A Scoping Review of Artificial Intelligence Detection of Voice Pathology: Challenges and Opportunities.

OBJECTIVE: Survey the current literature on artificial intelligence (AI) applications for detecting and classifying vocal pathology using voice recordings, and identify challenges and opportunities for advancing the field forward. DATA SOURCES: PubMed, EMBASE, CINAHL, and Scopus databases. REVIEW METHODS: A comprehensive literature search was performed following the Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews guidelines. Peer-reviewed journal articles in the English language were included if they used an AI approach to detect or classify pathological voices using voice recordings from patients diagnosed with vocal pathologies. RESULTS: Eighty-two studies were included in the review between the years 2000 and 2023, with an increase in publication rate from one study per year in 2012 to 10 per year in 2022. Seventy-two studies (88%) were aimed at detecting the presence of voice pathology, 24 (29%) at classifying the type of voice pathology present, and 4 (5%) at assessing pathological voice using the Grade, Roughness, Breathiness, Asthenia, and Strain scale. Thirty-six databases were used to collect and analyze speech samples. Fourteen articles (17%) did not provide information about their AI model validation methodology. Zero studies moved beyond the preclinical and offline AI model development stages. Zero studies specified following a reporting guideline for AI research. CONCLUSION: There is rising interest in the potential of AI technology to aid the detection and classification of voice pathology. Three challenges-and areas of opportunities-for advancing this research are heterogeneity of databases, lack of clinical validation studies, and inconsistent reporting.

Parosteal Lipoma Overlying an Osteochondroma of the Hyoid Bone: A Case Report and Literature Review.

Parosteal lipomas and osteochondromas of the head and neck are uncommon benign tumors, constituting a small fraction of lipoma and bone tumor cases. We present a unique case of a 66-year-old male with a parosteal lipoma overlying an osteochondroma in the anterior midline neck, causing dysphagia. Surgical excision confirmed the diagnosis, and a literature review revealed similar cases predominantly adjacent to the mandible or calvaria. This case emphasizes the need to have parosteal lipoma and osteochondroma on the differential diagnosis for patients presenting with a firm mass of the central neck, especially with a history of trauma. Laryngoscope, 2023.

End-to-end deep learning classification of vocal pathology using stacked vowels.

Objectives: Advances in artificial intelligence (AI) technology have increased the feasibility of classifying voice disorders using voice recordings as a screening tool. This work develops upon previous models that take in single vowel recordings by analyzing multiple vowel recordings simultaneously to enhance prediction of vocal pathology. Methods: Voice samples from the Saarbruecken Voice Database, including three sustained vowels (/a/, /i/, /u/) from 687 healthy human participants and 334 dysphonic patients, were used to train 1-dimensional convolutional neural network models for multiclass classification of healthy, hyperfunctional dysphonia, and laryngitis voice recordings. Three models were trained: (1) a baseline model that analyzed individual vowels in isolation, (2) a stacked vowel model that analyzed three vowels (/a/, /i/, /u/) in the neutral pitch simultaneously, and (3) a stacked pitch model that analyzed the /a/ vowel in three pitches (low, neutral, and high) simultaneously. Results: For multiclass classification of healthy, hyperfunctional dysphonia, and laryngitis voice recordings, the stacked vowel model demonstrated higher performance compared with the baseline and stacked pitch models (F1 score 0.81 vs. 0.77 and 0.78, respectively). Specifically, the stacked vowel model achieved higher performance for class-specific classification of hyperfunctional dysphonia voice samples compared with the baseline and stacked pitch models (F1 score 0.56 vs. 0.49 and 0.50, respectively). Conclusions: This study demonstrates the feasibility and potential of analyzing multiple sustained vowel recordings simultaneously to improve AI-driven screening and classification of vocal pathology. The stacked vowel model architecture in particular offers promise to enhance such an approach. Lay Summary: AI analysis of multiple vowel recordings can improve classification of voice pathologies compared with models using a single sustained vowel and offer a strategy to enhance AI-driven screening of voice disorders. Level of Evidence: 3.

Factors Associated With Otolaryngologists Performing Tracheotomy.

Importance: Tracheotomies are frequently performed by nonotolaryngology services. The factors that determine which specialty performs the procedure are not defined in the literature but may be influenced by tracheotomy approach (open vs percutaneous) and other clinicodemographic factors. Objective: To evaluate demographic and clinical characteristics associated with tracheotomies performed by otolaryngologists compared with other specialists and to differentiate those factors from factors associated with use of open vs percutaneous tracheotomy. Design, Setting, and Participants: This multicenter, retrospective cohort study included patients aged 18 years or older who underwent a tracheotomy for cardiopulmonary failure at 1 of 8 US academic institutions between January 1, 2013, and December 31, 2016. Data were analyzed from September 2022 to July 2023. Exposure: Tracheotomy. Main Outcomes and Measures: The primary outcome was factors associated with an otolaryngologist performing tracheotomy. The secondary outcome was factors associated with use of the open tracheotomy technique. Results: A total of 2929 patients (mean [SD] age, 57.2 [17.2] years; 1751 [59.8%] male) who received a tracheotomy for cardiopulmonary failure (652 [22.3%] performed by otolaryngologists and 2277 [77.7%] by another service) were analyzed. Although 1664 of all tracheotomies (56.8%) were performed by an open approach, only 602 open tracheotomies (36.2%) were performed by otolaryngologists. Most tracheotomies performed by otolaryngologists (602 of 652 [92.3%]) used the open technique. Multivariable regression analysis revealed that self-reported Black race (odds ratio [OR], 1.89; 95% CI, 1.52-2.35), history of neck surgery (OR, 2.71; 95% CI, 2.06-3.57), antiplatelet and/or anticoagulation therapy (OR, 1.74; 95% CI, 1.29-2.36), and morbid obesity (OR, 1.54; 95% CI, 1.24-1.92) were associated with greater odds of an otolaryngologist performing tracheotomy. In contrast, history of neck surgery (OR, 1.36; 95% CI, 0.96-1.92), antiplatelet and/or anticoagulation therapy (OR, 0.80; 95% CI, 0.56-1.14), and morbid obesity (OR, 0.94; 95% CI, 0.74-1.19) were not associated with undergoing open tracheotomy when performed by any service, and Black race (OR, 0.56; 95% CI, 0.44-0.71) was associated with lesser odds of an open approach being used. Age-adjusted Charlson Comorbidity Index score greater than 4 was associated with greater odds of both an otolaryngologist performing tracheotomy (OR, 1.26; 95% CI, 1.03-1.53) and use of the open tracheotomy technique (OR, 1.48, 95% CI, 1.21-1.82). Conclusions and Relevance: In this study, otolaryngologists were significantly more likely than other specialists to perform a tracheotomy for patients with history of neck surgery, morbid obesity, and ongoing anticoagulation therapy. These findings suggest that patients undergoing tracheotomy performed by an otolaryngologist are more likely to present with complex and challenging clinical characteristics.

Tracheal stenosis and airway complications in the Coronavirus Disease-19 era.

BACKGROUND: Severe Coronavirus Disease 2019 (COVID-19) infection is associated with prolonged intubation and its complications. Tracheal stenosis is one such complication that may require specialized surgical management. We aimed to describe the surgical management of post-COVID-19 tracheal stenosis. METHODS: This case series describes consecutive patients with tracheal stenosis from intubation for severe COVID-19 infection at our single, tertiary academic medical center between January 1st, 2021, and December 31st, 2021. Patients were included if they underwent surgical management with tracheal resection and reconstruction, or bronchoscopic intervention. Operative through six-month, symptom-free survival and histopathological analysis of resected trachea were reviewed. RESULTS: Eight patients are included in this case series. All patients are female, and most (87.5%) are obese. Five patients (62.5%) underwent tracheal resection and reconstruction (TRR), while three patients (38.5%) underwent non-resection-based management. Among patients who underwent TRR, six-month symptom free survival is 80%; one patient (20%) required tracheostomy after TRR due to recurrent symptoms. Two of the three (66.7%) of patients who underwent non-resection-based management experienced durable relief from symptoms of tracheal stenosis with tracheal balloon dilation, and the remaining patient required laser excision of tracheal tissue prior to experiencing symptomatic relief. CONCLUSIONS: The incidence of tracheal stenosis may increase as patients recover from severe COVID-19 infection requiring intubation. Management of tracheal stenosis with TRR is safe and effective, with comparable rates of success to TRR for non-COVID-19 tracheal stenosis. Non-resection-based management is an option to manage tracheal stenosis in patients with less severe stenosis or in poor surgical candidates.

Safety and Utility of Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) for Laser Laryngeal Surgery.

OBJECTIVE: Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) is gaining acceptance as a safe method for apneic ventilation and oxygenation during laryngeal procedures, but remains controversial during laser laryngeal surgery (LLS) due to the theoretical risk of airway fire. This study describes our experience with THRIVE during LLS. STUDY DESIGN: Retrospective cohort study. SETTING: Stanford University Hospital, October 15, 2015 to June 1, 2021. METHODS: Retrospective chart review of patients ≥18 years who underwent LLS involving the CO2 or KTP laser with THRIVE as the primary mode of oxygenation. RESULTS: A total of 172 cases were identified. 20.9% were obese (BMI ≥ 30). Most common operative indication was subglottic stenosis. The CO2 laser was used in 79.1% of cases. Median lowest intraoperative SpO2 was 96%. 44.7% cases were solely under THRIVE while 16.3% required a single intubation and 19.2% required multiple intubations. Mean apnea time for THRIVE only cases was 32.1 minutes and in cases requiring at least one intubation 24.0 minutes (p < .001). Mean apnea time was significantly lower for patients who were obese (p < .001) or had a diagnosis of hypertension (p = .016). Obese patients and patients with hypertension were 2.03 and 1.43 times more likely to require intraoperative intubation, respectively. There were no intraoperative complications or fires since the institution of our LLS safety protocol. CONCLUSION: By eliminating the fuel component of the fire triangle, THRIVE can be safely used for continuous delivery of high FiO2 during LLS, provided adherence to institutional THRIVE-LLS protocols.

Clinicodemographic Predictors of Tracheotomy Tube Size and Decannulation: A Multiinstitutional Retrospective Cohort Study on Tracheotomy.

OBJECTIVE: We aimed to discern clinico-demographic predictors of large (≥8) tracheostomy tube size placement, and, secondarily, to assess the effect of large tracheostomy tube size and other parameters on odds of decannulation before hospital discharge. SUMMARY OF BACKGROUND DATA: Factors determining choice of tracheostomy tube size are not well-characterized in the current literature, despite evidence linking large tracheostomy tube size with posttracheotomy tracheal stenosis. The effect of tracheostomy tube size on timing of decannulation is also unknown, an important consideration given reported associations between endotracheal tube size and probability of failed extubation. METHODS: We collected information pertaining to patients who underwent tracheotomy at 1 of 10 U.S. health care institutions between 2010 and 2019. Tracheostomy tube size was dichotomized (≥8 and <8). Multivariable logistic regression models were fit to identify predictors of (1) large tracheostomy tube size, and (2) decannulation before hospital discharge. RESULTS: The study included 5307 patients, including 2797 (52.7%) in the large tracheostomy cohort. Patient height (odds ratio [OR] = 1.060 per inch; 95% confidence interval [CI] 1.041-1.070) and obesity (1.37; 95% CI 1.1891.579) were associated with greater odds of large tracheostomy tube; otolaryngology performing the tracheotomy was associated with significantly lower odds of large tracheostomy tube (OR = 0.155; 95% CI 0.131-0.184). Large tracheostomy tube size (OR = 1.036; 95% CI 0.885-1.213) did not affect odds of decannulation. CONCLUSIONS: Obesity was linked with increased likelihood of large tracheostomy tube size, independent of patient height. Probability of decannulation before hospital discharge is influenced by multiple patient-centric factors, but not by size of tracheostomy tube.

Diagnosis and Management of Vocal Complications after Chondrolaryngoplasty.

OBJECTIVE: Transfeminine patients (transwomen/feminine nonbinary folks assigned male at birth) can undergo chondrolaryngoplasty ("tracheal shave") to feminize their neck appearance. While isolated cases of vocal complications have been reported following the procedure, aggregated outcomes have not been quantitatively studied. We present acoustic and stroboscopic data to describe a patient cohort with vocal complications after chondrolaryngoplasty and discuss reparative surgical technique. METHODS: Subjective and objective data, including videostroboscopy, were collected from patients with voice complaints after chondrolaryngoplasty. Dislocated anterior commissures were reconstructed with feminization laryngoplasty. Postoperative voice data were recorded and statistically compared to preoperative data using paired t-tests. RESULTS: On consecutive chart review, of the 94 transfeminine women with prior outside history of chondrolaryngoplasty, 27 (29%) reported chronic postoperative hoarseness, deepened pitch, or loss of upper register. On endoscopy, short, lax vocal folds with persistent anterior glottic gap and phase asymmetry were commonly noted; anterior commissure dislocation was confirmed in-office by using needle localization through absent thyroid cartilage. After open resuspension of the anterior commissure with feminization laryngoplasty, post-repair modal-speaking, minimum, and maximum fundamental frequencies (F0) increased on average by 7, 8, and 5 semitones, respectively (p < 0.01), when compared to pre-repair values. On average, perioperative maximum phonation time did not change significantly (p = 0.15). Average self-assessment of vocal femininity increased by 48% (p < 0.01). CONCLUSION: Anterior commissure dislocation should be suspected with signs of vocal impairment after chondrolaryngoplasty. Following proper diagnosis, resuspension of the anterior commissure via feminization laryngoplasty approach can be an effective reparative technique. LEVEL OF EVIDENCE: This work represents a 2011 OCEBM Level 4 evidence as a case series Laryngoscope, 133:2301-2307, 2023.

Social Perception of External Laryngeal Anatomy Related to Gender Expression in a Web-based Survey.

OBJECTIVE(S): To quantify the effect of laryngeal prominence size on socially perceived attributes relating to gender expression. Chondrolaryngoplasty ("tracheal shave") is a common procedure performed for transgender women to feminize neck appearance. The extent of thyroid cartilage resection needed to convey socially-perceived feminine gender expression without destabilizing the voice is incompletely understood. METHODS: Cross-sectional evaluation of a randomized allocation of images of varying laryngeal prominence to a non-repeated, random sample from November 2021 to December 2021. Photos of laryngeal prominence were isolated against a constant neck baseline with lateral, oblique, and frontal views. The images were embedded into a web-based survey with visual analog scales to capture perceived scaled gender expression (masculinity, femininity) and social traits (e.g., attractiveness, friendliness, leadership). We performed bivariate and multivariate analyses relating the laryngeal prominence to perceived gender expression and social traits. RESULTS: The analytic sample included 1,026 respondents. Laryngeal grades similar to the demonstrated "grade M" in this study and smaller demonstrated similar perceptions of increased femininity and decreased masculinity. Grades larger than M demonstrate significantly increased perceived masculinity and significantly decreased perceived femininity. The lateral and oblique views of the neck appear to be the most gender-informative. CONCLUSION: This crowd-sourced analysis of external laryngeal anatomy by a large population of observers provides clear, reproducible insights into social perceptions of gender identity and specifically femininity. These data will meaningfully inform patient counseling and surgical planning for gender-affirming interventions by establishing normative data representing the general public's perceptions. LEVEL OF EVIDENCE: NA Laryngoscope, 133:2292-2300, 2023.

Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique.

OBJECTIVES: Transfeminine patients can experience significant gender dysphoria in vocal communication. Feminization laryngoplasty (FL) is a gender-affirming surgery developed to elevate speaking vocal range, as well as alter vocal resonance and laryngeal cosmesis. The purpose here was to appraise FL's long-term voice outcomes across a 17-year review period. STUDY DESIGN: Level III, retrospective study and description of technique. SETTING: A single-institution transfeminine voice clinic. METHODS: Voice data (speaking fundamental frequency [F0], lowest F0, highest F0, F0 range in both Hertz and semitones, and maximum phonation time [MPT]) were collected and assessed. Self-assessment of voice femininity and complications were documented. RESULTS: The 162 patients, all transfeminine women, had a mean age of 40 years with 36-month mean follow-up. There were significant increases in mean speaking F0 (Δ = 50 ± 30 Hz, Δ = 6 ± 3 semitones; P < .001) and mean change in lowest F0 (Δ = 58 ± 31 Hz, Δ = 8 ± 4 semitones; P < .001). There was no significant difference in mean change in highest F0 or MPT. There was significant improvement (Δ = 60% ± 39%; P < .001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than 1-year follow-up and those who had 5-year follow-up. CONCLUSION: FL in this cohort was a safe and effective technique for increasing mean speaking F0, mean lowest F0, and voice gender perception over a prolonged follow-up period. These findings add to the possible treatments aimed at addressing the morbid dysphoria related to voice and communication for our transfeminine patients.

Otolaryngology Residency Interviews in a Socially Distanced World: Strategies to Recruit and Assess Applicants.

Due to concerns surrounding travel during the COVID-19 pandemic, the 2020-2021 otolaryngology residency application cycle will be conducted virtually for the first time. Residency programs should consider the logistics of video interviews, drawing on experiences of other programs that have successfully performed virtual interviews in the past. The lack of in-person interviews will create challenges in assessing applicants, and we recommend that programs develop structured and targeted questions and even consider having candidates answer standardized questions prior to the virtual interview day. From an applicant perspective, gauging the intangibles of individual residency programs, such as resident camaraderie, program culture, and program location, will be difficult. To address this, programs should consider hosting informal virtual gatherings, create videos that highlight the resident experience, and ensure that program websites are up-to-date. Ultimately, adaptability, resilience, and innovation will allow residency programs to achieve a successful 2021 otolaryngology match.

Multiparametric laryngeal assessment of the effect of thalamic deep brain stimulation on essential vocal tremor.

OBJECTIVE: EVT is a refractory voice disorder that significantly affects quality of life. This work aims to conduct a multiparametric assessment of the effect of deep brain stimulation (DBS) of the thalamic ventral intermediate nucleus (VIM) on essential vocal tremor (EVT) and investigate the relation between DBS lead location and EVT outcomes. METHODS: Nine participants underwent DBS for essential tremor and were diagnosed with co-occurring EVT in this prospective cohort study. Objective measurements including acoustic evaluation of vocal fundamental frequency (F0) and intensity modulation and subjective measurements including physiologic evaluation of the oscillatory movement of the laryngeal muscles and vocal tract and perceptual ratings of tremor severity were collected PRE and POST DBS. Finally, we investigated the relation between DBS lead location and EVT outcomes. RESULTS: Acoustic modulations of F0 and intensity were significantly improved POST DBS. Physiologic assessment showed a POST DBS reduction of oscillatory movement in the laryngeal muscles and vocal tract, but not significantly. Listener and participant perception, of EVT severity was also significantly reduced. Finally, our results indicate better EVT control with increased distance to midline of left VIM thalamic stimulation. CONCLUSIONS: By employing a battery of objective and subjective measures, our study supports the benefit of DBS for the treatment of EVT and specifies the acoustic and physiologic mechanisms that mediate its positive effect. We further provide preliminary results on the relation between lead location and EVT outcomes, laying the foundation for future studies to clarify the optimal DBS target for the treatment of EVT.

Coronavirus Disease-19: Challenges Associated with the Treatment of Head and Neck Oncology and Laryngology Patients in the Coronavirus Disease-19 Era.

This review explores the changes to practice associated with COVID-19 for providers treating patients with head and neck cancer and laryngeal pathology. The aim of the review is to highlight some of the challenges and considerations associated with treating this patient population during the pandemic. Additionally, it seeks to discuss some of the areas of concern related to ramping up clinical volume.

Intraoperative Evaluation of Essential Vocal Tremor in Deep Brain Stimulation Surgery.

Purpose Essential vocal tremor (EVT) is a prevalent and difficult-to-manage voice disorder. There is evidence that deep brain stimulation (DBS) of the ventral intermediate nucleus (Vim) of the thalamus may be beneficial for treating EVT. The objective of this preliminary investigation was to conduct intraoperative voice assessments during Vim-DBS implantation in order to evaluate immediate voice outcomes in medication-refractory essential tremor patients with co-occurring EVT. Method Seven adult subjects diagnosed with EVT undergoing Vim-DBS surgery participated in this investigation. Voice samples of sustained vowels were collected by a speech-language pathologist preoperatively and intraoperatively, immediately following Vim-DBS electrode placement. Voice evaluation included objective acoustic assessment of the rate and extent of EVT fundamental frequency and intensity modulation and subjective perceptual ratings of EVT severity. Results The rate of intensity modulation, extent of fundamental frequency modulation, and perceptual rating of EVT severity were significantly reduced intraoperatively as compared to preoperatively. Moderate, positive correlations were appreciated between a subset of acoustic measures and perceptual severity ratings. Conclusions The results of this study demonstrate a speech-language pathologist can conduct intra-operative evaluation of EVT during DBS surgery. Using a noninvasive, simple acoustic recording method, we were able to supplement perceptual subjective observation with objective assessment and demonstrate immediate, intraoperative improvements in EVT. The findings of this analysis inform the added value of intraoperative voice evaluation in Vim-DBS patients and contribute to the growing body of literature seeking to evaluate the efficacy of DBS as a treatment for EVT.

A Preliminary Study of Vocal Health Among Collegiate A Cappella Singers.

OBJECTIVE: Collegiate a cappella groups have grown significantly in popularity and prominence; however, there have been few studies that evaluate the vocal health of this subgroup of young singers. The objective of this preliminary study was to conduct a multiparametric evaluation of the vocal health characteristics of a sample of collegiate a cappella singers. We further tested whether differences in vocal health assessments exist between a cappella singers with and without vocal training and trained collegiate singers who do not participate in a cappella groups. STUDY DESIGN: Point prevalence study. METHODS: Forty-one collegiate singers participated in this study. Participants were divided into the following three groups: trained singers (TS), trained a cappella singers (ATS), and untrained a cappella singers (AUS). Participants were administered a set of surveys to assess self-perception of singing voice health and perceived access and attitudes toward voice-related health care. Acoustic and laryngoscopic assessments of participant's speaking and singing voice was performed and validated vocal health questionnaires administered as a means to objectively evaluate for the presence of voice problems. RESULTS: Overall, 87.5% of the ATS and 60% of the AUS groups reported experiencing problems with their singing voice. However, no vocal abnormalities were detected during laryngoscopic and acoustic assessments. Furthermore, minimal differences between any of the measured vocal health parameters were observed between the TS, ATS, and AUS groups. CONCLUSION: Collectively, a high percentage of collegiate a cappella singers with and without vocal training report singing voice problems. However, our sample of a cappella singers did not have increased singing voice problems as compared to vocally trained collegiate singers not in a cappella groups. We did find that a cappella singers may be more inclined to seek information about maintaining a healthy singing voice from their fellow musicians as opposed to singing teachers or other voice health professionals. Singing teachers, otolaryngologists, and speech-language pathologists may need to play a more active role in educating a cappella singers regarding maintaining good vocal health.

Outcomes in modified transoral resection of diverticula for Zenker's diverticulum.

PURPOSE: Transoral resection of Zenker's diverticulum (TORD) was first reported in 2010. We present results for our modified approach to transoral resection (MTORD)-full-thickness cricopharyngeal myectomy, diverticulum sac excision, and suture closure of the pharyngotomy-and evaluate its safety and efficacy compared to endoscopic stapling and open approaches. METHODS: A retrospective study was performed in patients who underwent transoral resection of Zenker's diverticulum using MTORD, endoscopic stapler-assisted diverticulotomy (ESD), or trancervical diverticulectomy (TCD) from July 2009 to August 2017. Pre-operative evaluation included barium swallow and subjective characterization of swallowing dysfunction using the EAT-10 and Reflux Symptom Index (RSI). Complications, length of hospitalization, recurrence, and revision rates were also evaluated. RESULTS: Of 92 patients reviewed, 18 underwent MTORD, 45 underwent ESD and 29 underwent TCD. Major complications were only observed in ESD and TCD. Recurrence which required revision surgery was only observed in ESD. EAT-10 and RSI scores significantly improved and RSI scores normalized post-operatively for all approaches in short-term (< 1 year) follow-up. CONCLUSIONS: MTORD is a safe and effective option for complete Zenker's diverticulectomy. Complication rates are low. To date, no patient has required reoperation, although more cases and longer term follow-up are needed for more complete comparison to ESD and traditional open excision.

Type I thyroplasty: A safe outpatient procedure.

OBJECTIVES/HYPOTHESIS: Overnight hospitalization is routinely advocated following type I thyroplasty (TP) because of concerns for airway compromise. Hospitalization increases cost and patient inconvenience, and may not necessarily be appropriate. This study evaluated complications following surgery and identified predictors for same to assess which patients benefit most from hospitalization. STUDY DESIGN: Retrospective chart review. METHODS: A study was conducted on patients who underwent TP with or without arytenoid repositioning procedures between June 2008 and March 2017. The demographic data of the subjects, characteristics, etiology of glottic insufficiency, interventions performed, and subsequent complications were evaluated. RESULTS: Of 147 patients reviewed, 100 underwent TP alone, 41 underwent TP with arytenoid adduction, and six patients underwent TP with adduction arytenopexy. Iatrogenic vocal fold paralysis was the most common indication. Major complications, which included transient airway compromise and hematoma requiring reoperation, occurred in 7% of patients. Revision surgery and thyroplasty combined with arytenoid repositioning maneuvers were associated with increased risk of major complications. CONCLUSIONS: In general, TP is a safe procedure, with a major complication rate that is lower than that of outpatient thyroidectomy. Overnight hospitalization should be considered in patients undergoing revision surgery and in those requiring concurrent arytenoid repositioning procedures. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1640-1646, 2019.

Treatment of early-stage laryngeal cancer: A comparison of treatment options.

Over the course of the last several decades, the treatment options for early laryngeal cancers (T1 and T2) have evolved; however, simultaneously the mortality rate has increased. As larynx preservation approaches have become the standard of care, the selection of the proper treatment modality has become paramount. Radiation therapy or transoral laser microsurgery are the most common options for treatment of these early lesions. Oncologic and functional outcomes are considered equivalent between the two modalities for early glottic cancers; however, no direct comparisons exist for robust analysis. In terms of larynx preservation, there also is not compelling data favoring one treatment option or another. For early stage lesions, the goal for any larynx-sparing technique, either radiation or surgery, should be the intent to cure with single modality treatment and minimal short- and long-term toxicity. This article is designed to create a frame of reference for managing early stage disease with respect to lesions of the glottis and supraglottis while weighing treatment implications from an oncologic, functional, and cost perspective.

Surgical Management of Supraglottic Stenosis Using Intubationless Optiflow.

OBJECTIVE: Airway management during endoscopic surgical treatment of supraglottic and pharyngeal stenosis is often challenging and can be accomplished by various means, including tracheostomy, jet ventilation, or direct laryngoscopy. We describe CO2 laser excision of supraglottic-pharyngeal stenosis using intubationless Optiflow high-flow nasal cannula (HFNC). METHODS: A 55-year-old male presented with dyspnea and dysphagia secondary to severe supraglottic-pharyngeal stenosis in the setting of previous chemoradiation for a T0N2aM0 squamous cell carcinoma. Laryngoscopy revealed severe supraglottic-pharyngeal stenosis with tethering of the epiglottis to the lateral pharyngeal walls. Optiflow HFNC was used to deliver 70 L/min of oxygen. After anesthetic induction, CO2 laser microlaryngoscopy was utilized to release scar tissue along the lateral epiglottic border, opening up the supraglottic airway sufficiently for endotracheal intubation and further laser resection. RESULTS: Airway management with Optiflow HFNC allowed initial endoscopic surgical access, partial stenotic release, and intubation. From anesthetic induction to intubation, the patient remained apneic for 26 minutes. The patient's stenosis was successfully addressed, and 10-month follow-up demonstrated stable patency of the airway. CONCLUSION: Optiflow is an important new tool in the management of severe supraglottic stenosis. It provides sufficient oxygenation to perform extended apneic surgery and improves endoscopic surgical access in a limited airway.

Improvement in the Reflux Symptom Index Following Surgery for Cricopharyngeal Dysfunction.

OBJECTIVES: Gastroesophageal reflux may contribute to the development of cricopharyngeal dysfunction and Zenker's diverticulum. Common dictum suggests that if upper esophageal sphincter tone is reduced through cricopharyngeal myotomy, symptoms of laryngopharyngeal reflux may worsen. We hypothesized that patients who undergo myotomy should show decreased dysphagia symptoms with concurrent worsening of reflux symptomatology and that these changes would be greater in those patients undergoing complete versus partial myotomy. METHODS: A retrospective chart review was performed for patients who underwent endoscopic or open cricopharyngeal myotomy, with or without Zenker's diverticulectomy. Preoperative and postoperative reflux symptomatology was subjectively measured with the Reflux Symptom Index (RSI), and dysphagia symptomatology was measured with the Eating Assessment Tool 10 (EAT-10). Patients who underwent partial myotomy via endoscopic stapling of Zenker's diverticulum were compared with patients who underwent complete myotomy (either endoscopic laser-assisted or via an open transcervical approach). The patients were further subdivided into three groups for data analysis: endoscopic staple diverticulotomy, laser cricopharyngeal myotomy, and open approach. RESULTS: A total of 41 patient charts were reviewed. Of these 41 patients, 17 underwent endoscopic stapler-assisted diverticulotomy, 4 underwent endosopic laser-assisted cricopharyngeal myotomy, and 20 underwent open transcervical cricopharyngeal myotomy, with diverticulectomy as indicated. Mean pre- and postoperative RSIs were 21.8 and 8.9, respectively (P < 0.001). Mean pre- and postoperative EAT-10 scores were 19.1 and 5.0, respectively (P < 0.001). CONCLUSIONS: Patients' reflux symptoms significantly improved after cricopharyngeal myotomy, with significant improvement in dysphagia symptoms. Concern for worsening of reflux symptoms following surgery does not appear to be clinically common.