morphology (hematoxylin and eosin) and immunohistochemical protein expression profile, including cytokeratins (CK13 and CK14), cornified envelope proteins (involucrin), basal cells (NGFR/p75), and proliferation markers (Ki67)., Results: We demonstrated that three distinct cell strata with unique marker profiles are present within the stratified squamous epithelium of the true vocal fold. We used these definitions to establish that cell proliferation is restricted to certain cell types and layers within the epithelium. These distinct cell types are reproducible across five normal adult larynges., Conclusion: We have established that three layers of cells are present within the normal adult stratified squamous epithelium of the true vocal fold. Furthermore, replicating cell populations are largely restricted to the parabasal strata within the epithelium. This delineation of distinct cell populations will facilitate future studies of vocal fold regeneration and cancer., Level of Evidence: N/A., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Design and validate a laryngeal surgical simulator to teach phonomicrosurgical techniques., Study Design: Device development and prospective validation., Setting: Tertiary medical center., Subjects and Methods: A novel laryngeal fixation device and custom laryngoscope were produced for use with ex vivo porcine larynx specimens. Vocal fold lesions such as nodules and keratotic lesions were simulated with silicone injections and epithelial markings. A prospective validation using postsimulation surveys, global rating scales, and procedure-specific checklists was performed with a group of 15 medical students, otolaryngology residents, fellows, and attending laryngologists. Three procedures were performed: vocal fold augmentation, excision of a simulated vocal fold nodule, and excision of a simulated vocal fold keratosis., Results: Participants overwhelmingly agreed that the simulator provided a realistic dissection experience that taught skills that would transfer to real operating scenarios. Expert performance was statistically superior to novice performance for excision of simulated vocal fold nodules and keratotic lesions, while no difference was observed for injection laryngoplasty., Conclusion: The ability to learn and rehearse surgical procedures in a safe environment is invaluable, particularly for delicate and highly technical phonomicrosurgical operations. We have developed a high-fidelity laryngeal surgical simulator complete with pathological lesions such as nodules and keratoses to teach these procedures. A prospective study demonstrated validity of our global rating scale and checklist assessments for vocal fold nodule and keratosis excision procedures, allowing them to be confidently incorporated into phonomicrosurgical training programs for surgeons of all levels of expertise., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.)

Importance: Vocal fold immobility following injury to the recurrent laryngeal nerve (RLN) may lead to substantial morbidity. A reinnervation treatment strategy offers several theoretical benefits over static treatment options. This study evaluates the robustness of reinnervation of the larynx using a split-hypoglossal nerve graft in an animal model, with outcomes assessed by independent blinded review., Objectives: To assess whether a full-hypoglossal nerve graft to the RLN after RLN section can provide return of dynamic vocal fold motion in a canine model, and to validate that a split-hypoglossal nerve graft to the RLN may also provide dynamic vocal fold motion to rehabilitate laryngeal function in a canine model., Design, Setting, and Subjects: A pilot animal study to assess the feasibility and morbidity of laryngeal reinnervation following RLN injury with an end-to-end full-hypoglossal or split-hypoglossal nerve graft was performed at an animal care and research facility in 10 adult female dogs. The study dates were January to July 2013., Interventions: We performed full-hypoglossal (full XII group [n = 5]) and split-hypoglossal (split XII group [n = 5]) nerve grafts to the RLN in a canine model following RLN section., Main Outcomes and Measures: Morbidity was evaluated through scored feeding observation. Laryngeal function was assessed by video laryngoscopy and evoked laryngeal electromyography was performed at baseline and 6 months after surgery. Video laryngoscopy was graded by independent reviewers blinded to study intervention., Results: No clinically significant morbidity was identified after surgery. On review of video laryngoscopy, all 5 animals in the full XII group and all 5 animals in the split XII group demonstrated vocal fold motion by at least 1 independent reviewer. All 3 reviewers agreed on motion in 1 of 5 animals in the full XII group and in 1 of 5 animals in the split XII group. Stimulation of the hypoglossal nerve demonstrated neural connection on evoked laryngeal electromyography in all animals at 6 months., Conclusions and Relevance: This study confirms that a full-hypoglossal or split-hypoglossal nerve graft may restore vocal fold motion, without significant functional morbidity, following RLN section in a canine model.

Legionella pneumophila (L. pneumophila) is a Gram-negative bacterium, which can be found worldwide in aquatic environments. It tends to persist because it is often protected within biofilms or amoebae. L. pneumophila biofilms have a major impact on water systems, making the understanding of the bacterial physiological adaptation in biofilms a fundamental step towards their eradication. In this study, we report for the first time the influence of the biofilm mode of growth on the proteome of L. pneumophila. We compared the protein patterns of microorganisms grown as suspensions, cultured as colonies on agar plates or recovered with biofilms formed on stainless steel coupons. Statistical analyses of the protein expression data set confirmed the biofilm phenotype specificity which had been previously observed. It also identified dozens of proteins whose abundance was modified in biofilms. Proteins corresponding to virulence factors (macrophage infectivity potentiator protein, secreted proteases) were largely repressed in adherent cells. In contrast, a peptidoglycan-associated lipoprotein (Lpg2043) and a peroxynitrite reductase (Lpg2965) were accumulated by biofilm cells. Remarkably, hypothetical proteins, that appear to be unique to the Legionella genus (Lpg0563, Lpg1111 and Lpg1809), were over-expressed by sessile bacteria.

Objectives/hypothesis: This study evaluated the efficacy of botulinum toxin type A injected into the interarytenoid muscle to treat recalcitrant vocal process granulomas., Study Design: Retrospective clinical review at a tertiary care center., Methods: Eight patients with vocal process granulomas refractory to a variety of prior treatments including surgical resection, proton pump inhibitor therapy, and voice therapy underwent percutaneous injection of botulinum toxin type A into the interarytenoid muscle, performed in an office setting. Doses ranged from 5 U to 25 U in one to two injections., Results: One patient demonstrated no improvement, two patients demonstrated partial resolution, and five patients demonstrated complete resolution of their granulomas. Four patients noted transient breathiness. There were no other side effects. All patients tolerated the injections without difficulty., Conclusion: Botulinum toxin injection into the interarytenoid muscle appears to be a safe and effective modality for treating recalcitrant vocal process granuloma., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

In prokaryote organisms, N-glycosylation of proteins is often correlated to cell-cell recognition and extracellular events. Those glycoproteins are potential targets for infection control. To date, many surface-glycosylated proteins from bacterial pathogens have been described. However, N-linked Pseudomonas surface-associated glycoproteins remain underexplored. We report a combined enrichment and labeling strategy to identify major glycoproteins on the outside of microorganisms. More precisely, bacteria were exposed to a mix of biotinylated lectins able to bind with glycoproteins. The latter were then recovered by avidin beads, digested with trypsin, and submitted to mass spectrometry. The targeted mixture of glycoproteins was additionally deglycosylated in the presence of H2(18)O to incorporate (18)O during PNGase F treatment and were also analyzed using mass spectrometry. This approach allowed us to identify a few tens of potential N-glycoproteins, among which flagellin FliC was the most abundant. To detect the possible sites of FliC modifications, a de novo sequencing step was also performed to discriminate between spontaneous deamidation and N-glycan loss. This approach led to the proposal of three potential N-glycosylated sites on the primary sequence of FliC: N26, N69, and N439, with two of these three asparagines belonging to an N-X-(S/T) consensus sequence. These observations suggest that flagellin FliC is a heterogeneous protein mixture containing both O- and N-glycoforms.