Microbial Composition of the Laryngotracheal Region: A Systematic Review.

INTRODUCTION: Microbiome research has predominantly focused on the oral cavity and oropharynx's role in disease, while the upper airway, specifically the larynx and trachea, has been relatively overlooked. Examining the microbial communities in these regions can shed light on how dysbiosis influences diseases and their management. This review evaluates laryngotracheal microbial compositions in both healthy and diseased patients. METHODS: We conducted a systematic review in EMBASE, MEDLINE, and Cochrane Central databases, yielding 1383 studies in the initial search. Inclusion criteria involved participants aged over 18 years and the use of next-generation 16s ribosomal sequencing methods. RESULTS: We included 10 studies-seven focused on larynx sequencing and four on trachea sequencing (one investigated both sites). In a healthy larynx, diverse species such as Streptococcus, Cloacibacterium, Prevotella, and Helicobacter were found. Benign laryngeal diseases exhibited reduced microbial diversity, mainly dominated by Streptococcus. Subglottic stenosis patients showed diminished diversity in both idiopathic and iatrogenic scars. Laryngeal squamous cell carcinoma displayed increased diversity, primarily featuring Fusobacterium. Among non-respiratory-compromised surgery patients, the tracheal microbiome was more diverse in diabetics and those later developing lower respiratory infections. Pneumonia patients exhibited an abundance of Prevotella and Streptococcus, linked to an increased 28-day survival rate, while Streptococcus and Haemophilus abundance correlated with successful extubation. CONCLUSIONS: The laryngotracheal region hosts a unique microbial community influenced by both benign and malignant conditions. Many lesions remain unexplored, underscoring the need for future studies encompassing diverse laryngotracheal conditions. Clinical trials assessing microbiome modifications may unveil novel therapeutic avenues. LEVEL OF EVIDENCE: NA Laryngoscope, 2024.

Adjuvant Reirradiation With Proton Therapy in Head and Neck Squamous Cell Carcinoma.

Purpose: For patients with head and neck squamous cell carcinoma (HNSCC), locoregional failure and second primary tumors are common indications for adjuvant reirradiation (re-RT). Given an absence of clear consensus on the role of adjuvant re-RT, we sought to assess histopathologic risk factors of patients with HNSCC and their resulting outcomes after adjuvant re-RT with proton therapy. Methods and Materials: We conducted a retrospective analysis of patients with HNSCC who underwent salvage surgery at our institution followed by adjuvant re-RT with proton therapy over 1.5 years. All included patients received prior radiation therapy. The Kaplan-Meier method was used to evaluate locoregional recurrence-free survival and overall survival. Results: The cohort included 22 patients, with disease subsites, including oropharynx, oral cavity, hypopharynx, larynx, and nasopharynx. Depending on adverse pathologic features, adjuvant re-RT to 66 Gy (32% of cohort) or 60 Gy (68%), with (59%) or without (41%) concurrent systemic therapy was administered. The majority (86%) completed re-RT with no reported treatment delay; 3 patients experienced grade ≥3 acute Common Terminology Criteria for Adverse Events toxicity and no patient required enteral feeding tube placement during re-RT. Median follow-up was 21.0 months (IQR, 11.7-25.2 months). Five patients had biopsy-proven disease recurrences a median of 5.9 months (IQR, 3.8-9.7 months) after re-RT. Locoregional recurrence-free survival was 95.2%, 70.2%, 64.8% at 6, 12, and 24 months, respectively. OS was 100%, 79.2%, and 79.2% at 6, 12, and 24 months, respectively. Four patients had osteoradionecrosis on imaging a median of 13.2 months (IQR, 8.7-17.4 months) after re-RT, with 2 requiring surgical intervention. Conclusions: Adjuvant re-RT for patients with HNSCC was well-tolerated and offered reasonable local control in this high-risk cohort but appears to be associated with a risk of osteoradionecrosis. Additional study and longer follow-up could help define optimal patient management in this patient population.

Treatment discordance in the utilization of neck dissection for stage I-II supraglottic tumors.

BACKGROUND: In 2018, the National Comprehensive Cancer Network treatment guidelines began recommending the use of neck dissection during surgical management of stage I-II supraglottic laryngeal squamous cell carcinoma (LSCC). METHODS: Trends and factors associated with the use of neck dissection during larynx-preserving surgery for patients with cT1-2, N0, M0 supraglottic LSCC in the National Cancer Database (2004-2020) were evaluated using multivariable-adjusted logistic regression. RESULTS: Of the 2080 patients who satisfied study eligibility criteria, 633 (30.4%) underwent neck dissection. Between 2018 and 2020, the rate of neck dissection was 39.0% (114/292). After multivariable adjustment, academic facility type, undergoing biopsy prior to surgery, and more radical surgery were significant predictors of receiving neck dissection. CONCLUSIONS: The results of this national analysis suggest that the utilization of guideline-concordant neck dissection for management of stage I-II supraglottic LSCC remains low and highlight the need to promote the practice of neck dissection for this patient population.

Early feeding after free flap reconstruction of the oral cavity: A systematic review and meta-analysis.

BACKGROUND: Traditionally, patients undergoing free flap reconstruction for oral cavity defects have been given nothing by mouth for 6-14 days post-operatively due to concern for orocutaneous fistula development. METHODS: Multiple databases were screened for studies assessing the rate of orocutaneous fistula formation in early (≤5 days) versus late (>5 days) feeding groups following oral cavity free flap reconstruction. Fixed- and random-effects meta-analyses were used. RESULTS: One randomized controlled trial, one prospective cohort, and three retrospective cohort studies were included. The early feeding group displayed no significant increase in orocutaneous fistula formation (RD = -0.02, p = 0.06) or free flap failure (RD = -0.01, p = 0.39), with a significantly shorter hospital length of stay (mean difference [days] = -2.43, p < 0.01). CONCLUSIONS: While further prospective trials are necessary, initiation of oral intake before post-operative day 5 may be appropriate in properly selected patients following oral reconstruction.

High-Resolution Profiling of Human Vocal Fold Cellular Landscapes With Single-Nuclei RNA Sequencing.

INTRODUCTION: The function of the vocal folds (VFs) is determined by the phenotype, abundance, and distribution of differentiated cells within specific microenvironments. Identifying this histologic framework is crucial in understanding laryngeal disease. A paucity of studies investigating VF cellular heterogeneity has been undertaken. Here, we examined the cellular landscape of human VFs by utilizing single-nuclei RNA-sequencing. METHODS: Normal true VF tissue was excised from five patients undergoing pitch elevation surgery. Tissue was snap frozen in liquid nitrogen and subjected to cellular digestion and nuclear extraction. Nuclei were processed for single-nucleus sequencing using the 10X Genomics Chromium platform. Sequencing reads were assembled using cellranger and analyzed with the scanpy package in python. RESULTS: RNA sequencing revealed 18 global cell clusters. While many were of epithelial origin, expected cell types, such as fibroblasts, immune cells, muscle cells, and endothelial cells were present. Subcluster analysis defined unique epithelial, immune, and fibroblast subpopulations. CONCLUSION: This study evaluated the cellular heterogeneity of normal human VFs by utilizing single-nuclei RNA-sequencing. With further confirmation through additional spatial sequencing and microscopic imaging, a novel cellular map of the VFs may provide insight into new cellular targets for VF disease. LEVEL OF EVIDENCE: NA Laryngoscope, 134:3193-3200, 2024.

The Use of Deep Learning Software in the Detection of Voice Disorders: A Systematic Review.

OBJECTIVE: To summarize the use of deep learning in the detection of voice disorders using acoustic and laryngoscopic input, compare specific neural networks in terms of accuracy, and assess their effectiveness compared to expert clinical visual examination. DATA SOURCES: Embase, MEDLINE, and Cochrane Central. REVIEW METHODS: Databases were screened through November 11, 2023 for relevant studies. The inclusion criteria required studies to utilize a specified deep learning method, use laryngoscopy or acoustic input, and measure accuracy of binary classification between healthy patients and those with voice disorders. RESULTS: Thirty-four studies met the inclusion criteria, with 18 focusing on voice analysis, 15 on imaging analysis, and 1 both. Across the 18 acoustic studies, 21 programs were used for identification of organic and functional voice disorders. These technologies included 10 convolutional neural networks (CNNs), 6 multilayer perceptrons (MLPs), and 5 other neural networks. The binary classification systems yielded a mean accuracy of 89.0% overall, including 93.7% for MLP programs and 84.5% for CNNs. Among the 15 imaging analysis studies, a total of 23 programs were utilized, resulting in a mean accuracy of 91.3%. Specifically, the twenty CNNs achieved a mean accuracy of 92.6% compared to 83.0% for the 3 MLPs. CONCLUSION: Deep learning models were shown to be highly accurate in the detection of voice pathology, with CNNs most effective for assessing laryngoscopy images and MLPs most effective for assessing acoustic input. While deep learning methods outperformed expert clinical exam in limited comparisons, further studies integrating external validation are necessary.

Head and Neck Cancer Patient Population, Management, and Oncologic Outcomes from the COVID-19 Pandemic.

The COVID-19 pandemic precipitated drastic changes in cancer care. Its impact on the U.S. head and neck cancer population has yet to be fully understood. This study aims to understand the impact of pandemic-related changes on the head and neck cancer population. An observational study of head and neck cancer patients at a single institution during the spring of 2020 and 2019 was performed. Clinical characteristics and survival outcomes were analyzed. In 2020, 54 head and neck cancer patients were evaluated in the department of radiation oncology vs. 74 patients seen in 2019; 42% of the patients were female in 2019 versus 24% in 2020 (p = 0.036). The median follow-up time was 19.4 and 31 months for 2020 and 2019, respectively. After adjusting for stage, the relapse-free survival probability at 6 and 12 months was 79% and 69% in 2020 vs. 96% and 89% in 2019, respectively (p = 0.036). There was no significant difference in the overall survival, with 94% and 89% in 2020 and 2019, respectively (p = 0.61). Twenty-one percent of patients received induction chemotherapy in 2020 versus 5% in 2019 (p = 0.011); significantly more treatment incompletions occurred in 2020, 9% vs. 0% in 2019 (p = 0.012). Moreover, the stage-adjusted RFS differed between cohorts, suggesting head and neck cancer patients seen during the initial wave of COVID-19 may experience worse oncologic outcomes.

Validation of a 3D-Printed Percutaneous Injection Laryngoplasty Simulator: A Randomized Controlled Trial.

OBJECTIVE: Simulation may be a valuable tool in training laryngology office procedures on unsedated patients. However, no studies have examined whether existing awake procedure simulators improve trainee performance in laryngology. Our objective was to evaluate the transfer validity of a previously published 3D-printed laryngeal simulator in improving percutaneous injection laryngoplasty (PIL) competency compared with conventional educational materials with a single-blinded randomized controlled trial. METHODS: Otolaryngology residents with fewer than 10 PIL procedures in their case logs were recruited. A pretraining survey was administered to participants to evaluate baseline procedure-specific knowledge and confidence. The participants underwent block randomization by postgraduate year to receive conventional educational materials either with or without additional training with a 3D-printed laryngeal simulator. Participants performed PIL on an anatomically distinct laryngeal model via trans-thyrohyoid and trans-cricothyroid approaches. Endoscopic and external performance recordings were de-identified and evaluated by two blinded laryngologists using an objective structured assessment of technical skill scale and PIL-specific checklist. RESULTS: Twenty residents completed testing. Baseline characteristics demonstrate no significant differences in confidence level or PIL experience between groups. Senior residents receiving simulator training had significantly better respect for tissue during the trans-thyrohyoid approach compared with control (p < 0.0005). There were no significant differences in performance for junior residents. CONCLUSIONS: In this first transfer validity study of a simulator for office awake procedure in laryngology, we found that a previously described low-cost, high-fidelity 3D-printed PIL simulator improved performance of PIL amongst senior otolaryngology residents, suggesting this accessible model may be a valuable educational adjunct for advanced trainees to practice PIL. LEVEL OF EVIDENCE: NA Laryngoscope, 134:318-323, 2024.

Evaluating depth of invasion across oral cavity subsites as part of the AJCC 8th edition T staging criteria for oral cavity squamous cell carcinoma.

BACKGROUND: The prognostic impact of depth of invasion (DOI) in American Joint Committee on Cancer 8th edition TNM staging for oral cavity squamous cell carcinoma (OCSCCa) across oral cavity subsites is unknown. METHODS: Overall survival of patients with pT1-4a OCSCCa in the National Cancer Database (2010-2017), stratified by tumor size and DOI across eight oral cavity subsites, was evaluated using multivariable-adjusted Cox proportional hazards modeling. RESULTS: When stratified by tumor size ≤2 cm and >2 cm, DOI >5 mm and DOI >10 mm were only associated with worse overall survival, respectively, for tumors of the oral tongue (Tumor size ≤2 cm, DOI >5 mm v DOI ≤5 mm: HR: 1.31, 95% CI: 1.12-1.53, p < 0.001; Tumor size >2 cm, DOI >10 mm v DOI ≤10 mm: HR: 1.15, 95% CI: 1.01-1.30, p = 0.03). DOI >5 mm and DOI >10 mm was not prognostic for any other tumor location. CONCLUSIONS: These findings suggest that the current staging schema for DOI in OCSCCa may not be prognostic across all oral cavity subsites.

The impact of undergoing surgical margin evaluation during endoscopic surgery for early-stage laryngeal squamous cell carcinoma.

BACKGROUND: The impact of evaluating versus not evaluating surgical margins for early-stage laryngeal squamous cell carcinoma (LSCC) has not been evaluated. METHODS: Overall survival was compared between patients who underwent endoscopic surgery for cT1-2, N0, M0 LSCC and had surgical margins evaluated versus not evaluated versus unevaluable in the National Cancer Database (2010-2019) using multivariable-adjusted Cox proportional hazards analyses. RESULTS: 7597 patients met study eligibility criteria. 4123 (54.3%) patients underwent margin evaluation, 1631 (21.5%) did not undergo margin evaluation, and 1843 (24.3%) had unevaluable margins. Patients undergoing margin evaluation had better overall survival than patients who did not undergo margin evaluation (HR: 0.88, 95% CI: 0.78-1.00, p = 0.044) and patients with unevaluable margins (HR: 0.88, 95% CI: 0.78-0.98, p = 0.021). Patients undergoing margin evaluation received significantly less adjuvant radiation. CONCLUSIONS: Surgical margin evaluation is an important prognostic factor for patients receiving endoscopic surgery for early-stage LSCC and should be conducted whenever possible.

Standardized Behavioral Treatment Improves Chronic Cough.

OBJECTIVES: Neurogenic Laryngeal Hypersensitivity (NLH) refers to a constellation of upper airway symptoms thought to be caused by a disturbance in afferent and/or efferent neural pathways creating an exaggerated hypersensitive laryngeal response. There is evidence to support behavioral therapy as treatment for improving symptoms from laryngeal motor dysfunction to sensory disturbance. This study aims to determine if there is significant symptomatic improvement in patients with NLH who received non-pharmacologic behavioral treatment performed by trained SLPs. STUDY DESIGN: A retrospective review. METHODS: A review of all patients with NLH from 2017 to 2020 was performed at a tertiary care voice and swallowing center. Subjects with persistent symptoms despite maximal medical management were considered for inclusion. Newcastle Laryngeal Hypersensitivity Questionnaire (NLHQ) was completed by patients before and after undergoing therapy by one of three trained SLPs. Posttherapy improvement was determined by utilizing the NLHQ's minimal clinically important difference of 1.7 points. RESULTS: A total of 81 patients were included in this study. Study participants included 61 women and 20 men with an average age of 60.64±14.05 years. There was a statistically significant difference between the pre and post therapy scores amongst all patients when treated by each individual SLP and all three SLPs combined (P < 0.008). There was a clinically significant change in 66% of all patients, 76% of which presented with abnormal NLHQ scores, and 14% who presented with normal NLHQ scores. CONCLUSIONS: A standardized behavioral treatment protocol for patients with symptoms consistent with NLH is effective in improving symptoms in a large majority of patients. When following a standardized protocol SLPs can obtain similar results for their patients.

Applications of Telemedicine in Speech-Language Pathology: Evaluation of Patient Satisfaction.

OBJECTIVES: The study aimed to evaluate patient satisfaction with speech-language therapy televisits and to identify factors influencing the level of satisfaction. METHODS: Participants were recruited from an academic tertiary voice and swallowing center who had completed ≥1 telehealth session of speech-language therapy with a speech-language pathologist between March, 2020 and April, 2021. Patient satisfaction was assessed using the Short Assessment of Patient Satisfaction (SAPS), a validated 7-item survey. Demographic characteristics of participants were collected from a review of patient charts. RESULTS: 65/239 patients completed the SAPS survey, representing a response rate of 27%. The average age of study participants was 54.92 ± 16.45 years, with 49.2% identifying as female, 33.9% as male, and 16.9% as trans-female. The mean SAPS score was 22.60 ± 3.89, with 84.62% of patients satisfied or very satisfied with their visit. Patients were most satisfied with provider respect (3.91 ± 0.34) and care received (3.74 ± 0.64), and least satisfied with visit length (2.32 ± 1.38) and explanation of treatment results (2.62 ± 1.72). Patient satisfaction was positively correlated with younger age and an increased number of televisits. Satisfaction did not differ significantly by gender identity, type of therapy received, insurance type, travel distance, or prior in-person therapy. CONCLUSION: Clinicians are able to achieve high patient satisfaction with speech-language therapy when delivered by telehealth. Patient satisfaction remained high across diverse patient populations and range of clinical needs. Clinicians should remain cognizant of the unique limitations of older patients when conducting telehealth visits. LAY SUMMARY: Clinicians are able to achieve high patient satisfaction with speech-language therapy when delivered via telehealth. Satisfaction remained high regardless of gender identity, type of therapy received, type of insurance, travel distance, or completion of prior in-person therapy. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:895-900, 2023.

Positive Predictive Value of Endoscopic Findings to Diagnose Vocal Fold Paresis.

OBJECTIVE: Laryngoscopy corresponding with laryngeal electromyography (LEMG) is essential in diagnosing vocal fold paresis. However, baseline asymmetry or other diseases oftentimes confound the exam, making diagnosis difficult. There is currently no agreed upon endoscopic criteria proven to reliably correlate with LEMG findings. We define a set of endoscopic findings termed "paresis triad" that, when present together, reliably correlate with LEMG. The paresis triad consists of (1) hypocontraction of the weak side of the larynx with increased ventricular show, (2) hypercontraction of the intact side with bulging of the false fold covering the ventricle, and (3) tilting of the interarytenoid cleft to the weak side. METHODS: We performed a retrospective review of patients with laryngeal asymmetry on laryngoscopy. Patients were divided into two groups: those with consistent paresis triad findings across all pitches and intensities, and those without. All patients underwent LEMG by a neurolaryngologist blinded to the laryngoscopic findings. The endoscopies were then rereviewed in a blinded manner by a second laryngologist to assess inter- and intrarater reliability for identification of the triad. RESULTS: Twelve patients met inclusion criteria (age 50 +/-15, 7F:5M). Nine had the paresis triad. Three had an inconsistent triad. All patients with the paresis triad had LEMG findings consistent with neurologic injury on the suspected side. All patients with inconsistent triad findings had normal LEMG. CONCLUSIONS: Our findings suggest the proposed laryngoscopic paresis triad may be useful objective criteria to diagnose paresis without the need for LEMG. Further prospective studies should examine a larger series of patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1712-1716, 2023.

IncobotulinimtoxinA (Xeomin) for the treatment of adductor laryngeal dystonia: A prospective, open-label clinical trial.

OBJECTIVES: Demonstrate an understanding of incobotulinumtoxinA efficacy in the treatment of adductor spasmodic dysphonia (SD). Understand that incobotulinumtoxinA can successfully be used as an alternative to onabotulinumtoxinA and for secondary non-responders. METHODS: We conducted a prospective open-label trial from 2016 until 2019 regarding the use of incobotulinimtoxinA for the treatment of adductor spasmodic dysphonia. Exclusion criteria included pregnant/nursing women, botulinum toxin for other indications, known allergy, neuromuscular or systemic diseases, use of aminoglycoside antibiotics, substance abuse, litigation regarding prior therapy, or other confounding conditions. Sixty-four injection sessions with completed with sixteen patients who were enrolled in the study and underwent EMG-guided incobotulinumtoxinA injections to the thyroarytenoid (TA) muscle using a hollow monopolar Teflon-coated needle via a trans-cricothyroid membrane approach. Dosages to each TA muscle were recorded and patients completed a Voice Handicap Index-10 (VHI-10), a validated worksheet regarding their perceived percent of normal function (PNF) following treatment, and a side effect profile. Outcomes were analyzed using the paired t-test. RESULTS: For primary transitioners to incobotulinimtoxinA, VHI-10 scores and best percent normal function did not significantly change. For non-responders, VHI-10 decreased from 32.5 on Botox to 19.5 on incobotulinimtoxinA and best PNF increased from 37.6 to 90 %, which was statistically significant. Transient side effects included breathiness. CONCLUSIONS: Our study demonstrates that incobotulinimtoxinA may be used successfully for adductor SD either as first line treatment or in secondary non-responders to onabotulinumtoxinA.

Management of Older Adults with Locally Advanced Head and Neck Cancer.

Thirty percent of patients with head and neck squamous cell carcinoma (HNSCC) are at least 70 years of age. This number continues to rise as life expectancy continues to increase. Still, older adults with HNSCC remain underrepresented in clinical trials, resulting in ambiguity on optimal management. Older adults are a complex patient population, often requiring increased support due to issues relating to functional and performance status, medical comorbidities, and medication management. Furthermore, in older adults with HNSCC, many of these conditions are independently associated with increased toxicity and worse outcomes. Toxicity in the older adult remains difficult to predict and to understand, and as treatment decisions are based on treatment tolerability, it is essential to understand the toxicities and how to minimize them. Novel predictive scores are being developed specifically for older adults with HNSCC to understand toxicity and to assist in personalized treatment decisions. There are clinical trials presently underway that are investigating shortened radiation courses and novel, less toxic systemic treatments in this population. In the forthcoming sections, we provide a detailed overview of the clinical data, treatment paradigms, and considerations in this population. This review provides a comprehensive overview of existing clinical data and clinical considerations in the older adult head and neck cancer population. Additionally, we provide a detailed overview of pertinent current and ongoing clinical trials, as well as future areas for investigation.

Long-term upper aerodigestive sequelae as a result of infection with COVID-19.

Objectives: Respiratory, voice, and swallowing difficulties after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may result secondary to upper airway disease from prolonged intubation or mechanisms related to the virus itself. We examined a cohort who presented with new laryngeal complaints following documented SARS-CoV-2 infection. We characterized their voice, airway, and/or swallowing symptoms and reviewed the clinical course of their complaints to understand how the natural history of these symptoms relates to COVID-19 infections. Methods: Retrospective review of patients who presented to our department with upper aerodigestive complaints as sequelae of prior infection with, and management of, SARS-CoV-2. Results: Eighty-one patients met the inclusion criteria. Median age was 54.23 years (±17.36). Most common presenting symptoms were dysphonia (n = 58, 71.6%), dysphagia/odynophagia (n = 16, 19.75%), and sore throat (n = 9, 11.11%). Thirty-one patients (38.27%) presented after intubation. Mean length of intubation was 16.85 days (range 1-35). Eighteen patients underwent tracheostomy and were decannulated after an average of 70.69 days (range 23-160). Patients with history of intubation were significantly more likely than nonintubated patients to be diagnosed with a granuloma (8 vs. 0, respectively, p < .01). Fifty patients (61.73%) were treated for SARS-CoV-2 without requiring intubation and were significantly more likely to be diagnosed with muscle tension dysphonia (19 vs. 1, p < .01) and laryngopharyngeal reflux (18 vs. 1, p < .01). Conclusion: In patients with persistent dyspnea, dysphonia, or dysphagia after recovering from SARS-CoV-2, early otolaryngology consultation should be considered. Accurate diagnosis and prompt management of these common underlying etiologies may improve long-term patient outcomes. Level of evidence: 4.

Predictive values of static endoscopic evaluation of swallowing in adults.

OBJECTIVE: Static endoscopic evaluation of swallowing (SEES) is an instrumental evaluation developed for in-office identification of patients who may benefit from a modified barium swallow study (MBSS). We aim to determine the predictive value of SEES for evaluating dysphagia. METHODS: A retrospective case series was performed on adults evaluated for dysphagia using SEES followed by MBSS at a single tertiary care center. Studies were evaluated by two blinded expert raters. RESULTS: Fifty-eight patients were included. Thin liquid penetration on SEES had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 0.86 (95% CI 0.70-0.95), 0.63 (95% CI 0.24-0.91), 0.91 (95% CI 0.76-0.98), and 0.5 (0.19-0.81), respectively, for predicting thin liquid penetration on MBSS, and 1.0 (95% CI 0.59-1.0), 0.29 (95% CI 0.15-0.47), 0.23 (95% CI 0.10-0.41), and 1.0 (95% CI 0.69-1.0) for predicting thin liquid aspiration on MBSS. Thin liquid aspiration on SEES had a sensitivity, specificity, PPV, and NPV of 0.67 (95% CI 0.09-0.99), 0.85 (95% CI 0.66-0.96), 0.33 (95% CI 0.04-0.78), and 0.96 (95% CI 0.79-1.0), respectively, for predicting thin liquid aspiration on MBSS. CONCLUSIONS: SEES may be used as an objective in-office test to screen for aspiration and penetration. Thin liquid penetration on SEES is moderately sensitive for predicting penetration on MBSS. Absence of thin liquid penetration or aspiration on SEES has a high NPV for excluding aspiration on MBSS. Abnormalities on SEES or the need to view the entire swallowing mechanism should prompt an MBSS for a more complete evaluation of dysphagia.Level of Evidence: 4.

How can we make better decisions about dystonic voice management?

PURPOSE OF REVIEW: The optimal diagnosis and management of dystonic voice disorders are rooted in the nuanced understanding of their phenomenology. Distinguishing between subtypes of vocal dystonia is challenging, not only because the audible and physical presentations of these dystonia's can seem similar, but also because there is a lack of scientific consensus regarding the diagnostic criteria for these conditions. To help improve the clinician's acumen we focus on outlining the classification of the top three neurological voice disorders, notably: spasmodic dysphonia, (2) spasmodic dysphonia with tremor, and essential tremor of the voice. We also provide an algorithmic approach based on current evidence-based literature to guide practitioners through the clinical diagnosis and management of each possible etiology. RECENT FINDINGS: Much remains unknown about the subtypes of vocal dystonia, and this gap in our knowledge likely limits our ability to advance clinical management. Still, continued experience evaluating and treating these patients yields refined clinical evaluations and decision making. SUMMARY: Improvements in our clinical decision-making can be made by acknowledging that our limited understanding of vocal dystonia may hinder what therapeutic interventions we can offer, yet our ability to accurately diagnose the dystonia is central to providing optimal patient management.

Bleomycin sclerotherapy following doxycycline lavage in the treatment of ranulas: A retrospective analysis and review of the literature.

OBJECTIVE: A ranula is a mucus-filled salivary pseudocyst that forms in the floor of the mouth, commonly arising from the sublingual or submandibular salivary glands following obstruction or trauma. Complete excision of the injured gland and removal of the cyst content is the first-choice therapy, but has the potential for complications related to injury to nearby structures. As such, minimally invasive approaches such as percutaneous sclerotherapy have been investigated. We aim to contribute to the literature by assessing the efficacy and safety of our technique through our experience with 18 patients over the last decade. METHODS: This retrospective study evaluated 18 patients with intraoral and plunging ranulas treated by percutaneous bleomycin ablation. The primary endpoint was the treatment result. Secondary endpoints included bleomycin dosage and complications. RESULTS: The study evaluated 12 males and six females with a median age of 23.5 years (range 13-39 years). At a final follow-up of at least 2 months (6.5±5.5 months), four patients demonstrated complete response (22%) and 14 patients demonstrated residual presence, recurrence, or regrowth of the lesion (78%). There were no statistically significant associations between outcomes and history of prior treatment, number of treatments, and size or type of ranula. No complications were noted. CONCLUSIONS: Our findings indicate that bleomycin, while safe for use in various head and neck malformations, is of limited utility in ranula therapy when the offending gland is not addressed primarily.

Enhancing Patient Experience in Office-Based Laryngology Procedures With Passive Virtual Reality.

OBJECTIVES: Virtual reality (VR) has been used as nonpharmacologic anxiolysis benefiting patients undergoing office-based procedures. There is little research on VR use in laryngology. This study aims to determine the efficacy of VR as anxiolysis for patients undergoing in-office laryngotracheal procedures. STUDY DESIGN: Randomized controlled trial. SETTING: Tertiary care center. METHODS: Adult patients undergoing office-based larynx and trachea injections, biopsy, or laser ablation were recruited and randomized to receive standard care with local anesthesia only or local anesthesia with adjunctive VR. Primary end point was procedural anxiety measured by the Subjective Units of Distress Scale (SUDS). Subjective pain, measured using a visual analog scale, satisfaction scores, and procedure time, and baseline anxiety, measured using the Hospital Anxiety and Depression Scale (HADS), were also collected. RESULTS: Eight patients were randomized to the control group and 8 to the VR group. SUDS scores were lower in the VR group than in the control group with mean values of 26.25 and 53.13, respectively (P = .037). Baseline HADS scores did not differ between groups. There were no statistically significant differences in pain, satisfaction, or procedure time. Average satisfaction scores in VR and control groups were 6.44 and 6.25, respectively (P = .770). Average pain scores were 3.53 and 2.64, respectively (P = .434). CONCLUSION: This pilot study suggests that VR distraction may be used as an adjunctive measure to decrease patient anxiety during office-based laryngology procedures. Procedures performed using standard local anesthesia resulted in low pain scores and high satisfaction scores even without adjunctive VR analgesia. LEVEL OF EVIDENCE: 1.