Preoperative Acetaminophen For Microsuspension Laryngoscopy Reduces Postoperative Opioid Use.

OBJECTIVES: The opioid crisis has prompted consideration of analgesic prescriptions. This study explored the value of preoperative acetaminophen for pain control following microsuspension laryngoscopy (MSL) and compared the results with a previous study of pain and opioid use following MSL (Tsang et al.). METHODS: A prospective open-label clinical trial was conducted in patients undergoing MSL. All patients were administered preoperative acetaminophen. Short-form McGill Pain Questionnaire (SF-MPQ), pain visual analogue scale (VAS), and present pain intensity (PPI) scores were collected preoperatively and on postoperative days (PODs) 1, 3, 7, and 14. Statistical analysis identified variables associated with opioid use or increased pain scores, and compared outcomes with Tsang et al. RESULTS: Eighty-nine patients were included (mean age 52.8 ± 17.3 years, 40 males). All patients received preoperative 1 g acetaminophen (77 (86.5%) orally) with no adverse effects. On POD1, opioid usage was 10%. Median [IQR] pain scores were 5 [2-11], 21 [12.3-56.8], and 3 [2-3.3] on SF-MPQ, VAS, and PPI, respectively. Post-Anesthesia Care Unit (PACU) opioid requirements significantly correlated with POD1 opioid consumption (τb = 0.214; p ≤ 0.05), and significant associations with PACU opioid administration were found for total anesthesia time (OR (95%CI) = 1.271 (1.043-1.548), p = 0.017) and total laryngoscope suspension time (OR (95%CI) = 0.791 (0.651-0.962, p = 0.019)). This cohort demonstrated reduced opioid usage on POD1 compared with Tsang et al (23%). CONCLUSIONS: Preoperative acetaminophen is a safe intervention, resulting in decreased postoperative opioid use following MSL. Anesthesia time correlated with need for postoperative opioids. LEVEL OF EVIDENCE: Level 4 Laryngoscope, 2024.

Surgical Nonresponders in Zenker Diverticulum and Lower Esophageal Pathology (POUCH Collaborative).

OBJECTIVE: To identify characteristics of patients who have poor improvement in symptoms following surgical management of Zenker Diverticulum (ZD). METHODS: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgical repair of ZD between August 2017 and January 2024. Patient demographics, esophagrams, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were obtained from a REDCap database. t-tests, Wilcoxon rank sum tests, Chi-square or Fisher's exact tests were used to compare the characteristics. Patients with <50% improvement in their EAT-10 scores were deemed surgical nonresponders (SNRs). Those with ≥50% improvement in their EAT-10 scores were deemed surgical responders (SRs). RESULTS: A total of 184 patients were prospectively followed after undergoing either open or endoscopic surgical management. Twenty-two patients (12%) were deemed SNRs. Preoperative presence of a hiatal hernia was statistically significant characteristic between the SNRs (63.6%) and SRs (32.1%) (p = 0.004). Size of the ZD and history of previous ZD surgery was not a significant characteristic. The length of stay and complication rate were not statistically different between the groups. CONCLUSION: Coexistent esophageal pathology may lead to poor symptomatic improvement following ZD surgery. Preoperative workup of other esophageal disorders is recommended to detect likely SNRs. For SNRs, further esophageal workup may be necessary to evaluate for other esophageal causes related to poor symptomatic improvement following ZD surgery. LEVEL OF EVIDENCE: Level 3 Laryngoscope, 2024.

Medicare Restriction of Telehealth Speech Services Negatively Impacts Patient Care.

OBJECTIVE: Ample literature shows voice and swallowing therapy, in-person or virtual, to be essential for Otolaryngology and Speech-Language Pathology care. In March 2023, Medicare announced discontinuing teletherapy reimbursement in hospital-based outpatient departments, effective May 2023. This decision was subsequently reversed; however, the uncertain interval period provided the opportunity to study the impact of eliminating teletherapy. STUDY DESIGN: Prospective cohort. SETTING: Tertiary laryngology center. METHODS: Affected Medicare patients were contacted via mailed letter, phone, and secure patient portal and offered to change appointments to in-person, teletherapy with cash self-payment ($165-282/session) or cancellation. Demographics and responses were collected. Statistical analyses conducted using Student's t test. RESULTS: Fifty-three patients (28 female; mean age 66.8 ± 14.2 years) were impacted. 64% (n = 34) changed to in-person appointment, 28% (n = 15) canceled, 8% (n = 4) did not respond. No patients opted to self-pay. 67% of patients that canceled telehealth care cited distance from in-person care location. The mean distance for canceled versus rescheduled patients was 92.3 ± 93.0 versus 32.8 ± 57.4 miles, P = .034. Mean age, gender, and number of sessions were not different between groups. Mean time to third next available therapy appointment was 96 ± 46 versus 46 ± 12 days before and after rule change, P = .007. Upon Medicare's reversal, this trend rebounded to nearly baseline (mean 77 ± 12 days, P = .12). CONCLUSION: Medicare's discontinuation of reimbursement for teletherapy services caused nearly 30% of patients to cancel voice and swallowing therapy, primarily due to distance. These cancellations led to decreased access to care for Medicare patients with voice/swallowing diagnoses, which affect function, quality of life, and potentially even mortality risk.

Technical Challenges for Laryngeal Electromyography.

BACKGROUND/OBJECTIVE: Laryngeal electromyography (LEMG) is a useful diagnostic test in the evaluation of vocal fold paralysis (VFP). This study investigates factors that can make LEMG challenging to perform. METHODS: Patients with subacute unilateral VFP presented for LEMG were prospectively enrolled. Demographic data including BMI, previous neck surgery, and anatomic factors were collected. Patient-reported pain related to the procedure was recorded on a visual analogue scale (VAS). Electromyographer and otolaryngologist recorded a consensus rating of the perceived difficulty in performing the test and confidence in using the results for clinical decision-making. RESULTS: A total of 111 patients (56.8% female) were enrolled between August 2015 and August 2018. The mean age was 55 ± 14 years, and the average body mass index (BMI) was 28.5 ± 6.4. The mean patient-reported VAS score for pain was 35 ± 24. Notably, 31.2% of the tests were considered "very easy," 32.1% were considered "mildly challenging" and 23.9% and 12.8% were considered "moderately challenging" and "extremely challenging," respectively, by the clinicians. Common factors affecting LEMG difficulty included poorly palpable surface anatomy (50.5%) and patient intolerance (15.6%). Clinicians felt confident in 76.1% of the test findings. Bivariate analyses showed that prior neck surgery is associated with elevated VAS (p = 0.02), but clinician-perceived difficulty of performing the test is not associated with elevated VAS scores (p = 0.55). CONCLUSIONS: Majority of LEMG tests are well tolerated by patients. Physicians reported more confidence using LEMG for clinical decision-making when the test was easier to perform. Difficult surface anatomy and patient intolerance affects clinician confidence in integrating the test results with clinical care. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:831-834, 2024.

Surgical Outcomes in Zenker Diverticula: A Multicenter, Prospective, Longitudinal Study.

OBJECTIVE: To compare improvement in patient-reported outcomes (PROM) in persons undergoing endoscopic and open surgical management of Zenker diverticula (ZD). METHODOLOGY: Prospective, multicenter cohort study of all individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative who underwent surgery for ZD. Patient survey, radiography reports, and the 10-item Eating Assessment Tool (EAT-10) pre- and post-procedure were abstracted from a REDCap database, which summarized means, medians, percentages, and frequencies of. Outcome based on operative intervention (endoscopic vs. open) was compared using t-test, Wilcoxon rank sum test or chi-square test, as appropriate. RESULTS: One hundred and forty-seven persons were prospectively followed. The mean age (SD) of the cohort was 68.7 (11.0). Overall, 66% of patients reported 100% improvement in EAT-10; 81% of patients had greater than 75% improvement; and 88% had greater than 50% improvement. Endoscopic was used for n = 109 patients, and open surgical intervention was used for n = 38. The median [interquartile range, IQR] EAT-10 percent improvement for endoscopic treatment was 93.3% [72, 100], and open was 100% [92.3, 100] (p = 0.05). The incidence of intraoperative complications was 3.7% for endoscopic and 7.9% for open surgical management. The median [IQR] in follow-up was 86 and 97.5 days, respectively. CONCLUSION: Both endoscopic and open surgical management of ZD provide significant improvement in patient-reported outcomes. The data suggest that open diverticulectomy may provide a modest advantage in symptomatic improvement compared to endoscopic management. The data suggest that the postoperative complication rate is higher in the open surgical group. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:97-102, 2024.

Postoperative Care of Zenker Diverticula: Contemporary Perspective from the Prospective OUtcomes Cricopharyngeaus Hypertonicity (POUCH) Collaborative.

OBJECTIVES: The aim of the study was to identify trends in postoperative management of persons undergoing surgery for Zenker diverticula (ZD) by evaluating length of stay (LOS), diet on discharge, and imaging with or without surgical complication. METHODS: Prospectively enrolled adult patients with cricopharyngeal muscle dysfunction with diverticula undergoing surgery from August 1, 2017 to February 1, 2023 were included. Data were extracted from a multi-institutional REDCap database, summarizing means, medians, percentages, and frequencies. Fisher's exact or chi squared analyses were utilized, as appropriate, to compare subsets of data. Descriptive analysis assessed differences in clinical course and the relationship to postoperative management. RESULTS: There were 298 patients with a mean (standard deviation) age of 71.8 (11.2) years and 60% male. Endoscopic surgery was performed in 79.5% (237/298) of patients versus 20.5% (61/298) open surgery. Sixty patients (20.1%) received postoperative imaging, with four leaks identified. Complications were identified in 9.4% of cases (n = 29 complications in 28 patients), more commonly in open surgery. Most (81.2%) patients were discharged within 23 h. About half of patients (49%) were discharged from the hospital on a pureed/liquid diet; 36% had been advanced to a soft diet. In patients without complications, LOS was significantly longer following open cases (p = 0.002); postoperative diet was not different between open and endoscopic (p = 0.26). CONCLUSIONS: Overall, most patients are discharged within 23 h without imaging. However, LOS was affected by surgical approach. Postoperative complications are different in endoscopic versus open surgery. Complications with either approach were associated with prolonged LOS, need for imaging, and diet restriction. LEVEL OF EVIDENCE: Level III Laryngoscope, 134:2678-2683, 2024.

Clinician accuracy in identifying essential laryngeal landmarks on swallowing fluoroscopy.

Objective: Identification of anatomical landmarks is essential for interpretation of video fluoroscopic swallow studies (VFSS). This investigation sought to confirm the location of essential laryngeal landmarks and determine clinician accuracy in structure identification on VFSS. Methods: A single human cadaver was used to generate unmarked standard lateral and anterior-posterior (AP) fluoroscopic images. Essential laryngeal structures (e.g., true vocal fold, arytenoid) were directly identified using a guidewire placed through an endoscope while obtaining corresponding marked fluoroscopic images. Licensed clinicians (speech-language pathologists [SLP], laryngologists) and trainees (otolaryngology residents, SLP clinical fellows [CF]) identified 18 structures (9 lateral, 9 AP) on unmarked images. Answers were compared to corresponding marked images. The percentage of accurate identification was calculated for each clinician and then compared between groups using t-tests. Results: Twenty-four individuals (10 SLPs, 1 CF, 9 residents, 4 laryngologists) from six institutions completed structure identification. Mean overall accuracy was 41.7 ± 13.0% (range 18.8-68.8%). There were no significant differences in mean overall accuracy between trainees (41.9 ± 12.9%) and clinicians (42.0 ± 13.1%), p = .97, or between SLPs (45.5 ± 12.8%) and physicians (38.9 ± 12.3%), p = .22. On average, participants were significantly more accurate identifying structures on lateral view (53.1 ± 16.1%) than AP (27.3 ± 22.8%), p < .001. Less than half of participants accurately identified the laryngeal ventricle, cricoid, epiglottic petiole, and the anterior commissure on lateral view. Conclusions: The ability of certified clinicians and trainees to correctly identify essential anatomic landmarks on swallowing fluoroscopy may be poor. Future work is needed to identify how we can train clinicians on more accurate identification of essential anatomic structures on swallowing fluoroscopy.Level of Evidence: NA.

Assessment of Patients Receiving Short-Interval Botulinum Toxin Chemodenervation Treatment for Laryngeal Dystonia and Essential Tremor of the Vocal Tract.

Importance: The gold-standard treatment for laryngeal dystonia (LD) and essential tremor of the vocal tract (ETVT) is botulinum toxin (BoNT) chemodenervation. Although safe and effective, it is not curative, and periodic injections are required. Some medical insurance companies only cover injections at a 3-month interval, though some patients benefit from injections more frequently. Objective: To determine the proportion and characteristics of patients who receive BoNT chemodenervation treatment in intervals shorter than 90 days. Design, Setting, and Participants: This retrospective cohort study across 3 quaternary care neurolaryngology specialty practices in Washington and California recruited patients who underwent at least 4 consecutive laryngeal BoNT injections for LD and/or ETVT in the past 5 years. Data were collected from March through June 2022 and analyzed from June through December 2022. Exposure: Laryngeal BoNT treatment. Main Outcomes and Measures: Biodemographic and clinical variables, injection characteristics, evolution during the 3 interinjection intervals, and lifetime laryngeal BoNT treatment data were collected from patient medical records. Logistic regression was used to assess association to the short-interval outcome, defined as an average injection interval shorter than 90 days. Results: Of 255 patients included from the 3 institutions, 189 (74.1%) were female, and the mean (SD) age was 62.7 (14.3) years. The predominant diagnosis was adductor LD (n = 199 [78.0%]), followed by adductor dystonic voice tremor (n = 26 [10.2%]) and ETVT (n = 13 [5.1%]). Seventy patients (27.5%) received short-interval injections (<90 days). The short-interval group was younger than the long-interval group (≥90 days), with a mean (SD) age of 58.6 (15.5) years and 64.2 (13.5) years, respectively, and a mean difference of -5.7 years (95% CI, -9.6 to -1.8 years). There were no patient-related differences between the short- and long-interval groups in terms of sex, employment status, or diagnosis. Conclusions and Relevance: This cohort study demonstrated that while insurance companies often mandate a 3-month or greater interval for BoNT chemodenervation financial coverage, there is a considerable subset of patients with LD and ETVT who receive short-interval treatment to optimize their vocal function. Short-interval chemodenervation injections demonstrate a similar adverse effect profile and do not appear to predispose to resistance through antibody formation.

Variations in Practices and Preferences of Vocal Fold Injection Materials: A National Survey.

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

Comparison of Outcome Measures (Subjective, Objective, and Patient-Based) in Laryngeal Dystonia Treatment With Botulinum Toxin A Injection.

BACKGROUND: Outcome assessment in laryngeal dystonia is hindered by lack of consensus on a core set of outcome measures to quantify treatment effect and disease severity on quality of life. Potential outcome measure domains include objective voice, clinician reported, and patient reported outcome measures (PROMs) for determining treatment success and longitudinal disease tracking. We aim to determine correlations between a selections of outcome measure tools following Botulinum toxin injection. METHODS: A selection of instruments were administered to assess adductor laryngeal dystonia patient outcomes before and after Botulinum toxin injection. Voice samples recorded using a cellular telephone application were used for objective acoustic measures (CPPS, acoustic voice quality index) and speech language pathologist perceptual analysis (CAPE-V). Additionally, patients completed a PROMs battery consisting of the Voice Handicap Index-10, Communicative Participation Item Bank-10, OMNI-Vocal Effort Scale, 3 visual analog scale (VAS) questions. Changes in these outcome measures pre-post treatment were compared between each other and with a global rating of change questionnaire (GRCQ) using Spearman's rank correlation coefficients. RESULTS: Twenty six patients (20 female, mean age 57.7 years) participated. Using an anchor based GRCQ, patients reported Botox efficacy was the only outcome measure found to have significant correlation (r = 0.54, P = 0.022); all other outcome measures did not meet statistically significant correlation. Amongst the selected outcome tools, several moderate-strong correlations were identified, largely for outcome measures within the same domain. Most notable were correlations between the patient reported OMNI-VES and VAS questions (r > 0.68, P < 0.05), clinician CAPE-V strain and overall severity (r = 0.900, P < 0.001), and acoustic voice quality index with sustained vowel CPPs (r = -0.797, P = 0.002). CONCLUSION: Correlation between outcome measures instruments used for patients with adductor laryngeal dystonia requires further attention. Weak correlations with an anchor based GRCQ were found for this study's selected outcome instruments. A select number of correlations were found between outcome instruments within each of the individual outcome measure domains (patient perception, clinical perception, objective acoustics), but there was largely a lack of correlation found for instruments between these three separate domains.

Presumptive Diagnosis in Tele-Health Laryngology: A Multi-Center Observational Study.

OBJECTIVES: Early in the COVID-19 pandemic, outpatient visits were adapted for the virtual setting, forcing laryngologists to presume certain diagnoses without the aid of laryngoscopy, solely based on history and the limited physical exam available via video visit. This study aims to examine the accuracy of presumptive diagnoses made via telemedicine, compared to subsequent in-person follow up, where endoscopic examination could confirm or refute suspected diagnoses. METHODS: A retrospective chart review was conducted of 38 patients evaluated for voice-related issues at NYU Langone Health and the University of California-San Francisco. Presumptive diagnoses at the initial telemedicine encounter were noted, along with diagnostic cues used for clinical reasoning and recommended treatment plans. These presumptive diagnoses were compared to diagnoses and plans established following laryngoscopy at follow-up in-person visits. RESULTS: After laryngoscopy at the first in-person visit, 38% of presumptive diagnoses changed, as did 37% of treatment plans. The accuracy varied among conditions. Muscle tension dysphonia and Reinke's edema were accurately diagnosed without laryngoscopy, but other conditions, including vocal fold paralysis and subglottic stenosis, were not initially suspected, relying on laryngoscopy for diagnosis. CONCLUSIONS: While some laryngologic conditions may be reasonably identified without in-person examination, laryngoscopy remains central to definitive diagnosis and treatment. Telemedicine can increase access to care, but it may provide more utility as a screening tool, triaging which patients should present more urgently for in-person laryngoscopy. LEVEL OF EVIDENCE: 4.

Gender-Affirming Voice Surgery: Considerations for Surgical Intervention.

The purpose of this article is to provide an overview of the current state and available evidence surrounding surgical voice care for the transgender and/or gender expansive population. The term "gender expansive" has been proposed as an inclusive term to classify those who do not identify with traditional gender roles but are otherwise not confined to one gender narrative or experience. We aim to review indications and candidacy for surgery, surgical procedure options for altering vocal pitch, and typical postoperative expectations. The role of voice therapy and considerations for perioperative care will also be discussed.

Assessment of Laryngeal Sensory Function using a Tactile Aesthesiometer in Healthy Adults.

INTRODUCTION: Laryngeal sensory function in healthy adults was assessed through the delivery of tactile stimuli using Cheung-Bearelly monofilaments. METHODS: 37 healthy adults were recruited with 340 tactile stimuli analyzed. Four calibrated tactile stimuli were delivered to three laryngeal sites: false vocal fold (FVF), aryepiglottic fold (AEF), and lateral pyriform sinus (LPS). Primary outcome was the elicitation of laryngeal adductor reflex (LAR). Secondary outcomes were gag, patient-reported laryngeal sensation (PRLS), and perceptual strength. Analysis was performed with mixed effects logistic regression modeling. RESULTS: Positive LAR was observed in 35.7%, 70.2%, and 91.2% of stimuli at LPS, AEF, and FVF respectively. LAR rates were significantly associated with laryngopharyngeal subsite (p < 0.001), tactile force (p = 0.001), age (p = 0.022) and sex (p = 0.022). LAR, gag, PRLS, and perceptual strength significantly increased as a more medial laryngeal subsite was stimulated and as stimulus force increased. Each of the ten years of age increase was associated with 19% reduction in odds of LAR (aOR = 0.81, 95% CI [0.68, 0.97]; p = 0.022). Male gender was associated with a 55% reduction in odds of LAR (aOR = 0.45, 95% CI [0.23, 0.89]; p = 0.022). CONCLUSION: LAR elicitation capability decreases in the male gender, aging, and a more lateral subsite. This study provides insight into the pathophysiology of hypo- and hyper-sensitive laryngeal disorders and is paramount to making accurate diagnostic assessments and finding novel treatment options for various laryngological disorders. Laryngoscope, 133:2525-2532, 2023.

Laryngeal Mucous Membrane Pemphigoid as an Immune-related Adverse Effect of Pembrolizumab Treatment.

Pembrolizumab is an immune checkpoint inhibitor (ICI) approved for multiple indications in a variety of malignancies. Although generally well tolerated, the potential for significant adverse effects, specifically immune related adverse effects (irAEs) needs to be taken into consideration. Several cases of bullous pemphigoid have been reported as a cutaneous adverse effect of ICIs since 2015, and there are recent reports of mucous membrane pemphigoid (MMP). We present the case of an 84-year-old male with metastatic urothelial carcinoma on treatment with pembrolizumab, who developed laryngeal mucous membrane pemphigoid as an irAE. The diagnosis was based on patient's clinical history and serologic testing, and supported by symptomatic improvement after ICI discontinuation and immunosuppression. Pembrolizumab-induced MMP is a newly described and infrequent irAE, requiring early suspicion and close monitoring for its diagnosis and management.

Stabilization of Recurrent Respiratory Papillomatosis with Pembrolizumab Therapy: A Case Report.

Recurrent respiratory papillomatosis (RRP) is a benign neoplastic disease of the respiratory tract that is caused by human papilloma virus (HPV). The current standard of care is surgical excision with adjuvant treatment as needed. Multiple adjuvant treatments have been used with some success, but long-term control of disease remains difficult. We report on a case of a patient with a long history of RRP who had stabilized true vocal fold disease while on pembrolizumab for concurrent early stage lung squamous cell carcinoma.

Intrinsic Laryngeal Muscle Activity During Subvocalization.

PURPOSE: Subvocalization, the low-grade activity of speech articulator muscles while thinking or reading, may mediate phonological representations of verbal material. However, no literature exists that directly measures whether intrinsic laryngeal muscles (ILMs) are active during subvocalization. The possibility of ILM activation during subvocalization has implications for establishing appropriate baselines when experimental conditions involve linguistic features. METHOD: In two separate studies, forty-five cisgender women completed one or two silentsil tasks (two in the first study, Experiments 1a and 1b, and one in the second, Experiment 2). Fine wire electromyography was used to directly measure ILM activity during an at-rest baseline and silent tasks used to determine whether subvocalization occurred (referred to hereafter as "subvocalization tasks"). Other muscles were measured via surface electromyography: submental muscle in Experiments 1a and 1b, anterior tibialis in Experiment 2, and upper trapezius in all experiments. RESULTS: Interrupted time-series analysis was used to directly measure changes in ILM activity from baseline to the subvocalization tasks. A paired two tailed t-test was used to measure mean differences in ILM activity across conditions for each participant. Some individuals displayed statistically significant increases from baseline during subvocalization tasks, whereas others displayed decreases. Cohen's d was used to calculate the effect size for each muscle across the three subvocalization conditions. Of the 21 muscles measured across three experiments, five yielded a small mean effect size, and the effect sizes for the remaining 16 muscles were negligible. At a group level, only the right cricothyroid showed statistically significant changes (Experiment 1b). CONCLUSION: The ILM responses during subvocalization vary in both magnitude and direction. Most but not all changes can be described as negligible. For future studies of ILM activity during conditions that involve linguistic processing, investigators should consider the idiosyncratic variation during subvocalization when determining the most appropriate baseline task.

Killian Jamieson Diverticulum, the Great Mimicker: A Case Series and Contemporary Review.

OBJECTIVE: To assess barium esophagram (BAS) as a diagnostic marker for patients with Killian Jamieson diverticula (KJD). METHODS: Prospective, multicenter cohort study of individuals enrolled in the Prospective OUtcomes of Cricopharyngeus Hypertonicity (POUCH) Collaborative. Patient demographics, comorbidities, radiographic imaging reports, laryngoscopy findings, patient-reported outcome measures (PROM), and operative reporting were abstracted from a REDCap database and summarized using means, medians, percentages, frequencies. Paired t-tests and Wilcoxon Signed Rank test were used to test pre- to post-operative differences in RSI, EAT-10, and VHI-10 scores. Diagnostic test evaluation including sensitivity, specificity, positive, and negative predictive value with 95% confidence intervals were calculated comparing BAS findings to operative report. RESULTS: A total of 287 persons were enrolled; 13 (4%) patients were identified with confirmed KJD on operative reports. 100% underwent open transcervical excision. BAS has a 46.2% (95% confidence interval [CI]: 23.2, 70.9) sensitivity and 97.8% (95% CI: 95.3, 99.0) specificity in detecting a KJD and 50% (95% CI: 25.4, 74.6) positive predictive value but 97.4% (95%CI: 94.8, 98.7) negative predictive value. Preoperatively, patients reported mean (SD) RSI and EAT-10 of 19.4 (9) and 8.3 (7.5) accordingly. Postoperatively, patients reported mean (SD) RSI and EAT-10 as 5.4 (6.2) and 2.3 (3.3). Both changes in RSI and EAT-10 were statistically significant (p = 0.008, p = 0.03). CONCLUSION: KJD are rare and represent <5% of hypopharyngeal diverticula undergoing surgical intervention. Open transcervical surgery significantly improves symptoms of dysphagia. BAS has high specificity but low sensitivity in detecting KJD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2110-2115, 2023.

An Ex Vivo Investigation of Tactile Aesthesiometer Force in Laryngopharyngeal Sensory Testing.

BACKGROUND/OBJECTIVE: Cheung-Bearelly aesthesiometers can deliver buckling-force stimuli to the laryngopharynx and objectively evaluate sensation. Ambiguity surrounds the transformation of stimuli in the laryngopharyngeal environment. This study aims to evaluate the effect of aesthesiometer size, saliva, successive compressions, and angles of tissue contact on stimulus force delivered. METHODS: An ex vivo stimulus delivery device was constructed to measure the buckling force of aesthesiometers. Dry and saliva-saturated aesthesiometers (6-0, 5-0, 4.5-0, and 4-0) were each compressed six times on cadaveric buccal mucosa on an electronic balance. The force for each compression was recorded at 0, 15, 30, 45, and 60° from the vertical plane. 240 compressions were analyzed utilizing a mixed-effects statistical model. RESULTS: The mean force delivered by the 6-0, 5-0, 4.5-0, and 4-0 aesthesiometers were 0.017, 0.082, 0.120, and 0.268 g respectively (p < 0.001). Mean force significantly reduced for the 4-0 aesthesiometer at 30° (p = 0.003) and 60° (p = 0.001). Force decreased by the 4th compression for the 5-0 aesthesiometer (p = 0.004) and after one compression for the 4.5-0 (p = 0.004) and 4-0 (p < 0.001) aesthesiometer. By the 4th compression, the 4.5-0 aesthesiometer was indistinguishable (p > 0.05) from the 5-0 aesthesiometer. The effect of saliva was insignificant (p = 0.83). CONCLUSION: Aesthesiometers can deliver discrete buckling-force stimuli to evaluate laryngopharynx sensory function. Up to 60° (15° for 4-0 aesthesiometer) deviation from orthogonal tissue contact and salivary forces do not significantly alter force delivered. 4.5-0 aesthesiometers should be exchanged after three compressions. For all other aesthesiometers, force reduction after six compressions is likely clinically insignificant given current laryngopharyngeal sensory testing protocols. LEVEL OF EVIDENCE: N/A Ex Vivo Laboratory Design Laryngoscope, 133:1933-1937, 2023.

Abnormal Laryngopharyngeal Sensation in Adductor Laryngeal Dystonia Compared to Healthy Controls.

BACKGROUND/OBJECTIVES: Laryngeal sensory abnormality has been implicated as a component of adductor laryngeal dystonia (AdLD). The study objective was to assess laryngopharyngeal sensation in AdLD utilizing a calibrated, tactile aesthesiometer to deliver differential stimuli to lateral pyriform sinus (LPS), aryepiglottic fold (AEF), and false vocal fold (FVF). METHODS: Patients with known Botox-responsive AdLD underwent sensory testing using a previously-validated methodology involving calibrated tactile stimuli (6-0, 5-0, 4.5-0, 4-0 nylon monofilaments). Laryngeal adductor reflex (LAR) and participant-rated perceptual strength of stimulI were evaluated. Responses were compared to normative controls (n = 33). Two-samples, Mann-Whitney and Fisher exact tests compared mean strength ratings and LAR between AdLD and control groups. Mixed-effects logistic regression and linear models assessed association of filament size, stimulus site, age, sex, and LD status on LAR and perceptual strength rating respectively. RESULTS: Thirteen AdLD patients (nine women, mean age 60+/-15 years) completed testing. Average LAR response rates were higher amongst all filament sizes in AdLD versus controls at LPS (56.3% vs. 35.7%) and AEF (96.1% vs. 70.2%) with comparable rates at FVF (90.2% vs. 91.7%). AdLD had 3.3 times the odds of observed LAR compared to controls (p = 0.005), but differences in subjective detection of stimuli, perceptual strength ratings, and cough/gag rates were insignificant on multivariate modeling (p > 0.05). CONCLUSIONS: This is the first study to objectively assess laryngopharyngeal sensation in AdLD. Findings demonstrated increased laryngopharyngeal sensation in AdLD compared to controls. The identification of increased laryngeal hypersensitivity in these patients may improve understanding of AdLD pathophysiology and identify future targets for intervention. LEVEL OF EVIDENCE: 2 Laryngoscope, 133:2271-2278, 2023.