Patient-Reported Outcomes after False Vocal Folds Injections for Adductor Spasmodic Dysphonia.

OBJECTIVES: The primary objective of this study is to investigate if false vocal folds (FVF) or simultaneous FVF with thyroarytenoid (FVF+TA) Botox® injections achieve comparable treatment effects to standard TA injections. This study also aims to determine how patient-reported outcomes contribute to the transition to, and continuation of, FVF or FVF+TA injections. METHODS: Retrospective chart review was performed for all patients receiving Botox® for adductor spasmodic dysphonia at a laryngology practice between 2005 and 2018. Twenty out of 103 patients met the study's inclusion criteria. All subjects began standard treatment with TA injections. Based on response to injection, patients either continued to receive TA injections (group TA; n = 7), switched to FVF injections (group FVF; n = 7), or switched to FVF+TA injections (group FVF+TA; n = 6). A comparison of group means before and after initiation of FVF±TA injections was performed between groups FVF and FVF+TA to group TA for the injection dosage, the duration of injection cycles, the patient-reported duration of best voice, and the presence and duration of breathiness and choking. Within-group observations were also compared before and after FVF±TA injections. RESULTS: There were no significant findings for the variables between group FVF and group TA before FVF injections. The duration of injection cycles was significantly shorter for group FVF than group TA after FVF injections (95% CI: -66.05, -0.34; P = 0.05). However, duration of best voice quality, breathiness, and choking were similar (P > 0.05) for group FVF to group TA after FVF injections. Group FVF+TA had a significantly shorter duration of injection cycles (95% CI: -66.97, -3.22; P = 0.03), best voice (95% CI: -0.76, -0.03; P = 0.04), and choking (95% CI: -2.68, 0.02; P = 0.05) than group TA before FVF+TA injections. Group FVF+TA displayed a similar duration (P > 0.05) of injection cycles, best voice quality, breathiness, and choking to group TA after FVF+TA injections. Within-group, increased duration of injection cycles and best voice were observed after FVF±TA injections for both group FVF and FVF+TA. Acute adverse events were variable within groups after FVF±TA injections. CONCLUSION: This study compared outcomes of FVF or FVF+TA injections to successive TA injections among patients. FVF injections displayed similar duration of best voice quality, breathiness, and choking to TA injections. FVF+TA injections achieved similar duration of injection cycles, best voice quality, breathiness, and choking to TA injections. This study demonstrates that patients guided by a reduced duration of adverse events, while tolerating a shorter injection cycle, may benefit from initiation and continuation of FVF injections. Patients guided by increased duration of injection cycle and best voice, while tolerating the duration of adverse events, may benefit from initiation and continuation of FVF+TA injections.

Laryngeal Cancer Screening During Flexible Video Laryngoscopy Using Large Computer Vision Models.

OBJECTIVE: Develop an artificial intelligence assisted computer vision model to screen for laryngeal cancer during flexible laryngoscopy. METHODS: Using laryngeal images and flexible laryngoscopy video recordings, we developed computer vision models to classify video frames for usability and cancer screening. A separate model segments any identified lesions on the frames. We used these computer vision models to construct a video stream annotation system. This system classifies findings from flexible laryngoscopy as "potentially malignant" or "probably benign" and segments any detected lesions. Additionally, the model provides a confidence level for each classification. RESULTS: The overall accuracy of the flexible laryngoscopy cancer screening model was 92%. For cancer screening, it achieved a sensitivity of 97.7% and a specificity of 76.9%. The segmentation model attained an average precision at a 0.50 intersection-over-union of 0.595. The confidence level for positive screening results can assist clinicians in counseling patients regarding the findings. CONCLUSION: Our model is highly sensitive and adequately specific for laryngeal cancer screening. Segmentation helps endoscopists identify and describe potential lesions. Further optimization is required to enable the model's deployment in clinical settings for real-time annotation during flexible laryngoscopy.

Computational fluid dynamics model of laryngotracheal stenosis and correlation to pulmonary function measures.

3D models of airway lumens were created from CT scans of 19 patients with laryngotracheal stenosis. Computational fluid dynamics (CFD) simulations were completed for each, and results were compared to measured peak inspiratory flow rate, grade of lumen constriction, and measures of airway geometry. Results demonstrate flow resistance and shear stress correlate with degree of lumen constriction and absolute cross-sectional area as well as flow rate. Flow recirculation depends on airway constriction but does not vary with flow rate. Resistance and wall shear stress did not correlate well with functional measures. Flow recirculation did differ between subjects with higher functional measures and subjects with lower functional measures. This analysis provides mathematical models to predict airway resistance, wall shear stress, and flow reversal according lumen constriction and inspiratory flow rate. It suggests aerodynamic factors such as flow recirculation play a role in differences in functional performance between patients with similar airway measures.

Investigation of Vocal Bifurcations and Voice Patterns Induced by Asymmetry of Pathological Vocal Folds.

PURPOSE: Vocal fold asymmetry creates irregular entrainments and modulations in voice, which may lead to rough perceptual quality. The presence of asymmetry can also cause mid-phonation bifurcations where a small change in the phonatory system causes a drastic change in vibration pattern, resulting in transitions in and out of rough voice. This study surveys sustained phonation recordings of speakers with the diagnoses of vocal fold polyp or unilateral vocal fold paralysis to investigate the resulting voice patterns. METHOD: This retrospective study observed 71 sustained phonation recordings from 48 patients. Segments with distinctive signal patterns were identified within each recording with narrowband spectrogram and computer-assisted analysis of spectral peaks. RESULTS: Phonation segmentation yielded 240 segments across all the recordings. Five voice patterns were recognized: (regularly or irregularly) entrained, modulated, uncoupled, unstable, and pulsed. Thirty-six patients (75%) exhibited irregular patterns. No single irregular pattern lasted for the entire phonation and was always accompanied by at least one mid-phonation bifurcation. Durations of the irregular segments (M = 0.4 s) were significantly shorter than the segments with the regular pattern (M = 1.4 s). CONCLUSIONS: The results suggest that vocal fold pathology frequently introduces dynamic vibratory patterns that affect both the acoustic signals and perceptions. Due to these abnormalities, it is important for clinical voice assessment protocols, both perceptual and acoustic, to account for these possible bifurcations, irregular signal patterns, and their tendencies.

Harmonics-to-noise ratio estimation with deterministically time-varying harmonic model for pathological voice signals.

The harmonics-to-noise ratio (HNR) and other spectral noise parameters are important in clinical objective voice assessment as they could indicate the presence of nonharmonic phenomena, which are tied to the perception of hoarseness or breathiness. Existing HNR estimators are built on the voice signals to be nearly periodic (fixed over a short period), although voice pathology could induce involuntary slow modulation to void this assumption. This paper proposes the use of a deterministically time-varying harmonic model to improve the HNR measurements. To estimate the time-varying model, a two-stage iterative least squares algorithm is proposed to reduce model overfitting. The efficacy of the proposed HNR estimator is demonstrated with synthetic signals, simulated tremor signals, and recorded acoustic signals. Results indicate that the proposed algorithm can produce consistent HNR measures as the extent and rate of tremor are varied.

A modular surgical simulator for microlaryngoscopy using standard instruments and the carbon dioxide laser.

Objective: Build a microlaryngoscopy surgical simulator for endoscopic laryngeal surgery using standard microsurgical instruments and a CO2 laser. Study design: Anatomical modeling, CAD design and 3D printed manufacturing. Subjects and methods: We created a modular design for a microlaryngoscopy simulator in CAD software. Components include plastic and stainless-steel models of a standard operating laryngoscope and a cassette system for mounting porcine or synthetic models of the vocal folds. All simulator parts, including the metallic laryngoscope model, were manufactured using 3D printing technology. Tumors were simulated in porcine tissue models by injecting a soy protein-based tumor phantom. Residents and faculty in the Louisiana State University otolaryngology department evaluated the system. Each participant performed microlaryngoscopy with laser resection on a porcine larynx and cold instrument procedures on synthetic vocal folds. Participants scored the simulator using a 5-point Likert scale. Results: The microlaryngeal surgical simulator demonstrated in this project is realistic, economical, and easily assembled. We have included 3D printed parts files and detailed assembly instructions that will enable educators interested in surgical simulation to build the device.Participants in the simulator evaluation session felt that the simulator faithfully represented the procedure to resect vocal fold lesions using a CO2 laser. The synthetic model allows the trainee to develop hand-eye coordination while using standard laryngeal instruments. Conclusions: The simulator described herein will enable surgeons to acquire the surgical skills necessary to perform operative microlaryngoscopy prior to operating on live patients.

Optical Biopsy: Automated Classification of Airway Endoscopic Findings Using a Convolutional Neural Network.

OBJECTIVES/HYPOTHESIS: Create an autonomous computational system to classify endoscopy findings. STUDY DESIGN: Computational analysis of vocal fold images at an academic, tertiary-care laryngology practice. METHODS: A series of normal and abnormal vocal fold images were obtained from the image database of an academic tertiary care laryngology practice. The benign images included normals, nodules, papilloma, polyps, and webs. A separate set of carcinoma and leukoplakia images comprised a single malignant-premalignant class. All images were classified with their existing labels. Images were randomly withheld from each class for testing. The remaining images were used to train and validate a neural network for classifying vocal fold lesions. Two classifiers were developed. A multiclass system classified the five categories of benign lesions. A separate analysis was performed using a binary classifier trained to distinguish malignant-premalignant from benign lesions. RESULTS: Precision ranged from 71.7% (polyps) to 89.7% (papilloma), and recall ranged from 70.0% (papilloma) to 88.0% (nodules) for the benign classifier. Overall accuracy for the benign classifier was 80.8%. The binary classifier correctly identified 92.0% of the malignant-premalignant lesions with an overall accuracy of 93.0%. CONCLUSIONS: Autonomous classification of endoscopic images with artificial intelligence technology is possible. Better network implementations and larger datasets will continue to improve classifier accuracy. A clinically useful optical cancer screening system may require a multimodality approach that incorporates nonvisual spectra. LEVEL OF EVIDENCE: NA Laryngoscope, 132:S1-S8, 2022.

Predicting Need for Surgery in Recurrent Laryngotracheal Stenosis Using Changes in Spirometry.

OBJECTIVES/HYPOTHESIS: We sought to identify changes that occur in spirometric values between surgical interventions in patients with recurrent laryngotracheal stenosis and assess the utility of tracking those changes in predicting the need to return to surgery. METHODS: This is a retrospective, case-control study of laryngotracheal stenosis. Charts from a 10 year period were reviewed, and 80 patients were identified with recurrent laryngotracheal stenosis and serial spirometry. Recorded forced expiratory volume in 1 second (FEV1 ), forced inspiratory volume in 1 second (FIV1 ), peak expiratory flow (PEF), and peak inspiratory flow (PIF), and body mass index (BMI) were tabulated. Calculations were then performed to determine deviations in spirometric measurements from maximums. Comparing the patients who required intervention to those who did not, we used a regression analysis to generate a decision tree based on factors with the strongest predictive power. We then calculated receiver operating characteristic (ROC) curves for all calculated variables. RESULTS: Deviations in PEF, PIF, and FIV1 from each patient's maximums had strong predictive power in determining return to surgery. PIF was the only fixed measurement found to have a statistically significant role in predicting return to surgery. BMI did not play a role. CONCLUSION: For each patient, the deviation from their overall spirometric maximums had the statistically strongest predictive power in determining need to return to surgery. This suggests the importance of the trends in spirometric measures for each individual, and implies these trends have greater import than fixed measures alone. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2199-2203, 2021.

Voice Outcomes Following Multiple Surgeries for Recurrent Respiratory Papillomatosis.

OBJECTIVES: Recurrent Respiratory Papillomatosis (RRP) is a rare disease caused by the human papilloma virus that presents as warty, exophytic growths in the upper airway. RRP in the larynx can lead to severe airway obstruction and voice changes. It is clinically known that patients with RRP frequently experience dysphonia. The purpose of this study was to assess the impact of multiple surgical treatments on RRP patients' voice outcomes, and to determine whether a higher number of repeated surgeries lead to decreased voice quality. METHODS: A retrospective cohort study was conducted of adult RRP patients (n = 23) who underwent multiple surgeries. Group 1 included patients (n = 11) who had <5 surgeries (range 2-4 surgeries) and Group 2 included patients (n = 12) who had ≥5 surgeries (range 5-50+ surgeries). Voice recordings were selected from the following clinic visits: initial office visit (initial presurgery), first postsurgery, and the last clinic encounter(s) with no immediate planned surgery. Blinded auditory-perceptual ratings along with cepstral and spectral acoustic measures assessed voice severity. RESULTS: There was significant improvement from the initial presurgery visit compared to each postoperative visit over time for all voice outcome measures for both Group 1 and Group 2. The results of the study indicated that the number of surgeries did not significantly affect mean postoperative voice outcomes, and there were no significant differences between patient groups for voice quality over time. CONCLUSIONS: The results of this study suggest that RRP patients' voice quality may not suffer cumulative negative effects when using modern tissue-sparing surgical techniques.

Simulators for Laryngeal and Airway Surgery.

There is growing support from the Accreditation Council for Graduate Medical Education and the Joint Commission of Accreditation of Health Care Organizations for a competency-based evaluation of medical and surgical performance. This is part of the quality movement in health care whereby the Centers for Medicare and Medicaid Services and third-party insurance companies have begun to link reimbursement incentives to positive surgical outcomes. Laryngeal and airway surgery require precise technique and significant mastered skill that can be difficult to obtain during otolaryngology residency training. Simulators are useful for developing laryngeal and airway surgery skills ultimately evaluated in a competency-based manner.

Ectopic parathyroid adenoma in the pyriform sinus.

BACKGROUND: Ectopic parathyroid glands may complicate the surgical approach to primary hyperparathyroidism. We describe a rare ectopic parathyroid location, the pyriform sinus. METHODS: Three patients, 2 after prior unsuccessful parathyroid exploration, were found to have ectopic parathyroid adenomas in the pyriform sinus. Two cases were identified by 4D-CT of the neck. The other was localized by a technetium 99m sestamibi single photon emission CT (SPECT). In each case, office endoscopy confirmed the lesions. The patients were treated by either transoral laser or robotic resection of the parathyroid adenoma. RESULTS: After surgery, the patients had resolution of their hyperparathyroidism. CONCLUSION: Ectopic parathyroid adenomas in the pyriform sinus are rare, but should be considered in those patients who have had a failed neck exploration and in those who undergo 4D-CT scanning or SPECT scanning.

Association of asthma with clinically aggressive recurrent respiratory papillomatosis.

OBJECTIVE: To determine whether there is an association between the presence of asthma and a clinically aggressive disease course in patients with recurrent respiratory papillomatosis (RRP). DESIGN: Retrospective multi-institutional cohort study (level III evidence). SETTING: Two academic medical centers in the southeastern United States. PATIENTS: Adult patients with RRP treated at the Georgia Health Sciences University or at the Emory University School of Medicine between January 1998 and December 2009. Excluded from the study were adult patients who had been diagnosed as having RRP when they were a child (<18 years). MAIN OUTCOME MEASURES: The primary outcome measure was the presence of a clinically aggressive RRP disease course (defined as distal spread of disease, >4 procedures performed in 12 months, or progression to laryngeal squamous cell carcinoma). The secondary outcome measure was the frequency of required surgical interventions. RESULTS: Identified were 90 patients with RRP (age range at first diagnosis, 19.1-86.4 years). Seventeen patients had aggressive disease, and 73 patients had nonaggressive disease. Seven patients had a history of asthma, 5 of whom were using daily inhaled corticosteroids. An association was noted between the presence of asthma and aggressive RRP, which was found in 57% (4 of 7) of patients with asthma vs 16% (13 of 83) of patients without asthma (P = .02). Patients with asthma using daily inhaled corticosteroids were especially likely to have aggressive RRP, which was found in 80% (4 of 5) of corticosteroid users vs 15% (13 of 85) of nonusers (P = .004). CONCLUSIONS: Patients with asthma, particularly those using daily inhaled corticosteroids, may have a more clinically aggressive RRP course. The cause of this association is unclear, and clinical recommendations should not yet be made based on these data.