Objective Comparison of White Light and Narrow-Band Imaging for Detecting Scars, Sulci and Nodules.

INTRODUCTION: Narrow-band imaging (NBI) can improve detection of lesions in the aerodigestive tract. However, its role in benign lesions of the larynx is unclear. This study aims to determine whether NBI improves the detection of scars, sulci, and nodules compared to panchromatic lighting using objective image analysis. METHODS: In total, 120 vocal folds (VFs) were analyzed with and without NBI (21 normal, 15 scars, 16 sulci, and 45 nodules). Each VF image had anterior, middle, and posterior thirds analyzed for brightness using an area morphometry software (Optimas 5.1a). The middle-third with the lesion was analyzed against surrounding VF segments for average and standard deviation (SD) in absolute grayscale. RESULTS: The use of panchromatic light resulted in greater illumination and grayscale values than NBI. All lesions tended to be in the mid-membranous fold. Under panchromatic light, change in brightness when comparing anterior versus middle (A-M) was +6.1% for normal, versus 6.5%, 8.1%, and 7.1% for sulci, nodules, and scars, respectively. Under NBI, they were 9.0% (normal), 12.3% (sulci), 13.7% (nodules), and 13.1% (scars). A greater SD of luminescence was observed at pathology sites (p < 0.05) when using NBI. The change in absolute grayscale at all lesion sites was greater when using NBI than when using panchromatic light (p < 0.05). CONCLUSION: NBI significantly enhanced the area of pathology in patients with nodules, sulci, and scars. Greater SD values in grayscale at pathologic sites were observed compared at normal sites. Thus, NBI may improve the detection of phonotraumatic lesions compared to panchromatic light. LEVEL OF EVIDENCE: N/A Laryngoscope, 2024.

Simultaneous High-Speed Video Laryngoscopy and Acoustic Aerodynamic Recordings during Vocal Onset of Variable Sound Pressure Level: A Preliminary Study.

Voicing: requires frequent starts and stops at various sound pressure levels (SPL) and frequencies. Prior investigations using rigid laryngoscopy with oral endoscopy have shown variations in the duration of the vibration delay between normal and abnormal subjects. However, these studies were not physiological because the larynx was viewed using rigid endoscopes. We adapted a method to perform to perform simultaneous high-speed naso-endoscopic video while simultaneously acquiring the sound pressure, fundamental frequency, airflow rate, and subglottic pressure. This study aimed to investigate voice onset patterns in normophonic males and females during the onset of variable SPL and correlate them with acoustic and aerodynamic data. MATERIALS AND METHODS: Three healthy males and three healthy females were studied by simultaneous high-speed video laryngoscopy and recording with the production of the gesture [pa:pa:] at soft, medium, and loud voices. The fiber optic endoscope was threaded through a pneumotachograph mask for the simultaneous recording and analysis of acoustic and aerodynamic data. RESULTS: The average increase in the sound pressure level (SPL) for the group was 15 dB, from 70 to 85 dB. The fundamental frequency increased by an average of 10 Hz. The flow was increased in two subjects, reduced in two subjects, and remained the same in two subjects as the SPL increased. There was a steady increase in the subglottic pressure from soft to loud phonation. Compared to soft to medium phonation, a significant increase in glottal resistance was observed with medium-to-loud phonation. Videokymogram analysis showed the onset of vibration for all voiced tokens without the need for full glottis closure. In loud phonation, there is a more rapid onset of a larger amplitude and prolonged closure of the glottal cycle; however, more cycles are required to achieve the intended SPL. There was a prolonged closed phase during loud phonation. Fast Fourier transform (FFT) analysis of the kymography waveform signal showed a more significant second- and third-harmonic energy above the fundamental frequency with loud phonation. There was an increase in the adjustments in the pharynx with the base of the tongue tilting, shortening of the vocal folds, and pharyngeal constriction. CONCLUSION: Voice onset occurs in all modalities, without the need for full glottal closure. There was a more significant increase in glottal resistance with loud phonation than that with soft or middle phonation. Vibration analysis of the voice onset showed that more time was required during loud phonation before the oscillation stabilized to a steady state. With increasing SPL, there were significant variations in vocal tract adjustments. The most apparent change was the increase in tongue tension with posterior displacement of the epiglottis. There was an increase in pre-phonation time during loud phonation. Patterns of muscle tension dysphonia with laryngeal squeezing, shortening of the vocal folds, and epiglottis tilting with increasing loudness are features of loud phonation. These observations show that flexible high-speed video laryngoscopy can reveal observations that cannot be observed with rigid video laryngoscopy. An objective analysis of the digital kymography signal can be conducted in selected cases.

Platelet Rich Plasma (PRP) Treatment in Recalcitrant, Bilateral Phono-traumatic Lesions.

OBJECTIVE: Mature vocal fold nodules and fibrous phono-traumatic lesions that have failed standard voice therapy can be challenging. Autologous platelet-rich plasma (PRP) is rich in growth factors and easily obtained from a simple blood draw. Growth factor injection into the vocal folds may reverse the scar and inflammation in recalcitrant, bilateral phono-traumatic lesions such as mature vocal fold nodules. This study reports the short-term (3months) voice results after PRP injection in 11 subjects with recalcitrant, bilateral phono-traumatic lesions that have failed voice therapy. MATERIALS AND METHODS: Serial autologous PRP injections were used to treat 11 patients with recalcitrant, bilateral phono-traumatic lesions in an office setting. All had prior conservative voice therapy or surgery and were deemed failures. Pre and post-treatment video stroboscopy, Voice Handicap Index (VHI-10), and Cepstral Spectral Index of Dysphonia (CSID) before and after treatment (3months) were tabulated and compared. An expert rater blinded to the treatment condition rated the stroboscopy and voice results. RESULTS: At 3months postinjection, 9 of the 11 patients reported improved VHI-10 and noted sustained voice improvement after PRP injections. Median VHI-10 changed from 20 to 13 (P < 0.05 paired t test). The CSID scores changed from 17 to 5 (NS P > 0.05, paired t test). Nine of 11 patients reported improved vocal effort and stamina. Stroboscopy ratings were better after treatment than before treatment in 7 of the 11 subjects. CONCLUSION: Short-term improvements in voice may occur in patients with recalcitrant, bilateral phono-traumatic lesions following PRP injection. PRP injections into the vocal folds may be a new treatment for nonsurgical intervention in patients with recalcitrant, bilateral phono-traumatic lesions. LEVEL OF EVIDENCE: II.

Transverse Cordotomy with Thyroarytenoid Myectomy for Bilateral Vocal Fold Immobility.

We propose a modification of the transverse cordotomy procedure which improves the predictable airway outcome and allows for better voice. Laryngoscope, 2023.

Platelet-rich plasma in treatment of scar, atrophy, and sulcus: Short- and long-term results.

Objective: Platelet-rich plasma (PRP) is rich in growth factors and is easily obtained from blood samples. Long-term data after PRP injection into the larynx should be improved. This study reports the short-term (3 months) and long-term (12 months) voice results after PRP injection. Materials and Methods: Sixty-three patients with scars (n = 34), sulcus vocalis (n = 17), recalcitrant nodules (n = 5), atrophy (n = 4), or a combination of these (n = 3) were included (158 injections; median follow-up = 12.3 months). Stroboscopy, voice handicap index (VHI-10), and cepstral spectral index of dysphonia (CSID) before and after treatment (3 months) and at 12 months were tabulated. Results: VHI-10 changed from 19.5 to 14 at 3 months and 21 to 15 in the long term. The CSID scores improved from 31 to 21 in the short term and 31 to 26 in the long term (p < 0.001, paired t-test). Patients reported improved vocal effort and stamina with slight VHI or CSID score changes. Stroboscopy revealed improved closure and mucosal waves. Patients with severe dysphonia were less likely to improve compared to those with mild to moderate dysphonia. Some patients showed short-term improvements and then deteriorated back to baseline CSID over time (p < .05, paired t-test). Conclusion: Both short- and long-term improvements in voice following PRP injection have been reported. Patients with mild-to-moderate dysphonia had better outcomes. PRP injection is an alternative treatment for patients with mild-to-moderate dysphonia due to vocal fold scarring, sulcus, and atrophy. Level of evidence: II Prospective case series treatment.

Long-Term Voice Outcomes After Type I, Type II, or Type V Cordectomy.

INTRODUCTION: We compare long-term voice outcomes in patients treated with European Laryngeal Society (ELS) classification Type I, Type II, or Type V cordectomy. The aim is to understand the impact of Type V cordectomy on voice outcomes in relation to Type I and Type II cordectomy. METHODS: A retrospective review of patients treated with Type I, Type II, or Type V cordectomy by a single surgeon over a 20-year period was performed. Voice Handicap Index-10 (VHI-10) scores, Cepstral Spectral Index of Dysphonia (CSID) measures from CAPE-V sentences, and two-rater GRBAS scores were analyzed. RESULTS: Sixty-two patients were identified with a mean follow-up of 52 months. Of these, there were 43 Type I and 19 Type II cordectomies, including 8 in each group with Type V resections. Significant differences in all parameters were noted between the Type I (VHI 5.7, CSID 20.6, Grade 1.3) and the Type II cohorts (VHI 12.6, CSID 36.3, Grade 1.8) who did not undergo Type V cordectomy. Patients undergoing Type V cordectomy demonstrated voice outcomes (VHI 9.4, CSID 35.6, Grade 1.7) which fell between those of Type I and Type II cordectomies. CONCLUSIONS: Better long-term subjective, objective, and computer-analyzed voice outcomes are noted for patients undergoing Type I rather than Type II cordectomy. When Type V cordectomy is performed, voice outcomes are comparable to those of both Type I and Type II cordectomy, a surprising finding given the expectation of worsened dysphonia in longer resections. Further work is needed to explain this finding and define voice outcomes after Type V cordectomy.

Short-Term Voice Improvement after Repeated Office-Based Platelet-Rich Plasma PRP Injection in Patients with Vocal Fold Scar, Sulcus, and Atrophy.

INTRODUCTION: Improving the voice of patients with vocal atrophy, scar, and sulcus vocalis remains challenging. Platelet-rich plasma (PRP) is an autologous biological suitable for regenerative medicine. Office-based injections of PRP may serve as a source of improved wound healing. MATERIALS AND METHODS: Thirty two office based injections of PRP were performed in 14 patients with scar, sulcus, and vocal atrophy (12 scars, 1 sulcus, and 1 atrophy). PRP was prepared using 20 cc blood draw and double centrifugation method. Injection laryngoplasty was performed using trans cervical or indirect trans oral technique (10 trans cervical, 22 trans-oral). Volume of PRP use was 0.5-0.7 cc per side. Injections varied from 1 to 3 injections at monthly intervals. Videostroboscopy, Voice Handicap Index (VHI-10), and an objective analysis of the voice using Cepstral Peak Prominence (Cepstral Spectral Index of Dysphonia) were recorded. An expert rater speech pathologist rated the audio and stroboscopy results. RESULTS: Median follow-up was 15 months. No patients were made worse. The mean VHI-10 before the injection was 23. VHI-10 after the injection was 12.5 (P < 0.01). The mean Cepstral Spectral Index of Dysphonia score for CAPE-V sentence was 42.5 before the injection and 23.5 (P < 0.01) after the injection. The expert rater thought the post treatment was better (9/14 acoustic, 10/14 stroboscopy). Eleven of the 14 patients thought the intervention was worthwhile to repeat. The other 3 patients thought the improvement was transient. CONCLUSION: Office PRP injection into the vocal fold of patients with scar, sulcus, and atrophy may result in short term voice improvements. It is a biological worth considering.

Simultaneous Botox and Augmentation Injection Laryngoplasty in Patients With Adductor Spasmodic Dysphonia (ASD) and Tremor.

OBJECTIVE: Although Botulinum Toxin (BOTOX) is effective for adductor spasmodic dysphonia (ASD) and essential vocal tremor (EVT), the side effects of breathy dysphonia may result in reluctance to pursue BOTOX treatment. We sought to improve results in selected elderly tremor patients with EVT and in professional voice users with ASD by simultaneous BOTOX injection and injection laryngoplasty using Hyaluronic acid (HA/Botox). MATERIAL AND METHODS: Between July 2018 and March 2022, 23 simultaneous HA/Botox using LEMG control were done in eight patients with ASD and EVT (23 of 406 Botox Injections). All eight patients have previously reported unwanted side effects with poor voice results with Botox. Three patients had tremor with presbyphonia. Injection of Botox is performed first using LEMG control, followed by bilateral LEMG guided injection of 0.1 cc of HA. RESULTS: All HA/Botox injections were tolerated well. All patients reported some improved voice. Two patients did not go on to further HA injections while the others six have requested ongoing simultaneous HA/Botox injections. Patients with EVT and presbyphonia noted greater stability of voice than Botox alone. It lasted through the injection cycle. The professional voice users reported less breathy voice that allowed them to work right after the BOTOX injection. CONCLUSION: Simultaneous BOTOX injection with injection laryngoplasty using HA may be helpful in patients with tremor and presbyphonia. It also may be considered in professional voice users with ASD to reduce side effects of BOTOX.

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.

Long-term outcomes of aminolevulinic acid photodynamic therapy for treatment of recalcitrant laryngeal premalignant lesions.

OBJECTIVE: To assess long-term outcomes of ALA-PDT in treating recalcitrant laryngeal leukoplakia. STUDY DESIGN: Retrospective Case-Control. METHODS: We reviewed all laryngeal leukoplakia patients treated with ALA-PDT compared with angiolytic laser treatment alone (585 nm PDL or 532 nm KTP laser) from 2000 to 2019. Patients with laryngeal cancer (or a history of laryngeal cancer), leukoplakia previously treated with radiation and no pathologic report were excluded. Patient demographics, procedure details and outcomes were examined including histopathologic diagnosis, procedures performed, ALA usage, recurrence of leukoplakia and the development of cancer. RESULTS: We identified 132 patients with laryngeal leukoplakia: 42 were treated with ALA-PDT and 90 were treated with an angiolytic laser alone (Laser group). The proportion of cases of high-grade dysplasia was 57.1% in the ALA-PDT group compared to 32.2% in the Laser group. In high-grade dysplasia cases, there was a statistically significant better recurrence-free survival (RFS) at 12 months and 60 months in those who underwent ALA-PDT 71.4% and 7.1% vs Laser 25% and 0% (p = .01). However, for overall groups, there was no difference in RFS (p = .25). Voice outcomes (patient subjective report) improved or were stable in 75% of subjects with no serious side effects reported. CONCLUSION: ALA-PDT for recalcitrant and high-grade dysplasia is highly effective with improved recurrence-free survival compared to laser alone. ALA-PDT may be an appropriate therapy in patients who have failed prior angiolytic laser alone.

Acute Vocal Fold Paresis and Paralysis After COVID-19 Infection: A Case Series.

OBJECTIVE: Evidence demonstrates neurotropism is a common feature of coronaviruses. In our laryngology clinics we have noted an increase in cases of "idiopathic" vocal fold paralysis and paresis in patients with no history of intubation who are recovering from the novel SARS-Cov-2 coronavirus (COVID-19). This finding is concerning for a post-viral vagal neuropathy (PVVN) as a result of infection with COVID-19. Our objective is to raise the possibility that vocal fold paresis may be an additional neuropathic sequela of infection with COVID-19. METHODS: Retrospective review of patients who tested positive for COVID-19, had no history of intubation as a result of their infection, and subsequently presented with vocal fold paresis between May 2020 and January 2021. Charts were reviewed for demographic information, confirmation of COVID-19 infection, presenting symptoms, laryngoscopy and stroboscopy exam findings, and laryngeal electromyography (LEMG) results. RESULTS: Sixteen patients presented with new-onset dysphonia during and after recovering from a COVID-19 infection and were found to have unilateral or bilateral vocal fold paresis or paralysis. LEMG was performed in 25% of patients and confirmed the diagnosis of neuropathy in these cases. CONCLUSIONS: We believe that COVID-19 can cause a PVVN resulting in abnormal vocal fold mobility. This diagnosis should be included in the constellation of morbidities that can result from COVID-19 as the otolaryngologist can identify this entity through careful history and examination.

Voice assessment of fat injection vs medialization laryngoplasty in nonparalytic dysphonia.

OBJECTIVE: Compare long-term voice outcomes in patients treated with FIM or BML for nonparalytic dysphonia. There is controversy whether fat injection medialization (FIM) is a durable alternative to bilateral medialization laryngoplasty (BML) for nonparalytic dysphonia (atrophy, sulcus, scar, paresis). Both interventions yield improved voice quality, yet comparison of patients' long-term perceptions of their voice after these procedures has not been performed. METHODS: Retrospective review of patients who underwent FIM or BML for nonparalytic dysphonia was performed from 2008-2018. Charts were reviewed for demographic information, preoperative diagnosis, intervention, Voice Handicap Index-10 (VHI-10), and follow-up time. RESULTS: Forty-nine patients met our criteria. Fifty procedures were performed (25 FIM, 25 BML). One patient underwent BML with subsequent FIM. There was no significant difference in pre-treatment or post-treatment VHI-10 scores between both groups (Pre-FIM 21 Post-FIM 10.28; Pre-BML 22.48, Post-BML 10.88). Total median follow-up time was 11.3 months (FIM 14.8 months, BML 9.5 months). Using VHI-10 scores recorded at each patient's latest follow-up visit, both groups demonstrated significant decrease (P < .05) compared to preoperative scores: VHI-10 decreased by a mean delta of 10.72 in the FIM group and 11.6 in the BML group. There was no significant difference in pre, post and change in VHI between groups. CONCLUSIONS: In patients with nonparalytic dysphonia, FIM is a durable alternative to BML. Patients treated in both groups gained substantial improvement in vocal function. For both treatment groups, we should anticipate less than complete satisfaction with surgery and revision procedures in a minority of patients. LEVEL OF EVIDENCE: IV.

Objective Measures of Stroboscopy and High-Speed Video.

Videostroboscopy and high-speed imaging is now an accepted way to evaluate laryngeal function in patients with voice disorders. In patients with neurolaryngological diseases such as tremor, laryngeal spasm, and paralysis, having an objective way to evaluate vocal function is desirable. Using digital imaging and analysis, both the videostroboscopy and the high-speed video can be analyzed to obtain relevant measures of vocal function. From the videostroboscopy, the montage of the glottal cycle derived from steady of vocal vibration can be analyzed by using edge tracking software to obtain the glottal area waveform. The waveform is an indication of the efficiency of the vocal folds in acting as an oscillator and gives direct information as to the open and closed phase, the symmetry of vocal fold vibration and the degree of amplitude contribution from each fold. High-speed video overcomes the deficiencies of stroboscopy by allowing for all voice gestures to be studies. Using digital kymography and analysis of the vibrogram, analysis of the onset of vocal fold oscillation, evaluation of diplophonia, tremor, and voice breaks becomes possible. Furthermore, analysis of the high-speed video kymograph tracing using signal analysis allow the investigator to evaluate the frequency and power relationships of vocal fold vibratory function in the normal and disordered state.

Vibratory Onset of Adductor Spasmodic Dysphonia and Muscle Tension Dysphonia: A High-Speed Video Study✰.

OBJECTIVE: Adductor spasmodic dysphonia (AdSD) is a challenging voice disorder to diagnose, often erroneously diagnosed as muscle tension dysphonia (MTD) or vocal tremor, due to its similarity in auditory and perceptual presentation. Assessments using laryngoscopy or strobolaryngoscopy procedures have demonstrated limited utility in the diagnosis of spasmodic dysphonia. High-speed videoendoscopy (HSV) provides visualization of the precise vibratory pattern of phonatory onset and thus, offers an alternative to previous diagnostic strategies for visual diagnosis of AdSD. The purpose of this study was to examine vibratory onset of patients with AdSD and patients with MTD using HSV methodology. METHODS: HSV of six adults with AdSD and five adults with MTD were captured during sustained phonation. Digital kymography was used to obtain precise vibrogram data at the mid-membranous region of the vocal fold prior to and at the onset of phonation. Voice onset delay was examined by (1) quantifying timing of prephonatory delay and steady state delay and (2) describing vocal fold onset movements qualitatively in each diagnosis. RESULTS: HSV adequately captured the phonatory onset of the vocal folds. Voice onset delay was not significantly different between AdSD and MTD. However, there were distinct differences in voice onset gestures. Both AdSD and MTD patients presented with vocal hyperfunction during the onset of phonation. In a subset of AdSD patients, a rapid sustained adduction occurred following the initial vibratory motion. Vocal fold vibration then continued until steady phonation was achieved. This oscillatory break pattern was not observed in patients with MTD. Therefore, there appears to be differences in vocal fold vibratory onset motion between MTD and AdSD. CONCLUSION: HSV captures the precise vibratory onset in patients with MTD and AdSD. Differences were most notable after vibratory onset as opposed to vibratory delay measurements. Examination of voice onset gesture may offer an additional laryngeal parameter to assist in the differential diagnosis of spasmodic dysphonia.

Infection Rates After Microlaryngeal and Open Phonosurgery: The Role of Postoperative Antibiotics.

OBJECTIVE: Although it is known that the airway has bacterial contamination that seeds the surgical site during microlaryngeal surgery, literature on the use of postoperative antibiotics is lacking. We performed a retrospective analysis of open phonosurgical and phonomicrosurgical cases at a single institution to assess whether use of postoperative antibiotics impacts the incidence of surgical site infections (SSI). METHODS: In this retrospective cohort study, we reviewed 228 phonomicrosurgery and 53 open phonosurgery cases performed for benign diseases. Surgeries were performed by two laryngologists between February 2016 and August 2018. The surgeons differ in their postoperative antibiotic regimens: no antibiotics versus a 5- to 7-day postoperative course. Data collected include demographics, medical comorbidities, type of benign laryngeal disease, and surgical procedure. The primary outcome measure was postoperative infection, defined as the patient requiring a new prescription for antibiotics, an extended course of antibiotics, or any mention of infection at follow-up/emergency visits within the first month postoperatively. RESULTS: The overall rate of SSI was 3.1% and 0% for phonomicrosurgery and open phonosurgery cases, respectively. For phonomicrosurgery, there was no difference in the rate of SSI for patients who received or did not receive antibiotics perioperatively: 2.9% versus 3.2% (P = 0.99). Similarly, there was no difference in the infection rate for open phonosurgical cases. CONCLUSION: Infection rates after endoscopic and open phonosurgery are low. In this study, we found no evidence to suggest a protective effect associated with postoperative use of antibiotics. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1128-1131, 2020.

Topical anesthetic techniques in office-based laryngeal surgery: A comparison of patient preferences.

OBJECTIVES: Multiple topical anesthesia techniques exist for office-based laryngeal surgery. Our objective was to assess patient and surgeon satisfaction for three different techniques. STUDY DESIGN: Cohort study. METHODS: All consecutive patients presenting to an outpatient laryngology office for awake surgical procedures were enrolled. Patients were anesthetized with local anesthesia (2 cubic centimeters of 4% lidocaine) in one of three ways: 1) nebulizer, 2) flexible cannula through a channeled laryngoscope, or 3) transtracheal instillation. Demographics, procedure times, and surgeon satisfaction were recorded. A validated 11-item patient satisfaction questionnaire (Iowa Satisfaction with Anesthesia Survey) was administered after the procedure to calculate an overall satisfaction score (-3[worst] to 3[best]). Descriptive and correlative statistics were performed. RESULTS: One hundred consecutive patients were included (37 females, 73 males), with relatively equal numbers between groups (32 nebulizer, 35 cannula, 33 transtracheal). Seven procedures were aborted (4 nebulizer, 2 cannula, 1 transtracheal) due to movement, anxiety, or technical issues. Three patients did not adequately complete the survey. Of the 90 remaining patients, patient satisfaction was highest with the transtracheal technique (2.04) versus cannula (1.46) or nebulizer (1.45), and this was statistically significant (P = 0.0167). This difference was driven by decreased pain and nausea scores in the transtracheal group. Surgeon satisfaction was lower with nebulizer and higher with transtracheal injection (P = 0.0081). There was a correlation between surgeon satisfaction and patient satisfaction (P < 0.0001). CONCLUSION: Transtracheal instillation was favored by both patients and the surgeon. Choice of local anesthetic techniques may impact patient preferences and surgical success. This may serve as a basis for optimizing anesthetic care in office-based laryngeal surgery. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:166-170, 2020.

Voice Outcomes After Radiation for Early-Stage Laryngeal Cancer.

OBJECTIVES: Radiation treatment for laryngeal cancer has been shown to cause tissue changes to the vocal folds, which can result in degradation of voice. Our objective in this study was to investigate changes in perceptual, acoustic, and patient-reported outcomes over an extended period of follow-up after radiation. DESIGN: Retrospective review. METHODS: All patients treated with radiation for early-stage laryngeal carcinoma (in situ, T1, or T2) by a single surgeon from 2011-2018 were reviewed. Demographics and treatment information were recorded. Only patients with at least two dates of follow-up with acoustic data (cepstral spectral index of dysphonia [CSID]) and patient-reported surveys (voice handicap index-10 [VHI-10]) were included. Voice samples were rated by two senior speech-language pathologists on the grade, roughness, breathiness, asthenia, and strain scale. RESULTS: Of 115 patients with early-stage laryngeal cancer, 31 patients met inclusion criteria. The average follow-up from time of treatment was 9.6 years (range 3.0-20.3 years), and the average time in between the first and last voice recordings was 2.6 years (range 0.3-5.5 years). The lesions represented were carcinoma in situ (n = 4), T1 (n = 22), and T2 (n = 5). The VHI-10 scores worsened slightly (mean increase +0.27, median +1) from first to last measurements as did the CSID score (median increase +7.0, median +7.4), though neither reached statistical significance when correlated with time since radiation (P = 0.269 and P = 0.0850). Perceptual analysis as rated by two speech-language pathologists raters showed excellent inter-rater reliability (Cronbach's alpha = 0.84), with no significant change over time (mean +0.39, median, with P = 0.347). Grade, roughness, breathiness, asthenia, and strain, VHI-10, and CSID were all correlated (all pairwise comparisons P < 0.001). CONCLUSION: Perceptual, acoustic, and patient-reported outcomes years after radiation for early-stage laryngeal cancer do not show voice degradation over time in this preliminary analysis. Further research with a larger cohort may elucidate voice changes in this population.

Transoral Tubed Supraglottoplasty: A New Minimally Invasive Procedure for Aspiration.

OBJECTIVES: We describe a new procedure for aspiration called tubed supraglottoplasty (TS). TS is a transoral procedure that approximates the aryepiglottic (AE) folds and arytenoids. This narrows the laryngeal inlet. This procedure has been used to improve swallowing and reduce aspiration in patients with vocal fold paralysis. We describe the technical aspects of TS and report on 11 patients. METHODS: TS is done by oral intubation followed by suspension laryngoscopy. An incision is made along the AE fold into the posterior commissure and then continued to the opposite AE fold. Dissection within this incision creates two mucosal flaps, one based on the laryngeal surface and the other on the pharyngeal surface. Two 1-cm releasing incisions are made at each end of the AE fold. The laryngeal mucosal flap is approximated using a 3-0 self-locking running suture. The pharyngeal mucosal flap is approximated as a second layer. This double-layered mucosal V-Y advancement flap builds up the posterior laryngeal height. It narrows and "tubes" the supraglottis. RESULTS: All patients tolerated TS without airway complications. Ten of the 11 patients reported improved swallowing function with less aspiration. Six of the 8 patients with prior G-tubes had their gastrostomy tube removed. Postoperative laryngoscopy showed a narrowed "tubed" supraglottis with a higher posterior wall preventing spillover and aspiration. An improved Functional Oral Intake Scale was recorded in ten of eleven patients. CONCLUSION: TS is a minimally invasive procedure that can improve swallowing and reduce aspiration.

Vocal fold scars: a common classification proposal by the American Laryngological Association and European Laryngological Society.

PURPOSE: Vocal fold scar is one the most challenging benign laryngeal pathologies. The purpose of this paper is to propose a classification that will allow for a common description of this entity between laryngologists, prevent discrepancies in interpretation, allow for comparison of related studies, and offer a training tool for young laryngologists. METHODS/RESULTS: Based on the depth and laterality of scarring, we propose 4 types: type I, characterized by atrophy of lamina propria with/without affected epithelium; type II, where the epithelium, lamina propria, and muscle are affected; type III, where the scar is located on the anterior commissure; type IV, which includes extended scar formation in both anteroposterior and rostro-caudal axis with significant loss of vocal fold mass. CONCLUSION: We believe that our proposal is comprehensive and encompasses all existing iatrogenic and non-iatrogenic etiologies in a simple and concise manner. It also serves its purpose as a descriptive, comparative, and training tool.

Laryngeal Cryptococcosis: An Evolving Rare Clinical Entity.

OBJECTIVES: Describe the demographics and clinical manifestations of laryngeal cryptococcosis. Develop a simple approach to the diagnostic workup and treatment of localized laryngeal cryptococcal infection. METHODS: A new case of laryngeal cryptococcosis encountered at our institution is presented and placed in context of the literature surrounding prior reported cases. PubMed, Google Scholar, SCOPUS, and Web of Science were queried from inception to August 2018 with the terms Larynx or Laryngeal and Cryptococcosis or Cryptococcus by two independent reviewers for English-language cases of cryptococcal infection of the larynx. RESULTS: Twenty-nine unique cases of laryngeal cryptococcosis were identified. Median age at presentation was 65 years old. All patients presented with persistent or progressive hoarseness. Lesions were predominantly on the true vocal cords (79%), 38% associated with an adherent white exudate or leukoplakia. A minority (28%) was immunocompromised, and of the remaining immunocompetent hosts, 67% were found to be using nebulized or inhaled corticosteroids (ICS) prior to infection. Diagnosis should be suspected in patients with chronic laryngitis or mass lesions with the aforementioned risk factors. Diagnosis was made by histopathology with cryptococcal yeasts identified on methenamine silver (55%) and/or mucicarmine stains (48%). Serum cryptococcal antigen testing was unreliable (sensitivity = 39%). The mainstay of effective treatment was prolonged oral Fluconazole therapy, with two cases of laser therapy ablation of residual lesions. Improvement in voice and vocal lesions varied from weeks to months. CONCLUSIONS: Laryngeal cryptococcosis is a rare cause of persistent hoarseness, which appears to be clinically evolving and more frequently affecting immunocompetent hosts chronically using nebulized or inhaled corticosteroids. Laryngeal cryptococcal infection is readily treatable with prolonged oral antifungals once biopsy and histopathological stains confirm the diagnosis.