Search

Objective: Dysphagia is multifactorial in unilateral vocal fold immobility (UVFI). Severe dysphagia could indicate greater functional deficits in UVFI. The purpose of this study is to evaluate the association of dysphagia with the need for surgical voice restoration in patients with UVFI., Study Design: Retrospective chart review., Setting: Single-institution, tertiary referral center., Methods: Records of UVFI patients from 2008 to 2018 were examined. Dysphagia severity was extracted from patient history. Etiology of UVFI and other relevant variables were analyzed to determine their association with dysphagia. Dysphagia severity and other clinical variables were then analyzed for their association with surgical voice restoration., Results: Eighty patients met selection criteria out of 478 patients with UVFI. There was significant concordance between dysphagia severity extracted from patient history and patient-reported EAT-10 scores (R = 0.59, p = 0.000035). Patients' EAT-10 scores were correlated with VHI-10 scores (R = 0.45, p = 0.011). Severe dysphagia (p = 0.037), high VHI-10 score on presentation (p = 0.0009), and longer duration of hoarseness before presentation (p = 0.008) were associated with surgical voice restoration in UVFI patients., Conclusion: In this pilot study, severe dysphagia and increased voice handicap on presentation were associated with the need for surgical voice restoration in UVFI patients. Presenting dysphagia may be an additional variable for clinicians to consider for management of UVFI., Competing Interests: Declaration of competing interest No conflicts of interest to disclose., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Background: Neonatal unilateral vocal fold paralysis may arise iatrogenically, idiopathically, or in the context of an underlying neurologic disorder. Management is often supportive, focusing on diet modification to allow for safe oral feeding. We describe the clinical course of six infants with unilateral vocal fold paralysis who developed predominantly unilateral laryngomalacia ipsilateral to the affected vocal fold with associated severe respiratory symptoms and feeding difficulty., Methods: Retrospective review of six infants with unilateral vocal fold paralysis and predominantly unilateral laryngomalacia. Charts were reviewed for etiology of vocal fold paralysis, presenting symptoms, operative details, postoperative course, and outcomes for breathing and swallowing., Results: Etiology of vocal fold paralysis included cardiac surgery in four patients, intubation-related in one, and idiopathic in one. Presenting symptoms included increased work of breathing, stridor, feeding difficulty, respiratory failure requiring noninvasive respiratory support, and weak cry. All infants were on nasogastric tube feedings. Direct microlaryngoscopy with unilateral or predominantly unilateral (conservative contralateral aryepiglottic fold division) supraglottoplasty was performed. Stridor and work of breathing improved in all six patients within 1 week postoperatively. Oral feeding improved in three patients within 2 weeks. Three patients had persistent feeding impairment with improvement within one year., Conclusions: Predominantly unilateral laryngomalacia may arise in the context of unilateral vocal fold paralysis. Addressing the ipsilateral cuneiform collapse can improve breathing and feeding. This may be an under-described phenomenon and represents an additional reason to include the otolaryngologist early in the care of infants with suspected possible new unilateral vocal fold paralysis. Breathing and swallow can improve post-operatively, but feeding may remain limited by the vocal fold paralysis and any medical comorbidities. Ongoing follow-up and collaboration with speech-language pathology to optimize feeding are important., Competing Interests: Declaration of competing interest none., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: One-lung ventilation (OLV) is a commonly used technique to facilitate surgical visualization during thoracic surgical procedures. Double-lumen endotracheal tubes and one-lumen tracheal tube combined with bronchial blocker might lead to intubation-related laryngeal injury., Patient Concerns: In the perioperative period, how to avoid further damage to the vocal cord while achieving OLV during operation is challenging work., Diagnosis: She was diagnosed with systemic lupus erythematosus, bilateral vocal cord paralysis, and lung tumor., Interventions: We used a combination of a laryngeal mask airway with bronchial blocker to avoid further damage to the vocal cord when achieving OLV., Outcomes: At 1-month follow-up, she had fully recovered without obvious abnormalities., Conclusion: When OLV was required for patients with bilateral vocal cord paralysis, a combination of a laryngeal mask airway with bronchial blocker was considered a better choice., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: To assess the outcomes of endoscopic assisted microscopic posterior cordotomy for bilateral abductor vocal fold paralysis (BAVFP) using radiofrequency versus coblation., Methods: This was a randomized prospective cohort study that carried out on 40 patients with BAVFP who were subjected to endoscopic/assisted microscopic posterior cordotomy. The patients were randomly allocated into two groups: group (A) patients were operated with radiofrequency, and group (B) patients were operated with coblation. Glottic chink, grade of dyspnea, voice handicap index 10 (VHI10), and aspiration were evaluated pre-operatively and 2 weeks and 3 months post-operatively., Results: There was a significant improvement in the glottic chink and VHI10 scores postoperatively with a non-significant difference between both groups regarding the degree of improvement. In addition, there was a significant improvement of the grade of dyspnea with a non-significant impact on the degree of aspiration in both groups post operatively. There was a lower incidence of oedema and granulation formation in the coblation group but without a statistical significance., Conclusion: Both techniques are effective alternatives for performing posterior transverse cordotomy in cases of BAVFP., (© 2023. The Author(s).)

Hoarseness due to vocal fold paresis (VFP) has a multitude of etiologies including systemic lupus erythematosus (SLE). During a clinical evaluation of a 58-year-old woman with long-standing hoarseness, an incidental finding of thyroid nodules was found to have VFP. Direct laryngoscopy and vocal fold biopsy confirmed the source was an inflammatory process involving the cricoarytenoid joint of the right hemilarynx. A presumptive diagnosis of SLE was made 3 years before meeting the clinical criteria of overt SLE. The VFP debut of SLE is extremely rare, and a literature review includes a handful of case reports (4 of a total of 37) since 1959. Only partial recovery of laryngeal function using glucocorticoids and Plaquenil was accomplished in the current case., (Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2023. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

Background/objectives: Growing reliance on telemedicine has created new triaging challenges. This study investigated how effectively otolaryngology resident auditory-perceptual voice assessments performed via telemedicine determined the need for urgent in-person clinic visits., Methods: Twelve otolaryngology resident physicians (PGY1-PGY5) performed auditory-perceptual assessments on 25 voice samples recorded during initial voice evaluations. Voice samples were balanced in severity and taken in equal numbers from patients with the following diagnoses: benign laryngeal lesions, laryngeal cancer, functional voice disorders, laryngeal edema (associated with LPR), and laryngeal paralysis/paresis. Urgent diagnoses were defined as laryngeal cancer and severe unilateral laryngeal paralysis. For each voice sample, residents were initially blinded to patient medical history. Residents rated severity of voice disorder, predicted patient diagnosis, and determined the urgency of seeing the patient in clinic. Residents then reviewed information from the patient's medical history and again rated urgency of voice disorder., Results: On average, residents identified urgent voice disorders in 56% of cases. After reviewing medical history, this number significantly increased to 77% (P = 0.001). Voice severity, smoking history, time since onset, and course of symptoms were considered most influential when determining medical urgency of voice patients. Year in residency program had no effect on rating accuracy. As expected, diagnostic accuracy of auditory-perceptual assessments was low, ranging from 40% for laryngeal paralysis/paresis to 5% for laryngeal edema., Conclusion: Auditory-perceptual voice assessment, combined with medical history, predicted most medically urgent voice disorders. Further work should investigate if task-specific training might improve these results and which medical history items are most critical. Until accuracy of auditory-perceptual assessment of medical urgency is improved, these data underscore the importance of laryngeal examination in identifying medical urgency and etiology of dysphonia., (Copyright © 2019. Published by Elsevier Inc.)

Objective: To determine the association of social determinants of health (SDOH) on the presentation and management of unilateral vocal fold immobility (UVFI)., Methods: Retrospective chart review of 207 adult UVFI patients evaluated at a tertiary-care hospital between 2018 and 2019 was performed. Sociodemographic factors including gender, median household income, preferred language, and insurance type were recorded. Confounding clinical factors including etiology of UVFI, Voice Handicap Index-10 (VHI-10) score, laryngoscopic findings, and intervention history were extracted from medical records. Multivariable logistic regression was performed using sociodemographic and clinical factors., Results: Patient demographics and socioeconomic status were not associated with time to presentation. Patients presenting with glottic insufficiency and UVFI due to malignancy or recurrent laryngeal nerve (RLN) sacrifice had a shorter time to presentation. Higher household income was associated with greater number of interventions (p = 0.02), but neither income nor insurance type affected intervention type or timing. Female patients were less likely to undergo injection medialization laryngoplasty (odds ratio [OR] 0.25, p = 0.005). Older patients were more likely to undergo injection (OR 1.04, p = 0.027). Patients with large glottic gaps (OR 21.2, p = 0.014) and higher VHI-10 scores (OR 1.06, p = 0.047) were more likely to undergo surgery., Conclusion: Higher household income was associated with greater number of interventions and longer duration of care at a private tertiary-care hospital. RLN sacrifice, known malignancy, and glottic insufficiency significantly reduced the time to presentation. Type of intervention received was a complex interplay of both demographic and clinical factors. Large prospective studies should examine the role of SDOH in the presentation and management of UVFI., Level of Evidence: 4 Laryngoscope, 134:297-304, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Despite the increasing use of minimally invasive esophagectomies, aspiration pneumonia remains the most serious complication. This study clarified the association between perioperative tongue pressure and postoperative aspiration after thoracoscopic-laparoscopic esophagectomy in patients with esophageal cancer. This retrospective, single-center, observational study evaluated data of 216 patients scheduled for thoracoscopic-laparoscopic esophagectomy. Tongue pressure was measured before the procedure and on postoperative day 6; perioperative changes were assessed. Patients were divided into non-aspiration and aspiration groups according to penetration-aspiration scale scores. Hierarchical and stratified logistic regression analyses were performed to identify factors associated with aspiration. Receiver operating characteristic curves were used to assess the cut-off value of perioperative changes in tongue pressure for aspiration. Perioperative changes in tongue pressure (odds ratio 0.92; 95% confidence interval 0.88-0.96, P < 0.001), age (odds ratio 1.07; 95% confidence interval 1.01-1.13, P = 0.013), and postoperative recurrent laryngeal nerve palsy (odds ratio 3.04; 95% confidence interval 1.15-8.03, P = 0.025) were significantly associated with aspiration. The cut-off value of perioperative changes in tongue pressure for postoperative aspiration was - 6.58%. In addition, decreases in tongue pressure were associated with aspiration regardless of recurrent laryngeal nerve palsy and age. The perioperative decrease in tongue pressure, higher age, and postoperative recurrent laryngeal nerve palsy were significant factors strongly associated with aspiration in the acute phase post-esophagectomy. Decreased tongue pressure is the only intervenable predictor of aspiration. Rehabilitation for preventing decreases in tongue pressure may reduce the risk of aspiration., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Tuberculous meningitis, a rare but severe form of extrapulmonary tuberculosis, frequently affects cranial nerves. While nerves III, VI and VII are commonly involved, involvement of caudal cranial nerves is rarely described. Here, we report a rare case of bilateral vocal cord palsy secondary to caudal cranial nerve involvement in tuberculous meningoencephalitis, that occurred in Germany, a country with low tuberculosis incidence., Case Presentation: A 71-year-old woman was transferred for further treatment of hydrocephalus as a complication of presumed bacterial meningitis with unknown pathogen at that time. Because of decreased consciousness, intubation was performed and an empiric antibiotic therapy with ampicillin, ceftriaxone and acyclovir was initiated. Upon admission to our hospital, an external ventricular drainage was placed. Cerebrospinal fluid analysis revealed Mycobacterium tuberculosis as the causative pathogen, and antitubercular treatment was initiated. Extubation was possible one week after admission. Eleven days later, the patient developed inspiratory stridor that worsened within a few hours. Flexible endoscopic evaluation of swallowing (FEES) revealed new-onset bilateral vocal cord palsy as the cause of respiratory distress, which required re-intubation and tracheostomy. The bilateral vocal cord palsy persisted despite continued antitubercular therapy on the follow-up examination., Conclusion: Considering the aetiology of infectious meningitis, cranial nerve palsies may be suggestive for tuberculous meningitis as underlying disease given their rarity in other bacterial forms of meningitis. Nevertheless, intracranial involvement of inferior cranial nerves is rare even in this specific entity, as only extracranial lesions of inferior cranial nerves have been reported in tuberculosis. With this report of a rare case of bilateral vocal cord palsy due to intracranial involvement of the vagal nerves, we emphasize the importance of timely initiation of treatment for tuberculous meningitis. This may help to prevent serious complications and associated poor outcome since the response to anti-tuberculosis therapy may be limited., (© 2023. The Author(s).)

Objectives: To characterize the presentation, clinical course and functional outcomes of patients with varicella zoster virus (VZV) reactivation involving the vagus nerve. To highlight the role of otolaryngology in acute and long-term management of laryngopharyngeal VZV and its sequelae., Methods: Retrospective review of 3 patients with laryngopharyngeal VZV, managed at a tertiary referral center., Results: All cases presented with vesicular lesions involving mucosa of the laryngopharynx. Each experienced vocal fold hypomobility, among other otolaryngologic sequelae. All were treated with systemic antivirals and corticosteroids. Mucosal lesions resolved within 7 days of treatment initiation; functional deficits persisted for months to years. Dysphonia improved to a plateau at 3 months, while dysphagia took longer to resolve. One patient with disseminated disease experienced bilateral vocal fold paralysis requiring temporary tracheostomy., Conclusions: Vagal neuropathy secondary to VZV reactivation is a rare clinical entity with a variety of laryngeal manifestations. Early initiation of systemic therapy and serial endoscopic evaluations are critical components of acute management when laryngopharyngeal involvement is suspected. Otolaryngologists should plan for long-term phonatory and deglutitive therapy in these cases, as neurologic sequelae can persist for months to years following initial insult., Level of Evidence: Level 4 (Case-series).

Objective: Bilateral selective reinnervation of the larynx aims to restore both vocal cord tone and abductor movements in patients with bilateral vocal cord palsy., Methods: Four females and one male treated by bilateral selective reinnervation of the larynx were included in the present study. In all cases, both posterior cricoarytenoid muscles were reinnervated using the C3 right phrenic nerve root through the great auricular nerve graft, while adductor muscle tone was bilaterally restored using the thyrohyoid branches of the hypoglossal nerve through transverse cervical nerve grafts., Results: After a minimum follow-up of 48 months, all patients were successfully tracheostomy free and had recovered normal swallowing. At laryngoscopy, the first patient recovered a left unilateral partial abductor movement, the second had complete bilateral abductor movements, the third did not show improvements of abductor movements, but symptomatology was improved, the fourth recovered partial bilateral abductor movements and the fifth case did not show improvements and needed posterior cordotomy., Conclusions: Bilateral selective laryngeal reinnervation, although a complex surgical procedure, offers a more physiologic recovery in the treatment of bilateral vocal fold paralysis. Selection criteria still needs to be precisely defined to avoid unexpected failures., (Copyright © 2023 Società Italiana di Otorinolaringoiatria e Chirurgia Cervico-Facciale, Rome, Italy.)

Introduction: Injection laryngoplasty (IL) is commonly performed for unilateral vocal fold immobility (UVFI). However, the safety and efficacy in patients <1 year of age are not widely recognized. This study analyzes the safety and swallow outcomes in a cohort of patients <1 year who underwent IL., Methods: This retrospective analysis evaluated patients at a tertiary children's institution between 2015 and 2022. Patients were eligible if they underwent IL for UVFI and were <1 year at time of injection. Baseline characteristics, perioperative data, oral diet tolerance, and preoperative and postoperative swallow data were collected., Results: 49 patients were included, 12 (24%) of whom were premature. The average age at injection was 3.9 months (SD 3.8), time from UVFI onset to injection 1.3 months (2.0), and weight at injection 4.8 kg (2.1). The baseline American Association of Anesthesiologists physical status classification scores were 2 (14%), 3 (61%), and 4 (24%). 89% of patients had improvements in objective swallow function postoperatively. Of the 35 patients who were preoperatively enterally-dependent and did not have medical circumstances precluding advancement to oral feeds, 32 (n = 91%) tolerated an oral diet postoperatively. There were no long-term sequelae. Two patients had intraoperative laryngospasm, one intraoperative bronchospasm, and one with subglottic and posterior glottic stenosis was intubated for <12 h for increased work of breathing., Conclusions: IL is a safe and effective intervention that can reduce aspiration and improve diet in patients <1 year old. This procedure can be considered at institutions with the appropriate personnel, resources, and infrastructure., Competing Interests: Declaration of competing interest None., (Copyright © 2023. Published by Elsevier B.V.)

The association between swallowing function and cough strength in patients with unilateral vocal fold paralysis (UVFP) is unknown. We evaluated the relationship between voluntary cough strength and dysphagia among patients with UVFP (UVFP group) by comparing their data with that of corresponding healthy participants (healthy control [HC] group) in a prospective observational study. From February 1st, 2018 to March 30th, 2019, we recruited patients with a voice disorder due to UVFP, who were referred to our university hospital. Patients with a history of laryngeal surgery, vagal nerve paralysis, or cardiac and respiratory failure were excluded. Descriptive and clinical data regarding swallowing, voice, and cough peak flow (CPF) were collected as a measure of cough strength. The UVFP group comprised six women and seven men (median age, 68.0 years), and the HC group comprised six women and eight men (median age 65.5 years). The groups differed significantly in the Eating Assessment Tool (EAT)-10 scores and CPF rates (P < 0.001). Among patients with UVFP, 84.6% had an abnormal EAT-10 score of ≥ 3. Additionally, 16.7% of the patients exhibited liquid aspiration with contrast medium on a videofluorographic swallowing study (VFSS). There was no correlation between the CPF values, EAT-10 scores, or the VFSS results. Therefore, patients with severe UVFP, whose condition had been fixed, had difficulties when swallowing (85% of cases), and some even presented with aspiration on VFSS (20% of cases), while receiving a regular diet., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: To assess dysphagia outcomes following surgical management of unilateral vocal fold immobility in children., Data Sources: Ovid Medline, Embase, Web of Science, and CENTRAL databases., Review Methods: A systematic review of the medical literature was performed following the PRISMA guidelines. An a priori protocol was defined to identify all articles that presented quantifiable outcome data in children aged <18 years who underwent surgical treatment to improve glottal competence for dysphagia. Two authors independently determined references meeting the inclusion criteria, extracted data, and assigned levels of evidence. Data were pooled via a random effects model where possible. The quality of studies was graded with the MINORS criteria., Results: An overall 398 publications were screened, with 9 meeting inclusion criteria. A total of 115 patients were included. Of these, 75% had preoperative swallowing symptoms. Surgical intervention for dysphagia included 61 injection laryngoplasties, 11 medialization laryngoplasties, and 10 reinnervations (ansa cervicalis to recurrent laryngeal nerve). The articles consistently reported success in improving dysphagia symptoms, and limited meta-analysis demonstrated a mean improvement after surgical intervention in 79% (95% CI, 67%-91%) of children. The reported rate of minor and major complications was 15% (95% CI, 1%-29%). The MINORS scores ranged from 5 to 12., Conclusion: Surgical management of unilateral vocal fold immobility in properly selected children can be an effective treatment for dysphagia when symptoms are present. Selection of surgical modalities relies on patient- and surgeon-related factors, and the rate of success is high across different interventions in treating these complex children., (© 2022 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: The aim of this study was to describe the clinical features of vocal cord lesions in patients with representative autoimmune diseases including systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA)., Method: A total of 31 SLE/RA patients (14 SLE and 17 RA) complicated with vocal cord lesions (SLE/RA-VC group) who had been admitted to Peking Union Medical College Hospital were retrieved from the electronic registration system. Ninety-three age and sex-matched SLE/RA patients (42 SLE and 51 RA) without vocal cord lesions (SLE/RA-nVC group) admitted during the same period were chosen randomly as controls. Medical files were reviewed and clinical data collected for comparisons., Results: Vocal cord paralysis (n = 12, 38.7%) and vocal cord mass (n = 14, 45.2%) were the most common types of vocal cord lesions in this cohort. Unilateral lesions were more common than bilateral lesions (67.8% vs 32.3%) and the two sides were affected equally. Two cases of vocal cord bamboo node lesion were observed in SLE-VC group even as an initial manifestation and SLE-VC group had a slightly higher disease activity index (SLEDAI-2K) than their control counterparts (18.56 ± 8.23 vs 13.63 ± 5.89, p = 0.041). The RA-VC group had less pulmonary interstitial disease (29.4% vs 63%, p = 0.017) and lower CRP levels (p = 0.006) than their controls. As for the treatment, 71% of SLE/RA-VC patients had received glucocorticoids and immunosuppressants and 30% had undergone surgery. 45.2% of SLE/RA-VC patients got improvement at the time of discharge., Conclusions: The association of vocal cord lesions with disease activity can be observed in SLE patients but not in RA patients. Vocal cord lesions in SLE/RA patients should be considered as a part of the systemic involvement and should be treated accordingly. Key Points • Vocal cord paralysis and vocal cord mass were the main types of vocal cord lesions in patients with SLE/RA. • Vocal cord lesions in SLE patients may associate with disease activity and vocal cord bamboo node lesions could be an initial manifestation. • Glucocorticoid and immunosuppressants could be effective for vocal cord lesions in SLE/RA patients., (© 2022. The Author(s), under exclusive licence to International League of Associations for Rheumatology (ILAR).)

Introduction: Glottic obstruction may arise secondary to bilateral vocal fold immobility (BVFI). Treatment options include a tracheostomy to bypass the site of obstruction as well as unilateral transverse cordotomy to alleviate the obstruction. The objective of this review is to determine the efficacy, adverse event profile, and long-term outcomes, including the need for tracheostomy, in patients undergoing unilateral cordotomy., Methods: The Preferred Reporting Systems for Systematic Reviews and Meta-Analysis (PRISMA) guidelines were followed for this systematic review. A literature search of unilateral cordotomy was performed by searching PubMed, Cochrane Library, and Embase. Articles presenting cases of BVFI treated with unilateral cordotomy were included. Review articles, animal studies, non-English-language articles, and abstracts were excluded. Articles presenting cases of bilateral cordotomy or cordotomy with arytenoidectomy were excluded., Results: We identified 14 studies and 291 patients undergoing unilateral cordotomy. Sixty-eight patients had a prior tracheostomy in place at the time of cordotomy. The most common post-operative complication was granulation tissue formation (n = 39). Thirty-one patients developed glottic edema with subsequent dyspnea. Three patients developed scarring of the primary cordotomy site with the return to an obstructed airway. Nine patients required a post-cordotomy tracheostomy due to these complications. Five patients required a long-term tracheostomy and were unable to be decannulated., Conclusion: Unilateral cordotomy is an effective treatment for glottic obstruction with high post-operative decannulation rates. Adverse events including worsening glottic obstruction are uncommon, although edema and granulation tissue may develop in the post-operative period and necessitate close post-operative monitoring. Laryngoscope, 133:6-14, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Glottal incompetence caused by unilateral vocal fold paralysis (UVFP) is a common cause of dysphagia and aspiration. Treatments targeted at reducing glottal incompetence by injection augmentation or medialization thyroplasty are well established at improving voice outcomes, but improvements in swallowing function are less clear. The objective of this systematic review was to determine the impact of vocal fold medialization on dysphagia outcomes. Six electronic bibliographic databases and one clinical trial registry were searched on 3/13/2020. Our patient population were adult patients with verified UVFP that underwent vocal fold medialization. We limited review to prospective studies that had formal dysphagia assessment both before and after medialization. Nine studies met selection criteria (7 prospective case series and 2 prospective cohort studies) totaling 157 patients. The most common etiology of UVFP was iatrogenic (74/157; 47%). The majority of patients underwent injection augmentation (92/157; 59%), and the remaining underwent medialization thyroplasty. A variety of methods were used to assess changes in dysphagia including patient-reported outcome measures, flexible endoscopic evaluation of swallowing, videofluoroscopic swallow study, and high-resolution manometry. 7/9 studies demonstrated clinically significant improvement in swallowing function following medialization; 4/9 studies demonstrated statistically significant improvement, and three studies did not show statistically significant improvement after intervention. Study participants and outcome measures evaluating swallowing function in this review were heterogeneous. Moreover, the reviewed studies are concerning for multiple risks of bias impacting their conclusions. Taken together, this systematic review demonstrates limited evidence that injection augmentation and medialization thyroplasty improve swallowing function and/or safety., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Ortner's syndrome refers to vocal cord paralysis resulting from compression of the left recurrent laryngeal nerve by abnormal mediastinal vascular structures. This retrospective case series details our experience with Ortner's syndrome due to thoracic aortic aneurysm., Methods: This study was a retrospective analysis of a case series. A total of 4 patients (mean age, 65.5 years) with Ortner's syndrome due to thoracic aortic aneurysm underwent thoracic endovascular aortic repair from July 2014 to May 2020. The patients' demographics, comorbidities, initial symptoms, time from hoarseness to treatment, aneurysm shape and size, surgical procedures and outcome are summarized., Results: A total of 4 patients with Ortner's syndrome due to thoracic aortic aneurysm were analyzed. All the patients underwent thoracic endovascular aortic repair with no complications during the hospitalization period. At a mean follow-up of 26.8 (8-77) months, hoarseness in 3 patients had completely resolved or improved, and the symptoms in 1 patient had not progressed., Conclusions: Hoarseness due to left recurrent laryngeal nerve palsy can be the presenting symptom of thoracic aortic aneurysm. Early diagnosis leads to timely treatment of these patients which may be helpful in the functional recovery of symptoms., (© 2022. The Author(s).)

Impaired swallowing in infants can impact upon the ability to feed orally, often resulting in dependency on supplementary feeding. Such difficulties can lead to an increased burden of care and associated costs. The primary aim of this study was to investigate the impact of vocal cord palsy (VCP), acquired intraoperatively during cardiac surgery, on the feeding outcomes of infants at a tertiary metropolitan children's hospital. An additional aim was to obtain preliminary information on the impact of feeding difficulties in this group on the quality of life of parents and families. A review of 48 patients who had been referred to the speech pathology service was undertaken. Participants presented with heterogeneous cardiac diagnoses, and had an initial Videofluoroscopic Swallow Study (VFSS) at a median corrected age of 3.6 weeks. Sixty percent of participants presented with silent aspiration on VFSS. Thirty percent of participants required supplementary tube feeding more than 6 months post-surgery. Six percent of participants with poor feeding progress and persistent aspiration required further surgical intervention to support nutrition. Findings revealed no significant relationship between participant factors and the presence of feeding difficulties, however, infants with concomitant genetic and syndromic conditions were found to be most at-risk for long-term feeding difficulties. Analysis of informal parent questionnaire responses indicated parents experienced stress and anxiety after their child's discharge. This was noted in regard to their child's feeding, which impacts quality of life across a number of domains. Findings of this study highlight the importance of communicating the potential feeding difficulties to parents of at-risk infants prior to cardiac surgery. This study further highlighted the importance of routine post-operative otorhinolaryngology examinations following high-risk surgeries, as well as speech pathology management for all infants and children identified with VCP. Post-operative input from appropriately trained Speech Pathologists is vital in assisting parents to support and mitigate their child's difficulties through the provision of early intervention for feeding difficulties., (© 2021. Crown.)

Objective: Patients with unilateral vocal fold paralysis commonly report dysphonia and dysphagia. Dyspnea also occurs, with studies on treatment-related change producing mixed results. Studies including patient-reported outcomes have focused on single-question global scales. The Dyspnea Index (DI) includes 10 questions, is specific to upper airway-related dyspnea, and may better capture these patients' symptoms. We evaluated change in DI after treatment., Study Design: Retrospective review., Setting: Academic medical center., Methods: Forty-three patients with unilateral vocal fold paralysis underwent injection augmentation (n = 25) or framework surgery (n = 18). DI was recorded preprocedure, 2 to 4 weeks afterward, and at approximately 3 months afterward in 19 patients. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 were also recorded. Change in parameters and correlations were assessed. Obesity, cardiac disease, pulmonary disease, and procedure (injection vs framework surgery) were evaluated for effect on DI., Results: Twenty-four patients had an abnormal baseline DI (>10). DI decreased from 14.9 ± 13.8 to 6.5 ± 9.3 after treatment ( P < .001; 95% CI, 4.7-12.1). Twenty-eight scores decreased, 9 remained unchanged, and 6 increased. Change in DI was influenced by the presence of cardiac disease. Decreased DI persisted at 3-month follow-up. Voice Handicap Index-10, Glottal Function Index, Cough Severity Index, and Eating Assessment Tool-10 scores decreased and were correlated with change in DI., Conclusion: Upper airway-related dyspnea is common in unilateral vocal fold paralysis, occurring in half of this cohort. Correcting glottic insufficiency may alleviate symptoms. Treatment decision making should consider postprocedural change in dyspnea, especially in patients for whom dyspnea is a motivating factor for seeking treatment.

Importance: No evidence-based treatment protocol currently exists for infants with vocal cord paresis (VCP)., Objective: To assess the impact of feeding position on feeding success among infants with unilateral VCP and examine other variables that may be associated with feeding success., Design: Retrospective descriptive study., Setting: Midwestern pediatric hospital serving rural and urban populations., Participants: Sixty-seven infants age <1 yr diagnosed with unilateral VCP by otolaryngologist while inpatient., Outcomes and Measures: Bottle or breastfeeding without the use of a thickening agent at discharge and without readmission for feeding difficulties ≤3 mo of discharge was considered feeding success., Results: Chart review was completed for 67 infants with unilateral VCP. Infants fed in side lying were more likely to feed without use of a thickened liquid than infants fed in upright (70% vs. 17%; p = .01). Infants who had patent ductus arteriosus (PDA) ligation and infants who were premature were more likely to need thickener and to be readmitted for feeding difficulties., Conclusions and Relevance: Further study is required to investigate the use of side-lying position versus upright position for feeding infants with VCP. Using the side-lying position allowed more infants to feed without thickener agents, and patient characteristics, including history of PDA ligation and prematurity, correlated with the need for thickened liquids and readmission. Consensus on the safety and efficacy of thickening breast milk is limited, so this information may allow more infants to breastfeed or drink expressed breast milk safely by bottle. It also provides medical providers information that can possibly prevent readmissions. What This Article Adds: The results of this study can inform occupational therapy feeding practice through use of the side-lying position, as well as being aware of patient characteristics that are correlated with increased feeding difficulties., (Copyright © 2022 by the American Occupational Therapy Association, Inc.)

Objective: We examined the influence of liquid thickness levels on the frequency of liquid penetration-aspiration in patients with dysphagia and evaluated the clinical risk factors for penetration-aspiration and aspiration pneumonia development., Study Design: A case series., Setting: Single-institution academic center., Methods: We reviewed medical charts from 2018 to 2019. First, we evaluated whether liquid thickness levels influence the frequency of liquid penetration-aspiration in patients with dysphagia. Penetration-aspiration occurrence in a videofluoroscopic swallowing study was defined as Penetration-Aspiration Scale (PAS) scores ≥3. Second, the association between liquid thickness level and penetration-aspiration was analyzed, and clinical risk factors were identified. Moreover, clinical risk factors for aspiration pneumonia development within 6 months were investigated., Results: Of 483 patients, 159 showed penetration-aspiration. The thickening of liquids significantly decreased the incidence of penetration-aspiration ( P < .001). Clinical risk factors for penetration-aspiration were vocal fold paralysis (odds ratio [OR], 1.99), impaired laryngeal sensation (OR, 5.01), and a history of pneumonia (OR, 2.90). Twenty-three patients developed aspiration pneumonia while undertaking advised dietary changes, including liquid thickening. Significant risk factors for aspiration pneumonia development were poor performance status (OR, 1.85), PAS score ≥3 (OR, 4.03), and a history of aspiration pneumonia (OR, 7.00)., Conclusion: Thickening of liquids can reduce the incidence of penetration-aspiration. Vocal fold paralysis, impaired laryngeal sensation, and history of aspiration pneumonia are significant risk factors of penetration-aspiration. Poor performance status, PAS score ≥3, and history of aspiration pneumonia are significantly associated with aspiration pneumonia development following recommendations on thickening liquids., Level of Evidence: 3.

Background: Thyroidectomy for massive goiters is challenging because of the increased risk of tracheomalacia, combined sternotomy, postoperative morbidity, and mortality, whereas studies investigating the clinicopathologic characteristics, postoperative morbidities, and surgical outcomes of massive goiters are limited., Methods: Patients with goiters undergoing thyroid surgery between 2009 and 2019 were retrospectively reviewed. A total of 227 patients were enrolled and divided into massive goiter group and large goiter group according to the weight of the goiter. Clinicopathologic characteristics, postoperative morbidities, and surgical outcomes were compared between the two groups., Results: Seventy-four patients (32.6%) had a goiter weighing more than 250 g and 153 patients (67.4%) were categorized in the large goiter group. Compared to large goiter patients, massive goiter patients had higher rates of retrosternal extension (82.4% vs. 30.7%), combined sternotomy (12.2% vs. 1.3%), intensive care unit admission (25.7% vs. 7.2%), transient hypoparathyroidism (41.9% vs. 25.5%), and transient recurrent laryngeal nerve palsy (10.8% vs. 3.3%) as well as prolonged length of hospital stay ( P < 0.05)., Conclusions: Massive goiter patients were at increased risk of combined sternotomy, intensive care unit admission, postoperative morbidities as well as prolonged length of hospital stay after thyroidectomy compared to large goiter patients, but most of them can be treated through a cervical approach with a favorable outcome., Competing Interests: The authors declare 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 © 2022 Chen, Su, Zou, Liu, Gong, Zhu, Li and Wei.)

Cell retention and survival after transplantation remains a major problem for long-term efficiency in therapy of severe vocal fold injury with autologous cells. In this study, injectable collagen scaffold was used to deliver autologous fat cells (AFCs) for repairing of severe vocal fold injury. We found injectable collagen scaffold could enhance the retention and survival of green fluorescent protein (GFP) labeled fat cells in the transplantation sites in rats. Based on these data, a randomized controlled clinical trial was conducted to evaluate the safety and efficiency of transplantation of collagen scaffold with AFCs for severe vocal fold injury. Ten patients with vocal fold paralysis were randomly assigned to control (AFCs only) and intervention (AFCs + collagen) groups. AFCs with or without collagen scaffold were injected into vocal folds of patients under general anesthesia, respectively. The safety and efficacy were regularly assessed during 24 months post-surgery. No obvious complications occurred in all patients during the follow-up. The collagen scaffold maintained the stability of implants after injection and reconstructed the vocal fold structure. The improvement of voice quality of patients was observed through voice quality evaluation with the voice handicap index (VHI) questionnaire, as well as acoustic analysis of maximum phonation time, jitter, and shimmer. The VHI score of patients in AFCs + collagen group improved significantly than those in AFCs group at 6, 12 and 24 months post-surgery. It demonstrates the injectable collagen scaffold is safe and efficient for delivering AFCs for vocal fold injury., (© 2022 IOP Publishing Ltd.)

Quantitative measures of swallowing function were extracted from modified barium swallowing studies (MBS) to characterize swallowing pathophysiology in patients with unilateral vocal fold immobility (UVFI). All individuals with UVFI completing a MBS during the prior 5 years were included. Demographic information, penetration-aspiration score, timing of aspiration and quantitative measures from the MBS were extracted from electronic medical records and compared across 1, 3, and 20 cc liquid bolus swallows. UVFI patient measures were compared to normal age-matched controls to identify swallowing pathophysiology associated with aspiration. The incidence of aspiration by UVFI etiology groups (i.e., central nervous system, idiopathic, iatrogenic, skull base tumor, or peripheral tumor) was also compared. Of the 61 patients who met inclusion criteria, aspiration was observed in 23%. Maximum pharyngeal constriction was abnormal in 79% of aspirators compared to 34% of non-aspirators (p = .003). Delay in airway closure was the most common swallowing abnormality identified in the study population (62%) but was not associated with aspiration. Among the 14 individuals who aspirated, the iatrogenic and skull base tumor etiology groups comprised the majority (i.e., 36% each). However, the incidence of aspiration for the iatrogenic group was 19% compared to 50% of the skull base tumor group. Aspiration in patients with UVFI was associated with abnormally reduced pharyngeal constriction. Delayed airway closure was common in both aspirators and non-aspirators., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: The aim of this study is to evaluate the efficacy of unilateral posterior glottic cleft dilatation with low-temperature plasma under the endoscope in the treatment of bilateral vocal cord paralysis dyspnea. Methods: Forty-one patients with bilateral vocal cord paralysis were recruited, and they were all admitted to the Department of Otorhinolaryngology Head and Neck Surgery, the First Affiliated Hospital of Zhengzhou University from March 2014 to June 2019. Those 41 patients were all treated with low-temperature plasma to completely resect unilateral arytenoid cartilage and the posterior 1/3 of the ipsilateral vocal cord. Fiber laryngoscopy was performed before and after operation. The clinical efficacy of the operation was evaluated by the size of glottis cleta, the improvement rate of dyspnea, voice satisfaction, swallowing function, the tracheal cannula removal rate and postoperative complication rate. Results: Forty-one patients were followed up for 24-88 months. The rate of one-pass extubation was 88.57%（31/35）. The satisfaction rate of voice was 92.11%（35/38）. The recovery rate of swallowing function was 97.56%（40/41）. Conclusion: This study demonstrated that the application of low-temperature plasma in unilateral posterior glottic cleft dilatation could significantly improved the ventilation function of patients with bilateral vocal cord paralysis, with a reliable curative effect and a high extubation rate. It is a safe, reliable, simple and minimally invasive treatment option for the treatment of bilateral vocal cord paralysis., Competing Interests: The authors of this article and the planning committee members and staff have no relevant financial relationships with commercial interests to disclose., (Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.)

Objectives: Laryngeal vibratory asymmetry occurring with paresis may result in a perceptually normal or abnormal voice. The present study aims to determine the relationships between the degree of vibratory asymmetry, acoustic measures, and perception of sound stimuli., Study Design: Animal Model of Voice Production, Perceptual Analysis of Voice., Methods: In an in vivo canine model of phonation, symmetric and asymmetric laryngeal vibration were obtained via graded unilateral recurrent laryngeal nerve (RLN) stimulation simulating near paralysis to full activation. Phonation was performed at various contralateral RLN and bilateral superior laryngeal nerve stimulation levels. Naïve listeners rated the perceptual quality of 182 unique phonatory samples using a visual sort-and-rate task. Cepstral peak prominence (CPP) was calculated for each phonatory condition. The relationships among vibratory symmetry, CPP, and perceptual ratings were evaluated., Results: A significant relationship emerged between RLN stimulation and perceptual rating, such that sound samples from low RLN levels were preferred to those from high RLN levels. When symmetric vibration was achieved at mid-RLN stimulation, listeners preferred samples from symmetric vibration over those from asymmetric vibration. However, when symmetry was achieved at high RLN levels, a strained voice quality resulted that listeners dispreferred over asymmetric conditions at lower RLN levels. CPP did not have a linear relationship with perceptual ratings., Conclusions: Laryngeal vibratory asymmetry produces variable perceptual differences in phonatory sound quality. Though CPP has been correlated with dysphonia in previous research, its complex relationship with quality limits its usefulness as clinical marker of voice quality perception., Level of Evidence: NA, basic science Laryngoscope, 131:2740-2746, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Evaluate swallowing and airway outcomes following laryngotracheoplasty with posterior grafting (LTP PCCG)., Methods: Retrospective review of pediatric patients undergoing LTP PCCG from 2016 to 2019 at a tertiary care pediatric hospital. We included demographics, indications, approach, and revision status. We evaluated preoperative and postoperative instrumental and functional swallow evaluations, and we also gathered information on airway outcomes., Results: Thirty-one patients were included in the study. Median (interquartile range [IQR]) age was 4.0 (2.0, 7.0) years old. Primary indication for surgery was bilateral vocal cord immobility (BVCI) in 11 (35.5%) and posterior glottic stenosis (PGS) in 20 (64.5%). Mean (standard deviation) length of follow-up was 11.0 (8.3) months. Twelve patients had gastrostomy tubes (GT) before surgery, and no patients required placement of GT after surgery. Of the remaining 19 patients, 6 required nasogastric feeding for >4 weeks (average length 1.8 months, longest 3.5 months). At last follow-up, 25 (80.6%) patients were primarily orally fed. Eighteen patients had tracheotomies prior to surgery. No patients without a tracheostomy required placement of tracheostomy before or after surgery and only 1 patient had a tracheostomy at last follow-up. Average time to decannulation was 3.7 months, with surgery-specific success of 87.1% and overall success of 96.8%. Four (12.9%) patients required a major intervention to achieve decannulation., Conclusion: LTP PCCG is an effective surgical technique to address PGS and BVCI with high decannulation rates. It may cause temporary swallowing dysfunction, but in this series a majority of children were orally fed at last follow-up., Level of Evidence: 4 Laryngoscope, 131:2798-2804, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc..)

Objective: Retrospective videofluoroscopic swallowing study (VFSS) evaluations of pharyngeal swallowing were used to evaluate the types of dysphagia alleviated by the chin-down maneuver., Materials and Methods: The study population consisted of 64 patients who underwent VFSS evaluations during neutral and chin-down maneuvers presenting specifically penetration or aspiration. The assessment of the VFSS movie clips of each maneuver was performed using parameters of the Modified Barium Swallow Impairment Profile (MBSImP) and the presence and degree of airway invasion(PDAI) by three blinded raters in the following five subcategorized groups, 1. patietns presenting penetration or aspiration during swallow 2. after swallow, patients of 3. head and neck, 4. digestive and 5. neuromuscular disorders, respectively. The scores registered for the two maneuvers were statistically compared. Additionally, we examined statistically which factors had the impact on the improvement of the PDAI using fisher's exact test., Results: Compared with the neutral position, PDAI, pharyngeal constriction, anterior hyoid movement, pharyngeal constriction, laryngeal elevation, laryngeal closure, upper esophageal sphincter opening, initiation of the pharyngeal swallow, and pharyngeal clearance in pyriform sinus were significantly (p < 0.01-0.05) improved with the chin-down maneuver. In a subcategory comparison with group 1, 3 and 4, the PDAI improved significantly (p < 0.01) with the chin-down maneuver, in which laryngeal elevation and laryngeal closure had statistically the impact (p < 0.01-0.05) on improvement of PDAI., Conclusion: The chin-down maneuver was most effective in improving swallow function when the impairment included penetration and aspiration during swallow caused by inadequate laryngeal elevation and laryngeal closure., Competing Interests: Declaration of Competing Interest None., (Copyright © 2021. Published by Elsevier B.V.)

Objectives/hypothesis: Applying the principles of misdirected nerve regeneration to the larynx, Roger Crumley in 1989 coined the term laryngeal synkinesis (LS) which he later (2000) classified into 4 types (type I - good voice, type II - involuntary twitches and poor voice, type III - adduction during inspiration, type IV - abduction during phonation). Neurophysiological data were not available for all LS patients at that time. The current study was undertaken to utilize and test the Crumley classification for a clinical interrater comparison and, secondly, compare predicted with actual laryngeal electromyography (LEMG) results., Study Design: Descriptive study., Methods: Laryngoscopic and LEMG data of patients with unilateral vocal fold paralysis (VFP) of 6 months duration or longer were combined for retrospective evaluation. Forty-five data sets were available for laryngoscopic classification by two local laryngologists and by Roger Crumley. Twenty-three data sets with complete thyroarytenoid (TA) and posterior cricoarytenoid (PCA) - EMG data were used to compare predicted with actual LEMG results., Results: Local laryngologists were able to classify 24 of 45, Crumley 30 of 45 cases into one of the 4 synkinesis types. There was substantial agreement between examiners (Cohens Kappa 0.66 [P < .001]). Comparison of predicted and actual LEMG data showed only moderate agreement. EMG sykinesis rates were lower in TA than in PCA and highest in Crumley type I cases., Conclusion: The Crumley classification is helpful in describing and understanding synkinesis. It does not always correlate predictably with actual LEMG data. A complete LEMG mapping of all intrinsic muscles may improve understanding of chronic VFP., Level of Evidence: 4. Laryngoscope, 131:E1605-E1610, 2021., (© 2020 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Over the past decade, the use of neuromonitoring in thyroid surgery has become well established and is increasing accepted across the world. In addition, new developments in energy devices have significantly improved efficacy in achieving hemostasis in thyroid surgery. Few studies focused on the complication rates in energy device-assisted sutureless neuro-monitored thyroidectomy. This study investigates a novel LigaSure Small Jaw (LSJ) technique for sutureless thyroidectomy and compares the surgical complication rates between LSJ and conventional clamp-and-tie technique in one thousand consecutive neuro-monitored thyroidectomy patients. Five hundred patients received sutureless thyroidectomy performed with LSJ (Group L), and 500 patients received surgery performed with conventional clamp-and-tie technique (Group C). Complication rates of postoperative hematoma, hypocalcemia and recurrent laryngeal nerve (RLN) palsy were compared between groups. The overall complication rates of hematoma, hypocalcemia (temporary/ permanent), and RLN (temporary/ permanent) palsy were 0.9%, 24.9% (24.6%/0.3%), and 1.7% (1.5%/0.2%), respectively. Group L and Group C significantly differed in postoperative hematoma rate (0.0% vs. 1.8%, respectively; p = 0.0026) and in postoperative hypocalcemia rate (20.1% vs. 30.0%, respectively; p = 0.0032). The incidence of RLN palsy did not significantly differ between Group L and Group C (1.38% vs. 2.08%; p = 0.2652). The overall surgical complication rates are low in neuro-monitored thyroidectomy. The LSJ is feasible for performing completely sutureless thyroidectomy and obtains superior outcomes of postoperative hematoma and hypocalcemia in comparison with clamp-and-tie hemostatic technique. The novel LSJ technique using double or overlapped sealing is useful for sutureless thyroidectomy. However, surgeons must carefully observe the tissue contraction that may reduce the LSJ-RLN distance and increase the risk of thermal injury during the LSJ activation., Competing Interests: The authors declare 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 Liu, Wang, Wu, Lin, Lu, Chang, Lien, Wang, Hwang, Huang and Chiang.)

Objective: Recurrent laryngeal nerve injury is a potential complication of cardiothoracic surgery and cause of unilateral vocal fold paralysis (UVFP). Injection laryngoplasty (IL) is an intervention offered to patients with UVFP to alleviate symptoms including dysphagia, dysphonia and weak cough. There is no definitive evidence that IL prevents pneumonia. In this study, we compare rates of pneumonia in patients with UVFP secondary to cardiothoracic surgery who did or did not undergo IL., Methods: A retrospective chart review identified patients diagnosed with UVFP by an otolaryngologist using flexible laryngoscopy following cardiothoracic surgery from January 1, 2008 to December 31, 2017. Each subject was grouped by IL status and assessed for subsequent pneumonia within 6 months of their diagnosis of UVFP. The association of IL with pneumonia was evaluated using Cox proportional hazards regression., Results: Of 92 patients who met inclusion criteria, 35 (38%) underwent IL and 57 (62%) did not. Twenty patients developed pneumonia, four who had undergone IL and 16 who had not; 12 patients developed aspiration pneumonia including two having undergone IL and 10 who had not. Those who had IL were less likely to develop total pneumonia compared to those who had not (HR = 0.33, P  = .045). The protective effect of IL was not as clearly sustained when measuring for aspiration pneumonia, specifically (HR = 0.34; P  = .10)., Discussion: Injection laryngoplasty may reduce the risk of pneumonia in patients with UVFP secondary to cardiothoracic surgery; however, further research is needed to quantify the potential protective nature of IL in this patient population., Level of Evidence: 3 (A retrospective cohort study).

Biallelic variants in inorganic pyrophosphatase 2 (PPA2) are known to cause infantile sudden cardiac failure (OMIM #617222), but relatively little is known about phenotypic variability of these patients prior to their death. We report a 5-wk-old male with bilateral vocal cord paralysis and hypertension who had a sudden unexpected cardiac death. Subsequently, molecular autopsy via whole-genome sequencing from newborn dried blood spot identified compound heterozygous mutations in PPA2, with a paternally inherited, pathogenic missense variant (c.514G > A; p.Glu172Lys) and a novel, maternally inherited missense variant of uncertain significance (c.442A > T; p.Thr148Ser). This report expands the presenting phenotype of patients with PPA2 variants. It also highlights the utility of dried blood spots for postmortem molecular diagnosis., (© 2020 Sanford et al.; Published by Cold Spring Harbor Laboratory Press.)

Objective: This study investigated the reliability of body plethysmography in comparison to spirometry in objectively measuring upper airway functions., Methods: The study population consisted of 53 participants, 23 patients with BVFI after endolaryngeal laser posterior cordectomy and 30 healthy volunteers. All of them had body plethysmography (airway resistance, Raw), spirometry (ratio of forced expiratory flow at 50% to forced inspiratory flow at 50%, FEF 50 /FIF 50 and peak inspiratory flow, PIF), 6 min-walking-test (6MWT) and Medical Research Council (MRC) dyspnea scale measurements. The tests were repeated and reliability was evaluated using intraclass correlation (ICC) and Spearman correlation., Results: The reliability of Raw was high with ICC of 0.92, comparable to the spirometry measurements: FEF 50 /FIF 50 (ICC = 0.72) and PIF (ICC = 0.97). The mean of Raw was significantly higher in patient group. A strong significant correlation between Raw and MRC dyspnea scale (r = 0.79; p<0.05) and a moderate negative correlation between Raw and 6MWT (r = 0.4; p<0.05) was demonstrated., Conclusion: Body plethysmography (Raw) is a reliable tool in objective measurement of upper airway resistance that reflects the patient's perception of breathlessness. A larger number of participants are necessary to confirm this finding., Competing Interests: Declaration of Competing Interest The funding of this study was provided by the Fundamental Grant of Faculty of Medicine of Universiti Kebangsaan Malaysia., (Copyright © 2020. Published by Elsevier B.V.)

Objectives/hypothesis: This study explored the feasibility and efficiency of main branch of ansa cervicalis nerve (ACN)-to-recurrent laryngeal nerve (RLN) anastomosis for management of paroxysmal laryngospasm due to unilateral vocal cord paralysis (UVCP)., Methods: Thirteen patients who underwent main branch of ACN-to-RLN anastomosis for management of paroxysmal laryngospasm due to UVCP were enrolled in the present study. Multidimensional assessments, including videostroboscopy, voice assessment, and laryngeal electromyography (LEMG), were performed preoperatively and postoperatively., Results: This series was limited to UVCP with iatrogenic causes, including thyroidectomy, cervical spine surgery, and thoracic surgery. After main branch of ACN-to-RLN anastomosis, all cases showed significant airway improvement, and laryngospasm was completely abolished in 92.3% (12 of 13) of cases. Videostroboscopy showed that the bulging and paradoxical adduction of the affected vocal cord during a sniff were abolished immediately after operation, and there was no significant difference in vocal fold position or glottal closure before versus after the operation. LEMG showed that the postoperative recruitment and amplitude of voluntary motor unit potential in the affected thyroarytenoid muscle during a sniff were significantly decreased compared to preoperative values, and postoperative recruitment showed significant improvement during phonation compared to that preoperatively. Voice assessment showed that there were no significant differences in overall grade, roughness, breathiness, jitter (local), shimmer (local), noise-to-harmonics ratio, or maximum phonation time after the operation compared to the preoperative values., Conclusions: Main branch of ACN-to-RLN anastomosis could have long-lasting efficacy in the management of paroxysmal laryngospasm due to UVCP, with no apparent compromise of voice quality., Level of Evidence: 4 Laryngoscope, 130:2412-2419, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Idiopathic pleuroparenchymal fibroelastosis (IPPFE) is a generally slow-progressing rare disorder of unknown etiology. The direct cause of death in cases of IPPFE is rarely investigated. We experienced an autopsy case of a Japanese man with IPPFE and found aspiration pneumonia to be the major trigger of death. The individual had left vocal cord paralysis at admission, which may have contributed to aspiration pneumonia, and which probably was affected by the fibrous adhesion of the left apex of the chest wall resulting from IPPFE. The prevention of aspiration pneumonia is important for maintaining the respiratory function, especially in IPPFE patients with repeated pneumothorax.

Objectives: Unilateral vocal fold palsy (UVFP) is the commonest neurological laryngeal disorder. Much of the research have focused on its implication on voice, with limited data on its impact on swallowing. The aim of this paper is to examine the current evidence on the pathophysiology, impact and management of UVFP and swallowing., Methods: A literature search was conducted on the PubMed, MedLine, and Embase databases based on the keywords "unilateral vocal cord palsy" and "dysphagia" for this narrative review., Results: Dysphagia is common in UVFP. A safe and effective swallow is more than just glottic competence but coordination of complex events within the aerodigestive tract's sensory and motor systems. It is an important secondary outcome which has short- and long-term impact on our patient's quality of life. It should be managed in a multi-disciplinary manner to optimise patient's outcome., Conclusion: It is important to consider the disease, patient and surgical factors when deciding on the type and timing of management options. There is increasing evidence of benefits with early surgical interventions, challenging the traditional conservative management to rule out spontaneous recovery and compensation., Competing Interests: Declaration of Competing Interest No conflict of interest to declare., (Copyright © 2020. Published by Elsevier B.V.)

Objective: Spontaneous vocal recovery from idiopathic vocal fold paralysis (VFP) appears to differ in time course from recovery in iatrogenic VFP. This study aimed to determine if this difference could be explained by differing mechanisms causing recurrent laryngeal nerve (RLN) dysfunction, specifically whether idiopathic VFP is consistent with a focal RLN axonal lesion., Study Design: Case series with mathematical modeling., Methods: A review of 1267 cases of unilateral VFP over a 10-year period yielded 114 subjects (35 idiopathic, 79 iatrogenic) with a discrete onset of spontaneous vocal recovery. The time-to-recovery data were fit to a previously described two-phase model that incorporates the Seddon classification of neuropraxia and higher grades of axonal injury. Alternatively, the data were fit to a single phase model that does not assume a focal axonal lesion., Results: Time to vocal recovery in iatrogenic VFP can be reliably modeled by the assumption of a focal axonal lesion, with an early recovery group corresponding to neuropraxia and a late recovery group with more severe nerve damage. Time to recovery in idiopathic VFP can be more simply modeled in a single phase, with a time course that mirrors those in diverse biological processes such as transcription and microtubule growth., Conclusion: Idiopathic VFP may not be caused by a focal axonal lesion. Neuritis may be a compatible mechanism. The iatrogenic VFP data lend further support to the concept that the severity of RLN injury, not the length of axon to regenerate, is the chief determinant of recovery time after iatrogenic injury., Level of Evidence: 4 Laryngoscope, 130:1520-1524, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Rationale: Parkinson disease (PD) is a chronic neurodegenerative condition often suffered by the elderly. Upper airway obstruction, though rare in patients with PD, can be life threatening and is associated with vocal cord paralysis, laryngeal spasm, and dystonia of jaw and neck muscles., Patient Concerns: We describe a life-threatening upper airway obstruction caused by bilateral vocal cord paralysis, in an elderly man with PD, during extubation after general anesthesia., Diagnoses: Based on clinical presentation and visual laryngoscopy, the patient was diagnosed with laryngeal spasm and bilateral vocal cord paralysis after extubation., Interventions: Re-intubation was carried out and dopamine hydrazine tablets were administered via a nasal feeding tube., Outcomes: After re-intubation and further treatment, the endotracheal tube was successfully removed and no symptoms of respiratory distress were observed., Lessons: Patients with PD may be at a risk of life-threatening upper airway obstruction after extubation, which should be prevented systematically.

Vocal fold paralysis (VFP) is an important cause of respiratory and feeding compromise in infants. The causes of neonatal VFP are varied and include central nervous system disorders, birth-related trauma, mediastinal masses, iatrogenic injuries, and idiopathic cases. Bilateral VFP often presents with stridor or respiratory distress and can require rapid intervention to stabilize an adequate airway. Unilateral VFP presents more subtly with a weak cry, swallowing dysfunction, and less frequently respiratory distress. The etiology and type of VFP is important for management. Evaluation involves direct visualization of the vocal folds, with additional imaging and testing in select cases. Swallowing dysfunction, also known as dysphagia, is very common in infants with VFP. A clinical assessment of swallowing function is necessary in all cases of VFP, with some patients also requiring an instrumental swallow assessment. Modification of feeding techniques and enteral access for feedings may be necessary. Airway management can vary from close monitoring to noninvasive ventilation, tracheostomy, and laryngeal surgery. Long-term follow-up with otolaryngology and speech-language pathology service is necessary for all children with VFP to ensure adequate breathing, swallowing, and phonation. The short- and long-term health and quality-of-life consequences of VFP can be substantial, especially if not managed early., (Copyright © 2020 by the American Academy of Pediatrics.)

Objective: The purpose of this study was to examine measures of phonation quotient (PQ) in two groups of persons with voice disorders using three different aerodynamic instruments representing low-tech and high-tech options., Study Design: Prospective, repeated measures design., Methods: Two groups of patients with a diagnosis of vocal fold paralysis/paresis (n = 9) or benign vocal fold lesions (n = 8) were assessed for maximum phonation time and vital capacity obtained from three aerodynamic instruments: a hand-held analog windmill-type spirometer; a hand-held digital spirometer; and the Phonatory Aerodynamic System (PAS), Model 6600. PQ was calculated using vital capacity from each instrument along with maximum phonation time. Univariate ANOVAs were performed to test for the main effects of disorder and instrument on derived PQ. Paired samples t tests were performed post hoc to investigate any significant main effects. Pearson product-moment correlation was performed to assess measurement reliability (parallel forms) between the instruments., Results: Statistically significant differences were found for measures of PQ as a function of disorder but not instrument type. There was not a significant interaction effect between disorder and instrument type. Strong positive correlations were present between all three instruments for measures of PQ., Conclusions: PQ was sensitive to differences in airflow as a function of disorder etiology (paralysis/paresis vs benign lesions). This clinical measure of laryngeal function can be used as a low-cost substitute in the absence of a pneumotachograph. These results are consistent with previous literature reporting data from adult male and female speakers with normal voice quality, and support the use of low-tech options for measurement of basic aerodynamic variables associated with voice production., (Copyright © 2018 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Wide variation in postinjury functional recovery is a hallmark of unilateral vocal fold paralysis (UVFP), ranging from zero to full recovery. The present study examined the impact of cricothyroid (CT) muscle involvement on recovery using quantitative laryngeal electromyography (LEMG) of the thyroarytenoid-lateral cricoarytenoid (TA-LCA) muscle complex at multiple times postinjury., Study Design: Prospective cohort study in a medical center., Methods: Eighty-one patients with UVFP (37 males and 44 females) received an initial assessment of quantitative LEMG, stroboscope, acoustic voice analysis and 36-Item Short Form Survey quality-of-life questionnaire at 3 to 6 months after UVFP onset and a follow-up assessment at 12 months after UVFP onset., Results: The initial and follow-up assessments were performed at 4.3 ± 1.9 and 12.5 ± 1.3 months after UVFP onset, respectively. The peak turn frequency of the TA-LCA muscle complex on the lesion side was improved at the follow-up (470 ± 294 Hz) compared with the initial assessment (300 ± 204 Hz) (P < .001). Patients were also divided into two groups with (n = 27) and without (n = 54) CT involvement, respectively. TA-LCA muscle complex turn frequency improved in patients without CT involvement (from 277 ± 198 to 511 ± 301 Hz; P < .001), but not in those with CT involvement (from 345 ± 211 to 386 ± 265 Hz; P = .46). Seventy-one of all patients received early intervention with intracordal hyaluronate injection, showing similar therapeutic effects in those with and without CT involvement., Conclusions: Acute UVFP with combined TA-LCA muscle complex and CT muscle involvement has a poor prognosis, with poorer recovery of TA-LCA muscle complex recruitment. Early interventions should be considered in patients with UVFP with CT involvement., Level of Evidence: 2 Laryngoscope, 130:139-145, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Unilateral vocal fold paralysis (UVFP) induces hoarseness due to progressive atrophy of the denervated thyroarytenoid (TA) muscle. Therefore, treatments aimed at regenerating the atrophied TA muscle are required. Basic fibroblast growth factor (bFGF) is involved in muscle development and regeneration. This study aimed to elucidate the effects of bFGF injection on atrophied TA muscle., Study Design: Animal research., Methods: A recurrent laryngeal nerve-paralysis rat model was established, and low- (200 ng) or high-dose (2,000 ng) bFGF or saline (control) was injected into the TA muscle 28 days later. The larynges were excised on day 1, 3, 7, 14, and 28 after treatment. The cross-sectional area of the TA muscle in normal and paralyzed sides was compared, and the Ki67-positive (Ki67 + ) dividing cells, paired box 7-positive (Pax7 + ) satellite cells (SCs), and myogenic differentiation-positive (MyoD + ) myoblasts were counted., Results: The TA muscle area of animals administered high-dose bFGF increased with time and was significantly larger than that of the saline-injected controls 28 days after treatment (P < .05). The counts of Ki67 + and Pax7 + cells were the highest on day 1, whereas the MyoD + myoblast count was highest on day 7. These results suggest that bFGF administration into the denervated TA muscles compensated for the atrophied TA muscles by inducing proliferation of SCs and their differentiation to myoblasts., Conclusions: A single injection of high-dose bFGF augmented regeneration and differentiation of the atrophied TA muscle by enhancing proliferation and differentiation of muscle SCs, suggesting its possible clinical application in humans with UVFP., Level of Evidence: NA Laryngoscope, 130:159-165, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: Disorders of voice can limit an individual's participation and impair social interaction, thus affecting overall quality of life. Perceptual and objective evaluations can provide the clinician with detailed information regarding voice disorders., Methods: This study comprised 40 subjects aged 34-46 years, 20 of whom (10 male, 10 female) had unilateral vocal fold palsy. Data were obtained for all participants from: the Voice Handicap Index, the grade, roughness, breathiness, asthenia and strain ('GRBAS') scale, acoustic voice analysis, electroglottography, and voice range profiles., Results: The voice evaluations revealed statistically significant (p < 0.05) differences between the controls and study group, both in males and females, pre- and post-therapy., Conclusion: Despite the normalisation of vocal parameters, acoustic, perceptual and self-rated assessments revealed statistically significant differences after therapy. Hence, acoustic measures, namely electroglottographic perturbation, and voice frequency and intensity range, are recommended prior to termination of therapy.

Objectives: We describe a new procedure for aspiration called tubed supraglottoplasty (TS). TS is a transoral procedure that approximates the aryepiglottic (AE) folds and arytenoids. This narrows the laryngeal inlet. This procedure has been used to improve swallowing and reduce aspiration in patients with vocal fold paralysis. We describe the technical aspects of TS and report on 11 patients., Methods: TS is done by oral intubation followed by suspension laryngoscopy. An incision is made along the AE fold into the posterior commissure and then continued to the opposite AE fold. Dissection within this incision creates two mucosal flaps, one based on the laryngeal surface and the other on the pharyngeal surface. Two 1-cm releasing incisions are made at each end of the AE fold. The laryngeal mucosal flap is approximated using a 3-0 self-locking running suture. The pharyngeal mucosal flap is approximated as a second layer. This double-layered mucosal V-Y advancement flap builds up the posterior laryngeal height. It narrows and "tubes" the supraglottis., Results: All patients tolerated TS without airway complications. Ten of the 11 patients reported improved swallowing function with less aspiration. Six of the 8 patients with prior G-tubes had their gastrostomy tube removed. Postoperative laryngoscopy showed a narrowed "tubed" supraglottis with a higher posterior wall preventing spillover and aspiration. An improved Functional Oral Intake Scale was recorded in ten of eleven patients., Conclusion: TS is a minimally invasive procedure that can improve swallowing and reduce aspiration.