The Role of Telemedicine in Voice Therapy.

Introduction: During the COVID-19 pandemic, our institution adopted telemedicine for voice therapy (VT) as an alternative to in-person sessions, which has been integrated into our routine practice following the pandemic. This study aims to explore factors influencing completion rates among the 2 methods. Method: A retrospective chart review at a single tertiary care institution between 2019 and 2021 was conducted. Patient zip codes were used to determine Neighborhood Atlas® Area Deprivation Index (ADI) scores and travel distance to our institution. Demographic data, Voice Handicap Index (VHI) scores, and completion status were extracted. Results: Between 2019 and 2021, 521 patients were referred to VT at our institution, with 29% opting for telemedicine VT (TVT) sessions and 71% choosing in-person sessions. Seventy-four percent was female, and average age was 57.1 years (range:10-89 years old). No statistically significant differences were observed between the 2 groups regarding sex, age, employment status, or insurance type. Participants in the TVT group demonstrated notably higher completion rates compared to the in-person group [70.0% vs 31.6% (P < .001)]. The TVT group also comprised of a higher percentage of white patients, reported longer travel distances and times to reach therapy, but had comparable ADI scores to the in-person group. Moreover, there were no significant differences in pretreatment VHI scores between the 2 groups or between those who completed therapy versus those who did not (P = .501). Conclusion: Our findings indicate that patients utilizing the telemedicine platform had significantly higher VT completion rates compared to patients appearing in person. These results highlight the importance of being able to offer telemedicine-based options in the management of voice patients.

Dysphagia in the Aging Population.

Older adults are projected to outnumber children aged under 18 years for the first time in United States history by 2034, according to Census Bureau projections. This will lead to significant increase in age-related disorders. One of the most important disorders that will increase in prevalence is dysphagia, as it leads to malnutrition, dehydration, aspiration pneumonia, and death. In this article, the physiology of dysphagia in the elderly, as well as the management options is discussed.

Early postoperative complications following tracheotomy: Does suturing technique influence outcomes?

Introduction: Tracheotomy is one of the most commonly performed procedure by otolaryngologists, but no consensus exists on the effect of suturing techniques on postoperative complications. Stay sutures and Bjork flaps are utilized frequently for securing the tracheal incision to the neck skin in order to create a tract for recannulation. Methods: Retrospective cohort study of tracheotomies performed by Otolaryngology-Head and Neck Surgery providers (May 2014 to August 2020) was conducted to determine the effect of suturing technique on postoperative complications and patient outcomes. Patient demographics, medical comorbidities, indication for tracheostomy, and postoperative complications were analyzed with a statistical alpha set of .05. Results: Out of 1395 total tracheostomies performed at our institution during the study period, 518 met inclusion criteria for this study. Three hundred and seventeen tracheostomies were secured by utilizing a Bjork flap, while 201 were secured with up and down stay sutures. Neither technique was noted to be more commonly associated with tracheal bleeding, infection, mucus plugging, pneumothorax, or false passage of the tracheostomy tube. One mortality was noted following decannulation during the study period. Conclusion: Though various techniques exist; adverse outcomes are not associated with the manner in which a new tracheostomy stoma is secured. Medical comorbidities and the indications for tracheostomy likely play a more significant role in postoperative outcomes and complications. Level of evidence: Level 3.

A randomized controlled trial of the effects of flow phonation voice treatment for primary muscle tension dysphonia.

OBJECTIVE: The purpose of the study was to investigate the effects of flow phonation voice therapy on laryngeal physiology and vocal quality in persons with primary Muscle Tension Dysphonia (MTD1). METHODS: Seventeen participants with a diagnosis of MTD1 completed the study. Participants were randomized to two groups. Group 1 (9 participants) received flow phonation treatment and individualized vocal hygiene education for 12 sessions over six weeks. Group 2 (8 participants) received vocal hygiene education only for three weeks (6 sessions), followed by another three weeks (6 sessions) of both vocal hygiene instruction and flow phonation therapy. Treatment consisted of cup-bubble blowing, gargling, and stretch and flow exercises. Visual-perceptual. auditory-perceptual, acoustic, aerodynamic and voice-related quality-of-life measures were obtained at three time points: before treatment, three weeks after initiation of treatment and after completion of treatment. RESULTS: Voice quality was perceived to be significantly improved in both groups. Voice related quality-of-life trended toward improvement for both groups across time points. Changes in aerodynamic and acoustic measures did not reach statistical significance compared to baseline for both groups. Visual comparisons of laryngeal closure patterns demonstrated comparably better outcomes for Group 1. CONCLUSIONS: Results of this study indicate flow phonation exercises can potentially be favorably employed for individuals with MTD1. In particular, it appears that the exercises aid in alleviating vocal hyperfunction, as evidenced by visual perceptual stroboscopic analysis, and clinically improved auditory-perceptual measures.

The Effects of Self-Esteem, Coping, and Voice-Related Quality of Life on Communicative Participation Before and After BOTOX® Treatment for Spasmodic Dysphonia.

OBJECTIVES/HYPOTHESIS: The purpose of this study was to (1) investigate the percent change in communicative participation in individuals with spasmodic dysphonia (SD) pre- and post-BOTOX® treatment; and (2) to investigate if percent change in communicative participation is predicted by change in self-esteem, coping, and/or Voice-Related Quality of Life (V-RQOL) pre- and post-BOTOX® treatment. STUDY DESIGN/METHODS: A cross-sectional study of 49 patients was conducted across three clinics, with each participant completing the Rosenberg Self-Esteem Scale, the Voice Disability Coping Questionnaire (VDCQ), the V-RQOL instrument, and the Communication Participation Item Bank (CPIB) before BOTOX® treatment and 10-14 days following BOTOX® treatment. DATA ANALYSIS: For Research Question 1, a paired t test was applied to test the equality of means for CPIB and to test the pre-post changes among other composite measurements before and after the BOTOX® treatment. For Research Question 2, a multivariable linear regression model was applied with percent change in CPIB as a main outcome, and change in Rosenberg Self-Esteem Scale, VDCQ, and the V-RQOL as independent variables (or covariates) in order to test the associations. RESULTS: The results indicated that pre- and post-BOTOX® measures of communicative participation are not statistically significantly different among the participants with SD. There was a strong positive correlation between change in coping and voice-related QOL. CONCLUSIONS: A better understanding of the relationship between communicative participation and voice-related QOL is warranted. Item analysis of the V-RQOL and the VDCQ may illustrate coping strategies and functional impairments and provide further information regarding highly variable communicative participation among individuals with SD.

An Investigation of the Relationship between Adherence to Voice Therapy for Muscle Tension Dysphonia and Employment, Social Support, and Life Satisfaction.

PURPOSE: The purpose of this study was to investigate whether a relationship exists between employment status, perception of life quality (ie, vocal impairment, health, life satisfaction, and social support), and adherence to voice therapy for persons with muscle tension dysphonia (MTD). This study extends recent work as it evaluates investigating the impact of social support and life satisfaction on adherence to voice therapy for MTD. METHOD: A cross-sectional study of 45 individuals diagnosed with MTD who participated in voice therapy between January 2014 and December 2015 at the University of Arkansas for Medical Science's Voice and Swallowing Center in Little Rock, Arkansas participated in this study. Participants provided information regarding employment status and completed the Satisfaction with Life Scale and the Quality of Relationships Inventory. RESULT: Sixty percent of participants completed voice therapy. Patients who completed voice therapy were more likely to report gainful employment (P = 0.038) or less confidence in a specific and significant personal relationship (P = 0.004). CONCLUSION: This study discovered a moderate effect between employment status and adherence to voice therapy for MTD as well as relationship confidence and adherence.

Using Didactics and Simulation to Enhance Comfort, Knowledge, and Skills of Nonsurgical Trainees Caring for Patients With Tracheostomy and Laryngectomy.

INTRODUCTION: Management of tracheostomy and laryngectomy is an important skill for physicians who often care for patients with multiple, comorbid, chronic medical conditions. There is little published literature on training for tracheostomy and laryngectomy care during nonsurgical specialty residencies. This project was designed to assess and improve comfort with, knowledge of, proficiency in tracheostomy and laryngectomy care. METHODS: This prospective observational study comprised 122 physician trainees from internal medicine, emergency medicine, and anesthesia training programs at the University of Arkansas for Medical Sciences participating in a simulation-based curriculum from April 2016 to December 2016. The curriculum included didactic session, hands-on experience performing a tracheostomy change, and practicing emergency scenarios on interactive, high-fidelity simulation mannequins. Preintervention and postintervention assessments of self-perceived comfort, objective knowledge, and tracheostomy change proficiency were performed and results compared. RESULTS: Self-perceived comfort improved from a mean Likert score from 2.12 to 4.43 (P = 0.009). Knowledge mean scores improved from 57% to 82% (P < 0.001) on multiple-choice testing. Tracheostomy change proficiency mean scores improved from 41% to 84% (P < 0.001) of proficiencies correctly performed. Six-month follow-up assessment of comfort and knowledge showed statistically significant retention of comfort (P = 0.002) and knowledge (P = 0.026). CONCLUSIONS: Comprehensive tracheostomy and laryngectomy education, which combines enhancement of knowledge with simulation of both routine and emergent aspects of care, is an effective strategy in improving confidence with, knowledge of, proficiency in tracheostomy and laryngectomy care. Retention of confidence and knowledge was demonstrated 6 months later.

Adverse Events after Rigid and Flexible Endoscopic Repair of Zenker's Diverticula: A Systematic Review and Meta-analysis.

OBJECTIVE: To determine adverse events after endoscopic flexible vs endoscopic rigid cricopharyngeal myotomy for treatment of Zenker's diverticulum (ZD). DATA SOURCES: Systematic review of MEDLINE, Web of Science, CINAHL, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials for all years according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Additional studies were identified from review citations and a by hand search of manuscripts referencing ZD. REVIEW METHODS: A structured literature search was conducted to identify studies for this systematic review. Methodological Index for Non-randomized Studies (MINORS) criteria were applied to assess study quality. For inclusion, each study had to provide data for at least 10 adult patients who had undergone endoscopic ZD repair reporting clear association with the postprocedure course in each case. Data extracted included all reported adverse events, recurrences, follow-up, and operative times. RESULTS: In total, 115 studies were included. All but 8 were retrospective case series. Sixty-one reported series of patients after rigid endoscopic stapler repair, 31 after rigid laser repair, and 13 with other rigid endoscopic instruments. Twenty-nine flexible endoscopic studies were included. Mortality, infection, and perforation were not significantly more likely in either the rigid or the flexible group, but bleeding and recurrence were more likely after flexible endoscopic techniques (20% vs <10% and 4% vs 0%, respectively). Dental injury and vocal fold palsy were reported rarely in the rigid endoscopic groups. CONCLUSIONS: Adverse events are rare after endoscopic Zenker's repair. The flexible approach minimizes exposure limitations and can be completed in some patients without general anesthesia. Transoral rigid approaches result in fewer revision surgeries compared with flexible diverticulotomy.

Assessment of Gender Differences in Perceptions of Work-Life Integration Among Head and Neck Surgeons.

IMPORTANCE: The factors that contribute to gender discrepancies among attending head and neck surgeons have yet to be fully characterized. OBJECTIVE: To evaluate the association of gender difference with the perceived quality of life of head and neck oncological surgeons. DESIGN, SETTING, AND PARTICIPANTS: Following approval from the American Head and Neck Society (AHNS) review board, a web-based survey study of 37 questions, mainly assessing daily lifestyle and quality of life, was sent to the entire membership. MAIN OUTCOMES AND MEASURES: The main outcome assessed was perceived quality of life among female and male surgeons. RESULTS: A total of 261 members (13.0%) responded, 71 women (27.2%) and 190 men (72.8%). In all, 66 female (92.5%) and 152 male (80%) surgeons worked at an academic institution. A greater percentage of women were at the associate professor level than men (20/64 [31%] vs 37/152 [24%]; difference, 6.9%; 95% CI, -5.6% to 20.5%) and a greater percentage of men were at the professor level than women (72/152 [47%] vs 18/64 [28%]; difference, 19%; 95% CI, 4.9% to 31.6%). This discrepancy was evident in administrative roles as well, with 4 female (6.2%) vs 23 male (17.6%) department chairs (difference, 11.3%; 95% CI, 0.9%-19.6%). Of the 71 women, 18 (25%) were not in a long-term relationship or were divorced, as opposed to 6 (3.2%) men (difference, 22%; 95% CI, 12.8%-33.5%). Women had a mean (median) 1.18 (1) children, whereas men had 2.29 (2) children. Mean age that participating women had their first child was 35.1 years, whereas the man age for men was 31.9 years. Overall, 117 men (61.9%) and 45 women (67.2%) found their family time limited compared with other otolaryngological subspecialties. Despite these results, 101 men (53.4%) vs 37 women (55.2%) stated that they had a good work-life balance. Six women vs 8 men indicated they would choose a different subspecialty if they could. CONCLUSIONS AND RELEVANCE: Despite improvements in work hours and gender balance in residency programs, discrepancy in the number of female surgeons with senior academic rankings continues. However, female and male head and neck surgeons appear equally content with their subspecialty choice.

Dysphagia in the Older Patient.

Dysphagia in older adults is a challenging problem and necessitates a team approach. The key to effective management is recognition. Patients tend to dismiss their symptoms as normal aging; therefore, early diagnosis depends on the diligence of the primary care doctors. No diagnostic technique can replace the benefits of a thorough history, with a detailed understanding of nutritional status and aspiration risk. Although one of the main goals in management is to ensure safe swallowing, the impact of a nonoral diet on the quality of life of patients should not be underestimated.

Retraction notice to: Sensitization of squamous cell carcinoma to cisplatin induced killing by natural agents.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor in Chief. An investigation by Wayne State University identified a discrepancy between the data reported in Figures 5 and the original collected data. The investigation committee concluded that this undermined the scientific basis of the publication, that no credible replacement data were available, and advised that the publication should be retracted.

Geriatric Dysphagia.

Geriatric dysphagia is an unrecognized and underdiagnosed problem with significant morbidity and potential mortality. It requires diligence by the clinician and a team approach for successful management. Careful history-taking is the key in the treatment of these patients and determines further workup, as well as treatment.

Voice and Swallowing Outcomes of Unilateral Vocal Fold Paralysis: Comparing Younger Adult and Geriatric Patients.

Objective To compare voice and swallowing outcomes after treatment in younger adult (<65 years) and geriatric (≥65 years) patients with unilateral vocal fold paralysis (UVFP). Study Design Case series with chart review. Setting Tertiary care center. Subjects and Methods The cases of patients presenting to a tertiary voice clinic with UVFP between June 2005 and February 2015 were reviewed. Clinical characteristics and outcomes in a geriatric subset were compared with those in younger adult group. Results A total of 206 patients met our inclusion criteria (n = 110, <65 years; n = 96, ≥65 years). Etiology was most commonly iatrogenic (59.2%), and computed tomography led to diagnosis for 62.3% of patients for whom it was obtained. The Voice Handicap Index improved on average by 31.3 points after treatment ( P < .001), with equal improvement between the patient subsets ( P = .71). Swallowing, as objectively assessed by the National Outcomes Measurement System for modified barium swallow, showed a statistically significant improvement in the patient population as a whole (-0.9, P = .02) but was not significantly different within the subgroups (younger, P = .07; geriatric, P = .25). Conclusion Geriatric patients have similar voice and swallowing outcomes as younger adults and should be treated equally aggressive.

Effects of supramaximal balloon dilatation pressures on adult cricoid and tracheal cartilage: A cadaveric study.

OBJECTIVES/HYPOTHESIS: Cricoid fracture is a serious concern for balloon dilatation in airway stenosis. Furthermore, there are no studies examining tracheal rupture in balloon dilatation of stenotic segments. The aim of this study was to evaluate the effect of supramaximal pressures of balloons on the cricoid and tracheal rings. STUDY DESIGN: Prospective cadaveric study. METHODS: Seven cadaveric laryngotracheal complexes of normal adults with intact cricothyroid membranes were acquired. Noncompliant vascular angioplasty balloons (BARD-VIDA) were used for dilatation. The subglottis and trachea were subjected to supramaximal dilatation pressures graduated to nominal burst pressure (NBP) and, if necessary, rated burst pressure (RBP). Larger-diameter balloons, starting from 18 mm size to 24 mm, were used. Dilatations were maintained for 3 minutes. RESULTS: The cricoid ring was disrupted by larger-diameter balloons (22 mm and 24 mm) even at lower pressures (less than NBP) in six cases. Tracheal cartilages were very distensible, and external examination after supramaximal dilatation (24 mm close to RBP) revealed no obvious cartilage fractures or trachealis tears. Histopathological examination revealed sloughing of mucosa in the areas corresponding to balloon placement, but no microfractures or disruption of the perichondrium of tracheal ring cartilages. CONCLUSIONS: These results indicate that the cricoid is vulnerable to injury from larger balloons even at lower dilatation pressures. The tracheal cartilages and the membranous wall of the trachea remained resilient to supramaximal dilatation and larger balloons. LEVEL OF EVIDENCE: NA. Laryngoscope, 128:1304-1309, 2018.

Cricopharyngeal dysfunction: A systematic review comparing outcomes of dilatation, botulinum toxin injection, and myotomy.

OBJECTIVES: Cricopharyngeal dysfunction may lead to severe dysphagia and aspiration. The objective of this systematic review was to evaluate the existing studies on the effectiveness of myotomy, dilatation, and botulinum toxin (BoT) injection in the management of cricopharyngeal dysphagia. METHODS: PubMed and Web of Science databases were searched to identify eligible studies by using the terms "cricopharyngeal dysfunction," "cricopharyngeal myotomy," "cricopharyngeal botox," "cricopharyngeal dilation," and their combinations from 1990 to 2013. This was supplemented by hand-searching relevant articles. Eligible articles were independently assessed for quality by two authors. Statistical analysis was performed. RESULTS: The database search revealed 567 articles. Thirty-two articles met eligibility criteria and were further evaluated. The reported success rates of BoT injections was between 43% and 100% (mean = 76%), dilation 58% and 100% (mean = 81%), and myotomy 25% and 100% (mean = 75%). In logistic regression analysis of the patient-weighted averages, the 78% success rate with myotomy was significantly higher than the 69% success rate with BoT injections (P = .042), whereas the intermediate success rate of 73% with dilation was not significantly different from that of either myotomy (P = .37) or BoT (P = .42). There was a statistically significant difference between endoscopic and open myotomy success rates (P = .0025). Endoscopic myotomy had a higher success rate, with a 2.2 odds ratio. CONCLUSIONS: The success rate of myotomy is significantly higher than the success rate of BoT injections in cricopharyngeal dysfunction. Moreover, endoscopic myotomy was found to have a higher success rate compared to open myotomy.

Comorbidities and factors associated with endoscopic surgical outcomes in adult laryngotracheal stenosis.

This study which is a retrospective chart review aims to characterize the comorbidities associated with adult laryngotracheal stenosis and evaluate the relationship of these with stenosis grade, length, surgical interventions, and surgical intervals. Patients' demographics, medical and surgical comorbidities, grade of stenosis, quantity and degree of balloon dilations, dilation intervals, open airway procedures, and tracheotomy status were recorded from 2002 to 2012, at a tertiary voice and airway center. Surgical outcomes were evaluated in relation to patient comorbidities, stenosis quality, and surgical procedures. A total of 101 patients with laryngotracheal stenosis were examined with female patients comprising 71 % of the population. Seventeen patients (16.8 %) had idiopathic stenosis. Number of balloon dilations ranged from 0 to 24 (mean = 3.3). The average time between dilations was 38.4 weeks (range = 1.14-215.8 weeks). The patients with idiopathic stenosis were found to have a lower grade (p = 0.0066). Fifty-two patients (51.5 %) received a tracheotomy at one point during their management. The 14 patients (13.9 %) who remained tracheotomy dependent had a body mass index (BMI) of >30. No statistically significant correlation was found when the patients' age, BMI and comorbidites were compared with the grade of stenosis, number of balloon dilatations needed and other surgical interventions. On the other hand, interval in between surgeries was found to be longer in patients without an intubation history, and in idiopathic SGS (p = 0.004, p = 0.015, respectively). There was no significant relationship between surgical interval and gender, BMI, length of stenosis, grade (p = 0.059, p = 0.47, p = 0.97, p = 0.36, respectively). Airway stenosis in adults is complicated by the presence of multiple comorbidities. Better understanding of the etiology could aid in the prevention of the injury before it forms.

Telepractice Versus In-Person Delivery of Voice Therapy for Primary Muscle Tension Dysphonia.

PURPOSE: The purpose of this study was to investigate the utility of telepractice for delivering flow phonation exercises to persons with primary muscle tension dysphonia (MTD). METHOD: Fourteen participants with a diagnosis of primary MTD participated, 7 on site and 7 at remote locations. Each participant received 12 treatment sessions across 6 weeks. Treatment consisted of flow phonation voice therapy exercises. Auditory-perceptual, acoustic, aerodynamic, and quality-of-life measures were taken before and after treatment. RESULTS: Perceptual and quality-of-life measures were significantly better posttreatment and were statistically equivalent across groups. Acoustic and aerodynamic measures improved in both groups, but changes did not reach statistical significance. Results for the 2 service delivery groups were comparable, with no significant differences observed for perceptual and quality-of-life measures. CONCLUSIONS: Although the American Speech-Language-Hearing Association supports the use of telepractice for speech-language pathology services, evidence for the use of telepractice for providing behavioral treatment to patients with MTD has been lacking. The results of this study indicate that flow phonation exercises can be successfully used for patients with MTD using telepractice.