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Purpose: Traditional radiation therapy for early-stage larynx cancer irradiates the whole larynx over 5.5 to 6 weeks. Phase 1 data suggest that stereotactic ablative radiotherapy (SABR) is a viable strategy to reduce the irradiated volume and compress treatment time. This phase 2 study evaluated the efficacy of gLoTtic larynx-SABR in 5 or 16 fractions., Methods and Materials: Eligibility required stage 0 to II squamous cell carcinoma of the glottic larynx. The arytenoid cartilage could not be involved beyond the vocal process, and patients smoking more than one pack per day were excluded. The treatment volume consisted of the gross tumor volume, with a 3 mm margin (5 mm craniocaudal) to create the planning target volume. Patients without active smoking and planning target volume <10 cc received 4250 cGy in 5 fractions, twice per week; other patients received 58.08 Gy in 16 daily fractions. The primary endpoint was the 2-year incidence of local failure., Results: Twenty-five patients were accrued to this study, with 21 and 4 treated with 5 and 16 fractions, respectively. The stage distribution was in situ (n = 1, 4%), T1a/b (n = 16/5, 64%/20%), and T2 (n = 3, 12%). The median age was 72 years, with a prior smoking history in 16 (64%) and active smoking in 1 (4%). At a median follow-up for surviving patients of 3.7 years (IQR, 3.1-4.4 years), there have been 2 in-field recurrences (1 in each dose cohort). The cumulative incidences of local failure were 4% (90% CI, 0.8%-20%) and 8% (90% CI, 3%-24%) at 1 and 2 years, respectively. There have been no acute or late grade 3+ toxicities in disease-free patients. The median baseline, 1, 6, 12, and 24 months Voice Handicap Index scores were 57 (IQR, 32-69), 28.5 (8-48), 4 (0-12), 7.5 (0-12), and 5 (0-24), respectively., Conclusions: Highly conformal stereotactic radiation therapy appears safe and efficacious for early-stage glottic larynx cancer, with encouraging patient-reported outcomes. These results need to be interpreted with caution given the small sample size and large noninferiority margin. Additional follow-up and ultimately comparative studies are necessary to validate this paradigm., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives/hypothesis: Voice therapy is a mainstay treatment modality in the management of phonotrauma in singers. However, the typical duration of therapy an injured singer undergoes is unknown. The primary aims of the study were to determine (1) the number of therapy sessions preceding a decision for surgery and (2) the number of sessions and length of time to achieve improvement in singers who did not undergo surgery. Whether specific singer factors were associated with the length of therapy was also investigated., Study Design: Retrospective., Methods: Records of singers with phonotraumatic vocal fold lesions seen over a 9-year period at a tertiary care voice center were reviewed., Results: Sixty singers who underwent surgery and 183 singers who did not undergo surgery were included in the final analysis. In nearly ¾ of the surgical patients, five or fewer voice therapy sessions were completed prior to the decision for surgery. Singers who did not undergo surgery required on average 3-4 sessions before noting improvement. Over 60% of the non-surgical singers improved within 3 months and 84% were judged to be improved by 6 months. Lesion type, professional/amateur status, formal voice training, and having a current voice teacher/coach were not associated with the length of voice therapy., Conclusions: The length of voice therapy prior to decision for surgery was limited, and so was the length of therapy leading to initial improvement in singers who did not require surgery. These findings provide a framework for voice therapy expectations and could be reassuring for this unique population., Competing Interests: DECLARATION OF COMPETING INTEREST None., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Primary muscle tension dysphonia (pMTD) is a functional voice disorder that reduces communicative abilities and adversely impacts occupational productivity and quality of life. Patients with pMTD report increased vocal effort, fatigue, discomfort, and odynophonia. Although laryngeal and paralaryngeal muscle tension and hyperfunction are the most commonly proposed mechanisms underlying these symptoms, recent studies suggest pMTD may have more to do with the somatosensory system. However, relationships between voice symptoms and somatosensory mechanisms are poorly understood, creating challenges for mechanistic-based pMTD management. The first objective was to compare laryngeal, paralaryngeal, and global somatosensation between subjects with and without pMTD. The second was to determine relationships between pMTD symptoms and somatosensation., Methods: Fifty-two (20 pMTD and 32 control) subjects underwent laryngeal sensory testing with aesthesiometers, as well as peripheral mechanosensory and dynamic temporal summation testing to paralaryngeal and limb regions. Voice symptom severities (vocal effort, fatigue, discomfort, and odynophonia) were collected on 100-mm visual analog scales before and after laryngeal sensory testing. Participants also completed the Central Sensitization Inventory., Results: Patients with pMTD reported significantly higher laryngeal sensations (P = 0.0072) and voice symptom severities (P < 0.001) compared with the control group, and had significantly more vocal tract discomfort postlaryngeal sensory testing compared with the prelaryngeal sensory testing timepoint (P = 0.0023). However, there were no significant group differences in laryngeal airway protection responses suggestive of peripheral laryngeal hypersensitivities (P = 0.444). There were also no significant group differences on paralaryngeal or global sensitivities (P > 0.05), and no correlations between severity of voice symptoms and perceptual laryngeal sensations or hypersensitivities (P > 0.05)., Conclusion: Patients with pMTD perceive more sensitivities in the larynx and feel more sensations related to the voice (vocal effort, fatigue, discomfort, and pain). However, in general, patients with pMTD do not have abnormal peripheral laryngeal hypersensitivities, increased global somatosensation, or heightened central sensitivity. The lack of significant correlations between peripheral laryngeal hypersensitivities and voice symptom severity ratings suggests these outcome variables target distinct mechanistic constructs., Competing Interests: Declaration of Competing Interest The authors have no conflicts of interest to disclose., (Copyright © 2024 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The paralaryngeal muscles are thought to be hyperfunctional with phonation in patients with primary muscle tension dysphonia (pMTD). However, objective, quantitative tools to assess paralaryngeal movement patterns lack. The objectives of this study were to (1) validate the use of optical flow to characterize paralaryngeal movement patterns with phonation, (2) characterize phonatory optical flow velocities and variability of the paralaryngeal muscles before and after a vocal load challenge, and (3) compare phonatory optical flow measures to standard laryngoscopic, acoustic, and self-perceptual assessments., Methods: Phonatory movement velocities and variability of the paralaryngeal muscles at vocal onsets and offsets were quantified from ultrasound videos and optical flow methods across 42 subjects with and without a diagnosis of pMTD, before and after a vocal load challenge. Severity of laryngoscopic mediolateral supraglottic compression, acoustic perturbation, and ratings of vocal effort and discomfort were also obtained at both time points., Results: There were no significant differences in optical flow measures of the paralaryngeal muscles with phonation between patients with pMTD and controls. Patients with pMTD had significantly more supraglottic compression, higher acoustic perturbations, and higher vocal effort and vocal tract discomfort ratings. Vocal load had a significant effect on vocal effort and discomfort but not on supraglottic compression, acoustics, or optical flow measures of the paralaryngeal muscles., Conclusion: Optical flow methods can be used to study paralaryngeal muscle movement velocity and variability patterns during vocal productions, although the role of the paralaryngeal in pMTD diagnostics (e.g., vocal hyperfunction) remains suspect., Level of Evidence: 2 Laryngoscope, 134:1792-1801, 2024., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To review the current literature about epidemiology, etiologies and surgical management of bilateral vocal fold paralysis (BVFP)., Data Sources: PubMED, Scopus, and Cochrane Library., Review Methods: A systematic review of the literature on epidemiology, etiologies, and management of adult patients with BVFP was conducted through preferred reporting items for systematic reviews and meta-analyses statements by 2 investigators., Results: Of the 360 identified papers, 245 were screened, and of these 55 were considered for review. The majority (76.6%) of BVFP cases are iatrogenic. BVFP requires immediate tracheotomy in 36.2% of cases. Laterofixation of the vocal fold was described in 9 studies and is a cost-effective alternative procedure to tracheotomy while awaiting potential recovery. Unilateral and bilateral posterior transverse cordotomy outcomes were reported in 9 and 7 studies, respectively. Both approaches are associated with a 95.1% decannulation rate, adequate airway volume, but voice quality worsening. Unilateral/bilateral partial arytenoidectomy data were described in 4 studies, which reported lower decannulation rate (83%) and better voice quality outcome than cordotomy. Revision rates and complications vary across studies, with complications mainly involving edema, granuloma, fibrosis, and scarring. Selective posterior cricoarytenoid reinnervation is being performed by more surgeons and should be a promising addition to the BVFP surgical armamentarium., Conclusion: Depending on techniques, the management of BVFP may be associated with several degrees of airway improvements while worsened or unchanged voice quality. The heterogeneity between studies, the lack of large-cohort controlled randomized studies and the confusion with posterior glottic stenosis limit the draw of clear conclusion about the superiority of some techniques over others., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objectives: It has been assumed that patients with primary muscle tension dysphonia (pMTD) have more extrinsic laryngeal muscle (ELM) tension, but tools to study this phenomenon lack. Shear wave elastography (SWE) is a potential method to address these shortcomings. The objectives of this study were to apply SWE to the ELMs, compare SWE measures to standard clinical metrics, and determine group differences in pMTD and typical voice users before and after vocal load., Methods: SWE measurements of the ELMs from ultrasound examinations of the anterior neck, supraglottic compression severities from laryngoscopic images, cepstral peak prominences (CPP) from voice recordings, and self-perceptual ratings of vocal effort and discomfort were obtained in voice users with (N = 30) and without (N = 35) pMTD, before and after a vocal load challenge., Results: ELM tension significantly increased from rest-to-voiced conditions in both groups. However, the groups were similar in their ELM stiffness levels at SWE at baseline, during vocalization, and post-vocal load. Levels of vocal effort and discomfort and supraglottic compression were significantly higher and CPP was significantly lower in the pMTD group. Vocal load had a significant effect on vocal effort and discomfort but not on laryngeal or acoustic patterns., Conclusion: SWE can be used to quantify ELM tension with voicing. Although the pMTD group reported significantly higher levels of vocal effort and vocal tract discomfort and, on average, exhibited significantly more severe supraglottic compression and lower CPP values, there were no group differences in levels of ELM tension using SWE., Level of Evidence: 2 Laryngoscope, 133:3482-3491, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background/objectives: False vocal fold (FVF) hyperfunction during phonation is thought to be a diagnostic sign of primary muscle tension dysphonia (pMTD). However, hyperfunctional patterns with phonation are also observed in typical speakers. This study tested the hypothesis that FVF posturing during quiet breathing, as measured by the curvature of FVF, could differentiate patients with pMTD from typical speakers., Methods: Laryngoscopic images were collected prospectively in 30 subjects with pMTD and 33 typical speakers. Images were acquired at the end of expiration and maximal inspiration during quiet breathing, during sustained /i/, and during loud phonation before and after a 30-min vocal loading task. The FVF curvature (degree of concavity/convexity) was quantified using a novel curvature index (CI, >0 for hyperfunctional/convex, <0 for "relaxed"/concave) and compared between the two groups., Results: At end-expiration, the pMTD group adopted a convex FVF contour, whereas the control group adopted a concave FVF contour (mean CI 0.123 [SEM 0.046] vs. -0.093 [SEM 0.030], p = 0.0002) before vocal loading. At maximal inspiration, the pMTD group had a neutral/straight FVF contour, whereas the control group had a concave FVF contour (mean CI 0.012 [SEM 0.038] vs. -0.155 [SEM 0.018], p = 0.0002). There were no statistically significant differences in FVF curvature between groups in either the sustained voiced or loud conditions. Vocal loading did not change any of these relationships., Conclusions: A hyperfunctional posture of the FVFs during quiet breathing especially at end-expiration may be more indicative of a hyperfunctional voice disorder than supraglottic constriction during voicing., Level of Evidence: 3 Laryngoscope, 133:3449-3454, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To evaluate the safety, immunogenicity, and efficacy of INO-3107, a DNA immunotherapy designed to elicit targeted T-cell responses against human papillomavirus (HPV) types 6 and 11, in adult patients with recurrent respiratory papillomatosis (RRP; NCT04398433)., Methods: Eligible patients required ≥2 surgical interventions for RRP in the year preceding dosing. INO-3107 was administered by intramuscular (IM) injection followed by electroporation (EP) on weeks 0, 3, 6, and 9. Patients underwent surgical debulking within 14 days prior to first dose, with office laryngoscopy and staging at screening and weeks 6, 11, 26, and 52. Primary endpoint was safety and tolerability, as assessed by treatment-emergent adverse events (TEAEs). Secondary endpoints included frequency of surgical interventions post-INO-3107 and cellular immune responses., Results: An initial cohort of 21 patients was enrolled between October 2020 and August 2021. Fifteen (71.4%) patients had ≥1 TEAE; 11 (52.4%) were Grade 1, and 3 (14.3%) were Grade 3 (none treatment related). The most frequently reported TEAE was injection site or procedural pain (n = 8; 38.1%). Sixteen (76.2%) patients had fewer surgical interventions in the year following INO-3107 administration, with a median decrease of 3 interventions versus the preceding year. The RRP severity score, modified by Pransky, showed improvement from baseline to week 52. INO-3107 induced durable cellular responses against HPV-6 and HPV-11, with an increase in activated CD4 and CD8 T cells and CD8 cells with lytic potential., Conclusion: The data suggest that INO-3107 administered by IM/EP is tolerable and immunogenic and provides clinical benefit to adults with RRP., Level of Evidence: 3 Laryngoscope, 133:3087-3093, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To compare characteristics of patients ≥65 years presenting with idiopathic subglottic stenosis (iSGS) to patients diagnosed at <65 years. We hypothesize that the groups have similar comorbidities and disease courses., Data Sources: Medical records of patients treated for iSGS at a tertiary care institution from January 2005-September 2022., Review Methods: Patient demographics, time from symptom onset to diagnosis, medical history and comorbidities, and treatment modalities/intervals were recorded and analyzed. Characteristics of patients ≥65 and <65 years at presentation were compared using Chi-square analysis for non-numeric values and the Mann-Whitney U-test for numeric values., Results: One hundred seven patients with iSGS were identified and 16 (15%) were aged ≥65 years (mean age 72.6, 15 female) at presentation. These patients were compared to 91 patients aged <65 years (mean age = 47.6, 90 female). Patients ≥65 years had higher rates of type 2 diabetes mellitus (T2DM) (p = 0.004) and tobacco use (p = 0.004). There were no significant differences in body mass index, gastroesophageal reflux disease, hormone replacement therapy, time from symptom onset to presentation, or length of operative treatment intervals., Conclusion: Patients ≥65 years with iSGS have higher rates of tobacco use, suggesting that alterations in wound healing may play a role in the development of iSGS in this age group. Although rates of T2DM were higher in the elderly group, clinical significance may be limited given the overall higher rate of diabetes mellitus in the elderly population., Level of Evidence: 4 Laryngoscope, 133:3075-3079, 2023., (© 2023 The Authors. The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Background/objectives: Tightly-focused ultrafast laser pulses (pulse widths of 100 fs-10 ps) provide high peak intensities to produce a spatially confined tissue ablation effect. The creation of sub-epithelial voids within scarred vocal folds (VFs) via ultrafast laser ablation may help to localize injectable biomaterials to treat VF scarring. Here, we demonstrate the feasibility of this technique in an animal model using a custom-designed endolaryngeal laser surgery probe., Methods: Unilateral VF mucosal injuries were created in two canines. Four months later, ultrashort laser pulses (5 ps pulses at 500 kHz) were delivered via the custom laser probe to create sub-epithelial voids of ~3 × 3-mm 2 in both healthy and scarred VFs. PEG-rhodamine was injected into these voids. Ex vivo optical imaging and histology were used to assess void morphology and biomaterial localization., Results: Large sub-epithelial voids were observed in both healthy and scarred VFs immediately following in vivo laser treatment. Two-photon imaging and histology confirmed ~3-mm wide subsurface voids in healthy and scarred VFs of canine #2. Biomaterial localization within a void created in the scarred VF of canine #2 was confirmed with fluorescence imaging but was not visualized during follow-up two-photon imaging. As an alternative, the biomaterial was injected into the excised VF and could be observed to localize within the void., Conclusions: We demonstrated sub-epithelial void formation and the ability to inject biomaterials into voids in a chronic VF scarring model. This proof-of-concept study provides preliminary evidence towards the clinical feasibility of such an approach to treating VF scarring using injectable biomaterials., Level of Evidences: N/A Laryngoscope, 133:3042-3048, 2023., (© 2023 The American Laryngological, Rhinological and Otological Society, Inc.)

Purpose: Supraglottic compression is thought to underlie vocal effort in patients with primary muscle tension dysphonia (pMTD). However, the relationship between supraglottic compression and vocal effort in this clinical population remains unclear. Gold standard laryngoscopic assessment metrics for supraglottic compression are also lacking. The goals of this study were to identify metrics proposed in the literature that could distinguish patients diagnosed with pMTD from typical voice users and determine their relationships to the vocal effort., Methods: Flexible laryngeal endoscopy was performed on 50 participants (25 pMTD, 25 controls). The presence of supraglottic compression was characterized using a categorical (nominal) scale and severity was quantified on ordinal and continuous scales. The three laryngoscopic metrics were correlated with self-perceived ratings of vocal effort on a 100 mm visual analog scale., Results: Inter-rater reliability was strongest for the continuous scale (P's < 0.0001) compared to categorical (P's < 0.001) and ordinal (P's < 0.001) scales. The presence of different supraglottic compression patterns varied in both groups, and there were no significant group differences on categorical (P's > 0.05) scales. Mediolateral (M-L) supraglottic compression was significantly greater in the pMTD group (P < 0.0001), and anteroposterior (A-P) compression was significantly greater in the control group (P = 0.001) using continuous scales. There were no significant relationships between any of the three laryngoscopic metric types and vocal effort ratings (P's > 0.05), except for a significantly positive relationship between anterior-posterior compression on the ordinal scale and vocal effort in the control group (P = 0.047)., Conclusions: Continuous scales are reliable and valid for distinguishing individuals with pMTD from those without voice disorders, especially occupational voice users. M-L supraglottic compression may be a better indicator of pMTD than A-P compression. However, the poor correlation between supraglottic compression and vocal effort suggests that one may not influence the other. Future studies should focus on other mechanisms underlying vocal effort in patients with pMTD., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2023 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To determine if (1) the likelihood of presenting with phonotraumatic lesions differs by singing genre in treatment-seeking singers and (2) if the distribution of phonotraumatic lesion types differs by singing genre., Study Type: Retrospective., Methods: Records of singers who presented with a voice complaint over the course of 2.5 years (June 2017-December 2019) were reviewed to determine the proportion of those with phonotraumatic lesions as a function of genre (Study 1). Separately, the lesion types and genres of singers diagnosed with phonotraumatic lesions over a 9-year period (July 2011-March 2020) were determined (Study 2)., Results: In Study 1, 191 of 712 (26.8%) dysphonic singers were diagnosed with phonotraumatic lesions. Country/folk, gospel/jazz, and musical theater singers were more likely to present with phonotraumatic lesions. In Study 2, in 443 singers with phonotraumatic lesions, polyps and pseudocysts, but not nodules, were found to be distributed unequally across genres (χ 2 p = 0.006, p < 0.0001, p = 0.064, respectively). Praise/worship singers had significantly higher proportions of polyps compared to choral singers (OR 4.8 [95% CI 1.9-12.5]) or compared to musical theater singers (OR 7.2 [95% CI 2.5-20.8]). Opera singers had significantly higher proportions of pseudocysts than choral singers (OR 3.1 [95% CI 1.5-6.1]) or musical theater singers (OR 3.7 [95% CI 1.8-7.6])., Conclusions: The higher incidence of polyps in praise/worship singers likely reflects the more emphatic nature of singing and the tendency for acute injury. The higher incidence of pseudocysts in opera singers may reflect a more chronic nature of injury., Level of Evidence: 4 Laryngoscope, 133:1683-1689, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: The clinical determination of vocal fold (VF) hypomobility based on laryngoscopy is subjective. Previous studies point to VF motion anomaly as the most commonly reported factor in the diagnosis of hypomobility. This study tested the hypotheses that VF angular velocities and angular range of motion (ROM) differ between the two VFs in cases of unilateral VF hypomobility., Study Design: Retrospective., Methods: Semi-automated analysis of laryngoscopic videos of 18 subjects diagnosed with unilateral VF hypomobility and 13 subjects with normal VF mobility was performed to quantify/compare the VF angular velocity and ROM between the two VFs during /i/-sniff and laugh., Results: In the hypomobile VF group, 7 out of 15 (47%) videos with /i/-sniff and 5 out of 8 (63%) with laugh had a statistically significant difference in the angular velocities between the VFs in either abduction or adduction. For VF ROM, 8 out of 15 (53%) /i/-sniff videos and 4 out of 8 (50%) with laughter had a statistically significant difference between VFs. In the group without the diagnosis of VF hypomobility, 9 out of 13 subjects (69%) had no difference in VF angular velocity and ROM during either /i/-sniff or laugh., Conclusions: Differences in VF angular velocity or ROM are measurable in a substantial subset of subjects diagnosed with unilateral VF hypomobility. Clinicians' ability to gauge VF motion goes beyond what can be extracted from frame-by-frame analysis. Other visual cues, in addition to VF angular velocity and ROM, likely contribute to the perception of unilateral VF hypomobility., Level of Evidence: 3 Laryngoscope, 133:866-874, 2023., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Creation of sub-epithelial voids within scarred vocal folds via ultrafast laser ablation may help in localization of injectable therapeutic biomaterials towards an improved treatment for vocal fold scarring. Several ultrafast laser surgery probes have been developed for precise ablation of surface tissues; however, these probes lack the tight beam focusing required for sub-surface ablation in highly scattering tissues such as vocal folds. Here, we present a miniaturized ultrafast laser surgery probe designed to perform sub-epithelial ablation in vocal folds. The requirement of high numerical aperture for sub-surface ablation, in addition to the small form factor and side-firing architecture required for clinical use, made for a challenging optical design. An Inhibited Coupling guiding Kagome hollow core photonic crystal fiber delivered micro-Joule level ultrashort pulses from a high repetition rate fiber laser towards a custom-built miniaturized objective, producing a 1/e 2 focal beam radius of 1.12 ± 0.10 μm and covering a 46 × 46 μm 2 scan area. The probe could deliver up to 3.8 μJ pulses to the tissue surface at 40% transmission efficiency through the entire system, providing significantly higher fluences at the focal plane than were required for sub-epithelial ablation. To assess surgical performance, we performed ablation studies on freshly excised porcine hemi-larynges and found that large area sub-epithelial voids could be created within vocal folds by mechanically translating the probe tip across the tissue surface using external stages. Finally, injection of a model biomaterial into a 1 × 2 mm 2 void created 114 ± 30 μm beneath the vocal fold epithelium surface indicated improved localization when compared to direct injection into the tissue without a void, suggesting that our probe may be useful for pre-clinical evaluation of injectable therapeutic biomaterials for vocal fold scarring therapy. With future developments, the surgical system presented here may enable treatment of vocal fold scarring in a clinical setting., (© 2022. The Author(s).)

Objectives: The objectives of this study were to (1) compare laryngeal configuration patterns in occupational voice users with and without primary muscle tension dysphonia (pMTD), (2) characterize laryngeal configurations in relation to other clinical metrics (acoustic, perceptual), and (3) determine the effects of vocal demands (load) on these clinical parameters., Methods: Thirty subjects (15 pMTD, 15 control) were recruited for the study. Laryngoscopic examinations and voice samples for sustained /i/ were obtained before and after a half hour vocal load task. Subjects rated their vocal effort and discomfort before and after the vocal load. Laryngeal configurations were analyzed subjectively with dichotomous and categorical rating scales and hyper function severity quantified (endolaryngeal area outlets). Overall dysphonia severity and vocal instability of each voice sample was rated on 100mm visual analog scales and cepstral peak prominence (CPP) extracted from each voice sample., Results: Laryngeal configurations between groups or vocal load condition were not distinguishable with any of the dichotomous, categorical, or quantitative laryngeal metrics. Vocal effort and discomfort ratings were significantly higher in the pMTD group compared to the control group. Vocal load also had significant effects across groups on vocal effort and vocal tract discomfort ratings. Although CPP values fell within the normal range in both groups, CPP was significantly lower in the pMTD group at both pre-load and post-load time points. Auditory-perceptual ratings were also significantly worse in the pMTD group. Vocal load did not have a significant effect on acoustic or auditory-perceptual measures., Conclusion: Similar laryngeal configurations between groups at both pre- and post-vocal load suggests classic patterns of laryngeal "hyperadduction" may occur variably in occupational voice users and may not be indicative of pMTD pathophysiology. Greater vocal effort, discomfort, instability, and perturbation within the vocal system may better define pMTD than laryngeal configuration in occupational voice users with pMTD., (Copyright © 2022 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: To discover patterns of phonotraumatic lesions in singers and investigate factors that differentiate those who underwent surgery from those who did not. We hypothesized that 1) lesion type distribution differs by age, sex, singer classification (professional/amateur), and history of formal voice training; 2) the likelihood of surgery is associated with singer classification and voice training., Study Design: Retrospective., Methods: Retrospective review of 438 singers with phonotraumatic lesions over a 9-year period. Lesion type distribution was analyzed with respect to sex, age, singer classification, and voice training. The association of eventual surgery with these factors was also analyzed., Results: Nodules accounted for over half of the cohort (58%), followed by pseudocysts (20%), polyps (14%), and cysts (4%). Nearly two of every three injured female singers, but fewer than one out of every three injured male singers, had nodules. In contrast, over half of the injured males had polyps, whereas only 6% of injured females had polyps. In females, polyps occurred at a later age, and in males, nodules occurred at a younger age compared to other lesion types. Only 14% of the total cohort eventually underwent surgery. Professional singers without formal voice training were almost eight times more likely to have undergone surgery than amateur singers with voice training., Conclusions: Professional singers were more likely to undergo surgery than amateurs, and formal voice training was associated with a lower likelihood of surgery. The observation that polyps tended to occur in older women may have implications for the pathogenesis of vocal fold polyps., Level of Evidence: 4 Laryngoscope, 132:2180-2186, 2022., (© 2022 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: (1) To describe a combination voice rest and steroid regimen to clarify ambiguous diagnoses in singers who present with phonotraumatic lesions and (2) to determine which videostroboscopic parameters show the most consistent response to this regimen., Study Design: Chart review., Methods: Singers with phonotraumatic vocal fold lesions seen at a tertiary care voice center over a 10-year period were identified. Those who had uncertain diagnoses on initial presentation, completed a combination regimen including voice rest and steroids, and had follow-up examinations were included in the analysis. The effect of this combination regimen was assessed by ratings of pre- and postregimen videostroboscopy examinations and by auditory perceptual ratings. Whether the combination regimen clarified the diagnosis was noted., Results: Twenty-nine singers were prescribed the combination regimen with the intent to clarify the diagnosis. In 79% (23/29) of these singers, the regimen helped clarify diagnosis, for example, ruling in or ruling out specific lesions, confirming areas of scar, or distinguishing acute from chronic phonotraumatic injury. Stroboscopic exams were improved in 86% (25/29). The most common stroboscopic finding was a reduction in the lesion size (66%). Auditory perceptual ratings improved in 48% (14/29) of patients., Conclusions: A "cool down" combination of voice rest and steroids can improve diagnostic clarity in a subset of singers with phonotraumatic lesions. This combination regimen can be considered, with both the side effect profile of steroids and possible financial ramifications of strict voice rest in mind, when the initial diagnosis is unclear., (Copyright © 2020 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: To examine patterns of recurrence of benign phonotraumatic vocal fold lesions over time for insights into pathophysiology., Study Design: Case series with mathematical modeling., Methods: Medical records and stroboscopic exams of adults who underwent microlaryngoscopic resection of phonotraumatic vocal fold lesions over a 13-year period were reviewed for time to recurrence after surgery. Uniform and log-normal probability distributions were fitted to the time to recurrence curves for vocal fold polyps, midfold masses, and pseudocysts. Model fits were compared using the Akaike information criterion corrected, a standard measure of the goodness of fit. Stochastic simulations were used to verify that the mechanistic hypotheses were concordant with the selected probability distributions and empiric data., Results: Of 567 patients who underwent microlaryngoscopic resection, 65 had a recurrence (16 polyps, 14 midfold masses, and 35 pseudocysts). Midfold mass and pseudocyst recurrences were predominantly seen in younger women. Polyps were best fit by a uniform distribution rather than log-normal, whereas midfold masses and pseudocysts were better fit by log-normal rather than uniform. Stochastic simulations suggest that polyps recur sporadically according to a paroxysmal-developmental model, whereas midfold mass and pseudocyst recurrences follow a force-multiplication, damage-accumulation process., Conclusions: Vocal fold polyps are acute lesions evenly distributed by age and gender that recur uniformly over time, suggesting they arise from sudden tissue reactions to phonotraumatic stress. Pseudocysts and midfold fibrous masses are chronic lesions predominantly found in young women that recur with log-normal distribution over time, suggesting gradual damage accumulation in larynges predisposed to enhanced phonotrauma., Level of Evidence: 4 Laryngoscope, 131:2523-2529, 2021., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Anterior (Wendler) glottoplasty has become a popular surgery for voice feminization. However, there has been some discrepancy between its theoretical pitch-raising potential and what is actually achievable, and downsides to shortening the glottis have not been fully explored. In addition, descriptions of the surgery are inconsistent in their treatment of the vocal ligament. This study aimed to determine 1) how fundamental frequency (f o ) is expected to vary with length of anterior glottic fixation, 2) the impact of glottic shortening on sound pressure level (SPL), and 3) the effect of including the ligament in fixation., Study Design: Computational simulation., Methods: Voice production was simulated in a fiber-gel finite element computational model using canonical male vocal fold geometry incorporating a three-layer vocal fold composition (superficial lamina propria, vocal ligament, and thyroarytenoid muscle). Progressive anterior glottic fixation (0, 1/8, 2/8, 3/8, etc. up to 7/8 of membranous vocal fold length) was simulated. Outcome measures were f o , SPL, and glottal flow waveforms., Results: f o increased from 110 Hz to 164 Hz when the anterior one-half vocal fold was fixed and continued to progressively rise with further fixation. SPL progressively decreased beyond 1/8 to 1/4 fixation. Inclusion of the vocal ligament in fixation did not further increase f o . Any fixation increased aperiodicity in the acoustic signal., Conclusions: The optimal length of fixation is a compromise between pitch elevation and reduction in output acoustic power. The simulation also provided a potential explanation for vocal roughness that is sometimes noted after anterior glottoplasty., Level of Evidence: NA Laryngoscope, 131:1081-1087, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Carbon dioxide laser transverse posterior cordotomy (TPC) aims to improve airway aperture in patients with glottic obstruction. Postoperative complications may worsen airway compromise and necessitate additional interventions. We sought to identify factors impacting outcomes after TPC., Study Design: Retrospective chart review., Methods: Medical records of patients who underwent TPC for glottic airway obstruction at a tertiary-care medical center between 2008 and 2018 were reviewed. Demographics, comorbidities, and intra- and postoperative management strategies were analyzed., Results: Twenty patients who underwent TPC for glottic airway obstruction met inclusion criteria. The mean age was 57 years, and 13 patients were female. Mean follow-up time was 442 days. Seven patients had posterior glottic stenosis, and 13 had bilateral vocal fold paralysis. Twelve patients developed postoperative complications including granuloma formation (four patients), hospital readmission for dyspnea due to glottic edema (five patients), need for revision surgery (nine patients), or failure to decannulate tracheotomy (five patients). Eight patients had an uncomplicated recovery with improved dyspnea, with two patients with tracheotomies decannulated. Patients with a history of smoking tobacco were more likely to experience complications (P = .035). There were no significant differences in outcomes with respect to history of head and neck radiation or gastroesophageal reflux disease. Steroid injection at the surgical site and postoperative medications did not significantly impact outcomes. With respect to granuloma formation, none of the variables analyzed reached significance., Conclusions: History of tobacco use increases complication rates after TPC. Other patient comorbidities and intra- and postoperative management strategies do not impact outcomes., Level of Evidence: 4 Laryngoscope, 131:1066-1070, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society Inc, “The Triological Society” and American Laryngological Association (ALA).)

Tracheotomy is a surgical procedure through which a tracheostomy, an opening into the trachea, is created. Indications for tracheostomy include facilitation of airway management during prolonged mechanical ventilation, treatment of acute upper airway obstruction when tracheal intubation is unfeasible, management of chronic upper airway obstructive conditions, and planned airway management for major head and neck surgery. Patients who have a recent or long-term tracheostomy may present for a variety of surgical or diagnostic procedures performed under general anesthesia or sedation/analgesia. Airway management of these patients can be challenging and should be planned ahead of time. Anesthesia personnel should be familiar with the different components of cuffed and uncuffed tracheostomy devices and their connectivity to the anesthesia circuits. An appropriate airway management plan should take into account the indication of the tracheostomy, the maturity status of the stoma, the type and size of tracheostomy tube, the expected patient positioning, and presence of patient's concurrent health conditions. Management of the patient with a T-tube is highlighted. Importantly, there is a need for multidisciplinary care involving anesthesiologists, surgical specialists, and perioperative nurses. The aim of this narrative review is to discuss the anesthesia care of patients with a tracheostomy. Key aspects on relevant tracheal anatomy, tracheostomy tubes/devices, alternatives of airway management, and possible complications related to tracheostomy are summarized with a recommendation for an algorithm to manage intraoperative tracheostomy tube dislodgement., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Objective: Most type 1 thyroplasty implants and some common injectable materials are mechanically stiff. Placing them close to the supple vocal fold mucosa can potentially dampen vibration and adversely impact phonation, yet this effect has not been systematically investigated. This study aims to examine the effect of implant depth on vocal fold vibration and vocal output., Study Design: Computational simulation., Methods: Voice production was simulated with a fiber-gel finite element computational model that incorporates a three-layer vocal fold composition (superficial lamina propria, vocal ligament, thyroarytenoid muscle). Implants of various depths were simulated, with a "deeper" or more medial implant positioned closer to the vocal fold mucosa and replacing more muscle elements. Trajectories of surface and within-tissue nodal points during vibration were produced. Outcome measures were the trajectory radii, fundamental frequency (F 0 ), sound pressure level (SPL), and smoothed cepstral peak prominence (CPPS) as a function of implant depth., Results: Amplitude of vibration at the vocal fold medial surface was reduced by an implant depth of as little as 14% of the total transverse vocal fold depth. Increase in F 0 and decrease in CPPS were noted beyond 30% to 40% implant depth, and SPL decreased beyond 40% to 60% implant depth., Conclusions: Commonly used implants can dampen vibration "from a distance," ie, even without being immediately adjacent to vocal fold mucosa. Since implants are typically placed at depths examined in this study, stiff implants likely have a negative vocal impact in a subset of patients. Softer materials may be preferable, especially in bilateral medialization procedures., Level of Evidence: N/A Laryngoscope, 130:2192-2198, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Spontaneous vocal recovery from idiopathic vocal fold paralysis (VFP) appears to differ in time course from recovery in iatrogenic VFP. This study aimed to determine if this difference could be explained by differing mechanisms causing recurrent laryngeal nerve (RLN) dysfunction, specifically whether idiopathic VFP is consistent with a focal RLN axonal lesion., Study Design: Case series with mathematical modeling., Methods: A review of 1267 cases of unilateral VFP over a 10-year period yielded 114 subjects (35 idiopathic, 79 iatrogenic) with a discrete onset of spontaneous vocal recovery. The time-to-recovery data were fit to a previously described two-phase model that incorporates the Seddon classification of neuropraxia and higher grades of axonal injury. Alternatively, the data were fit to a single phase model that does not assume a focal axonal lesion., Results: Time to vocal recovery in iatrogenic VFP can be reliably modeled by the assumption of a focal axonal lesion, with an early recovery group corresponding to neuropraxia and a late recovery group with more severe nerve damage. Time to recovery in idiopathic VFP can be more simply modeled in a single phase, with a time course that mirrors those in diverse biological processes such as transcription and microtubule growth., Conclusion: Idiopathic VFP may not be caused by a focal axonal lesion. Neuritis may be a compatible mechanism. The iatrogenic VFP data lend further support to the concept that the severity of RLN injury, not the length of axon to regenerate, is the chief determinant of recovery time after iatrogenic injury., Level of Evidence: 4 Laryngoscope, 130:1520-1524, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Odynophonia is generally regarded as a symptom of a voice disorder. However, a subset of patients with odynophonia have debilitating pain out of proportion to the relatively mild degree of dysphonia and are not responsive to voice therapy. The goals of this study were to 1) describe the symptomatology of this subset of patients and differentiate it from typical odynophonia, 2) propose alternate models to explain this phenomenon of primary odynophonia, and 3) present a new treatment paradigm based on the proposed models., Study Design: Case series., Methods: Inclusion criteria were complaint of persistent pain associated with voicing, normal vocal fold mobility, complete glottic closure, and limited or lack of response of pain to voice therapy. Presenting symptoms, voice evaluation, and treatment outcomes were reviewed., Results: Eleven patients fit the inclusion criteria. The degree of pain did not follow the trajectory of vocal improvement with therapy. The pain was stagnant or worsened with voice exercises. The most dramatic improvement came about in one patient who received false vocal fold Botox injections, and another who received thyrohyoid lidocaine/triamcinolone injection. We propose that these patients had developed primary odynophonia, in which the pain had become self-sustaining and no longer responded to correction of hyperfunctional vocal behavior. The mechanism of pain persistence may involve superior laryngeal neuralgia, cartilaginous or ligamentous inflammation, and/or central sensitization., Conclusions: A minority of patients have primary odynophonia distinct from typical odynophonia. Direct treatment of pain may be advisable prior to or in conjunction with voice therapy., Level of Evidence: 4 Laryngoscope, 130:E183-E189, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Gel-based injectable biomaterials have significant potential for treating vocal fold defects such as scarring. An ideal injectable for vocal fold lamina propria restoration should mimic the microenvironment of the lamina propria to induce scarless wound healing and functional tissue regeneration. Most current synthetic or natural injectable biomaterials do not possess the same level of complex, tissue-specific constituents as the natural vocal fold lamina propria. In this study we present a newly-developed injectable gel fabricated from decellularized bovine vocal fold lamina propria. Blyscan assay and mass spectrometry indicated that the vocal fold-specific gel contained a large amount of sulfated glycosaminoglycans and over 250 proteins. Gene Ontology overrepresentation analysis revealed that the proteins in the gel dominantly promote antifibrotic biological process. In vivo study using a rabbit vocal fold injury model showed that the injectable gel significantly reduced collagen density and decreased tissue contraction of the lamina propria in vocal folds with chronic scarring. Furthermore, this acellular gel only elicited minimal humoral immune response after injection. Our findings suggested that the tissue-specific, injectable extracellular matrix gel could be a promising biomaterial for treating vocal fold scarring, even after the formation of mature scar. STATEMENT OF SIGNIFICANCE: Vocal fold lamina propria scarring remains among the foremost therapeutic challenges in the management of patients with voice disorders. Surgical excision of scar may cause secondary scarring and yield inconsistent results. The present study reports an extracellular matrix-derived biomaterial that demonstrated antifibrotic effect on chronic scarring in vocal fold lamina propria. Its injectability minimizes the invasiveness of the delivery procedure and the degree of mucosal violation. In this work we also describe a new methodology which can more accurately identify proteins from the complex mixture of an acellular extracellular matrix gel by excluding interfering peptides produced during the enzymatic digestion in gel fabrication., (Copyright © 2019 Acta Materialia Inc. Published by Elsevier Ltd. All rights reserved.)

Ultrafast laser ablation may provide a treatment for vocal fold (VF) scarring. Optical properties of VFs must be known prior to clinical implementation to select appropriate laser surgery conditions. We present scattering lengths of epithelium ℓs  ,  ep, superficial lamina propria ℓs  ,  SLP, and ablation thresholds Fth of human and canine VF tissues. Our experimental approach involves an image-guided, laser-ablation-based method that allows for simultaneous determination of ℓs and Fth in these multilayered tissues. Studying eight canine samples, we found ℓs  ,  ep  =  75.3  ±  5.7  μm, ℓs  ,  SLP  =  26.1  ±  1.2  μm, Fth  ,  ep  =  1.58  ±  0.06  J  /  cm2, and Fth  ,  SLP  =  1.55  ±  0.17  J  /  cm2. Studying five human samples, we found ℓs  ,  ep  =  42.8  ±  3.3  μm and Fth  ,  ep  =  1.66  ±  0.10  J  /  cm2. We studied the effects of cumulative pulse overlap on ablation threshold and found no significant variations beyond 12 overlapping pulses. Interestingly, our studies about the effect of sample storage on the scattering properties of porcine VF show a 60% increase in ℓs  ,  ep for fresh porcine VF when compared to the same sample stored in isotonic solution. These results provide guidelines for clinical implementation by enabling selection of optimal laser surgery parameters for subsurface ablation of VF tissues.

Purpose The aim of this study was to test the hypothesis that stretch-and-flow voice therapy (SnF) is noninferior to resonant voice therapy (RVT) for speakers with muscle tension dysphonia. Method Participants with primary muscle tension dysphonia were randomly assigned to 1 of 2 treatment groups. Participants received 6 sessions of either SnF or RVT for 6 weeks (1 session per week). Pretreatment and posttreatment audio recordings of sustained vowels and connected speech were acquired. Response to treatment was assessed using the voice handicap index (VHI) as the primary outcome measure. Secondary outcome measures included the acoustic voice quality index, the smoothed cepstral peak prominence, and scales from the Consensus Auditory-Perceptual Evaluation of Voice instrument. Data were analyzed for 21 participants who completed the study (12 in the SnF group, 9 in the RVT group). Results Direction of change for the primary outcome measure and all 3 secondary outcome measures at posttreatment was in the direction of improvement for both SnF and RVT. Confidence intervals for VHI measures did not cross the null effect line on forest plots, suggesting significant effects for both treatments on the primary outcome measure. The effect sizes for pretreatment to posttreatment changes in VHI were large for both treatment groups. Similar results were found for the secondary acoustic outcome measures. There were statistically significant pretreatment to posttreatment changes in the primary and secondary outcome measures for patients receiving both treatments, indicating significant improvement in response to both RVT and SnF. There were no statistically significant differences in pretreatment to posttreatment changes in the primary outcome measure or any secondary outcome measure between the two groups. The within-group pretreatment to posttreatment changes in Consensus Auditory-Perceptual Evaluation of Voice scales did not reach statistical significance for either RVT or SnF. Conclusions Both SnF and RVT produced positive treatment response in speakers with muscle tension dysphonia, with no statistically significant difference in the outcome measures between the two treatments. This suggests that SnF is noninferior to RVT and that both are effective options for treating vocal hyperfunction. Results from this study also support previous findings documenting the sensitivity of multidimensional acoustic measurements to treatment response.

The effective depth of vocal fold vibration is self-regulated and generally not known a priori in vocalization. In this study, the effective depth was quantified systematically under various phonatory conditions using a fiber-gel finite element vocal fold model. The horizontal and vertical excursions of each finite element nodal point trajectory were recorded to compute trajectory areas. The extent of vibration was then studied based on the variation of trajectory radii as a function of depth in several coronal sections along the anterior-posterior direction. The results suggested that the vocal fold nodal trajectory excursions decrease systematically as a function of depth but are affected by the layered structure of the vocal folds. The effective depth of vibration was found to range between 15 and 55% of the total anatomical depth across all phonatory conditions. The nodal trajectories from the current study were compared qualitatively with the results from excised human hemi-larynx experiments published in Döllinger and Berry [(2006). J. Voice. 20(3), 401-413]. An estimate of the effective mass of a one-mass vocal fold model was also computed based on the effective depth of vibration observed in this study under various phonatory conditions.

Vibratory function of the vocal folds is largely determined by the rheological properties or viscoelastic shear properties of the vocal fold lamina propria. To date, investigation of the sample size estimation and statistical experimental design for vocal fold rheological studies is nonexistent. The current work provides the closed-form sample size formulas for two major study designs (i.e. paired and two-group designs) in vocal fold research. Our results demonstrated that the paired design could greatly increase the statistical power compared to the two-group design. By comparing the variance of estimated treatment effect, this study also confirms that ignoring within-subject and within-vocal fold correlations during rheological data analysis will likely increase type I errors. Finally, viscoelastic shear properties of intact and scarred rabbit vocal fold lamina propria were measured and used to illustrate theoretical findings in a realistic scenario and project sample size requirement for future studies., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Purpose: The purposes of this study are to introduce the concept of vocal priorities based on acoustic correlates, to develop an instrument to determine these vocal priorities, and to analyze the pattern of vocal priorities in patients with voice disorders., Method: Questions probing the importance of 5 vocal attributes (vocal clarity, loudness, mean speaking pitch, pitch range, vocal endurance) were generated from consensus conference involving speech-language pathologists, laryngologists, and voice scientists, as well as patient feedback. The responses to the preliminary items from 213 subjects were subjected to exploratory factor analysis, which confirmed 4 of the predefined domains. The final instrument consisted of a 16-item Vocal Priority Questionnaire probing the relative importance of clarity, loudness, mean speaking pitch, and pitch range., Results: The Vocal Priority Questionnaire had high reliability (Cronbach's α = .824) and good construct validity. A majority of the cohort (61%) ranked vocal clarity as their highest vocal priority, and 20%, 12%, and 7% ranked loudness, mean speaking pitch, and pitch range, respectively, as their highest priority. The frequencies of the highest ranked priorities did not differ by voice diagnosis or by sex. Considerable individual variation in vocal priorities existed within these large trends., Conclusions: A patient's vocal priorities can be identified and taken into consideration in planning behavioral or surgical intervention for a voice disorder. Inclusion of vocal priorities in treatment planning empowers the patient in shared decision making, helps the clinician tailor treatment, and may also improve therapy compliance.

Objective: To determine the extent to which a sequential anesthetic technique 1) shortens time under sedation for thyroplasty with arytenoid adduction (TP-AA), 2) affects the total operative time, and 3) changes the voice outcome compared to TP-AA performed entirely under sedation/analgesia., Study Design: Case-control study., Methods: A new sequential anesthetic technique of performing most of the TP-AA surgery under general anesthesia (GA), followed by transition to sedation/analgesia (SA) for voice assessment, was developed to achieve smooth emergence from GA. Twenty-five TP-AA cases performed with the sequential GA-SA technique were compared with 25 TP-AA controls performed completely under sedation/analgesia. The primary outcome measure was the time under sedation. Voice improvement, as assessed by Consensus Auditory-Perceptual Evaluation of Voice, and total operative time were secondary outcome measures., Results: With the conventional all-SA anesthetic, the duration of SA was 209 ± 26.3 minutes. With the sequential GA-SA technique, the duration of SA was 79.0 ± 18.9 minutes, a 62.3% reduction (P < 0.0001). There was no significant difference in the total operative time (209.5 vs. 200.9 minutes; P = 0.42) or in voice outcome. This sequential anesthetic technique has been easily adopted by multiple anesthesiologists and nurse anesthetists at our institution., Conclusion: TP-AA is effectively performed under sequential GA-SA technique with a significant reduction in the duration of time under sedation. This allows the surgeon to perform the technically more challenging part of the surgery under GA, without having to contend with variability in patient tolerance for laryngeal manipulation under sedation., Level of Evidence: 3b. Laryngoscope, 127:2813-2817, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Silent speech recognition (SSR) converts non-audio information such as articulatory movements into text. SSR has the potential to enable persons with laryngectomy to communicate through natural spoken expression. Current SSR systems have largely relied on speaker-dependent recognition models. The high degree of variability in articulatory patterns across different speakers has been a barrier for developing effective speaker-independent SSR approaches. Speaker-independent SSR approaches, however, are critical for reducing the amount of training data required from each speaker. In this paper, we investigate speaker-independent SSR from the movements of flesh points on tongue and lip with articulatory normalization methods that reduce the inter-speaker variation. To minimize the across-speaker physiological differences of the articulators, we propose Procrustes matching-based articulatory normalization by removing locational, rotational, and scaling differences. To further normalize the articulatory data, we apply feature-space maximum likelihood linear regression and i-vector. In this paper, we adopt a bidirectional long short term memory recurrent neural network (BLSTM) as an articulatory model to effectively model the articulatory movements with long-range articulatory history. A silent speech data set with flesh points was collected using an electromagnetic articulograph (EMA) from twelve healthy and two laryngectomized English speakers. Experimental results showed the effectiveness of our speaker-independent SSR approaches on healthy as well as laryngectomy speakers. In addition, BLSTM outperformed standard deep neural network. The best performance was obtained by BLSTM with all the three normalization approaches combined.

Objectives/hypothesis: Patients with unilateral vocal fold paralysis (UVFP) are commonly told to wait 12 months for spontaneous recovery. This study aims to 1) determine the time to vocal recovery in UVFP, 2) use that data to develop a neurophysiologically plausible model for recovery, and 3) use the model to generate meaningful predictions for patient counseling., Study Design: Case series with de novo mathematical modeling., Methods: Patients with UVFP who could pinpoint a discrete onset of vocal improvement were identified. The time-to-recovery data were modeled by assuming an "early" recovery group with neuropraxia and a "late" recovery group with more severe nerve injury. For the late group, a two-stage model was developed to explain the time to recovery: regenerating axons must cross the site of injury in stage 1 (probabilistic), followed by unimpeded regrowth to the larynx in stage 2 (deterministic)., Results: Of 727 cases of UVFP over a 7-year period, 44 reported spontaneous recovery with a discrete onset of vocal improvement. A hybrid distribution incorporating the two stages (exponentially modified Gaussian) accurately modeled the time-to-recovery data (R 2 = 0.918). The model predicts 86% of patients with recoverable UVFP will recover within 6 months, with 96% recovering within 9 months. Earlier vocal recovery is associated with recovery of vocal fold motion and younger age., Conclusions: Waiting 12 months for spontaneous recovery is probably too conservative. Repair across the site of injury, and not regrowth to larynx, is likely the rate-determining step in reinnervation, consistent with other works on peripheral nerve regeneration., Level of Evidence: 4. Laryngoscope, 127:2585-2590, 2017., (© 2017 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective To identify factors associated with the likelihood of attending voice therapy among patients referred for it in the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure. Study Design Prospectively enrolled cross-sectional study. Setting CHEER network of community and academic sites. Methods Data were collected on patient-reported demographics, voice-related diagnoses, voice-related handicap (Voice Handicap Index-10), likelihood of attending voice therapy (VT), and opinions on factors influencing likelihood of attending VT. The relationships between patient characteristics/opinions and likelihood of attending VT were investigated. Results A total of 170 patients with various voice-related diagnoses reported receiving a recommendation for VT. Of those, 85% indicated that they were likely to attend it, regardless of voice-related handicap severity. The most common factors influencing likelihood of VT attendance were insurance/copay, relief that it was not cancer, and travel. Those who were not likely to attend VT identified, as important factors, unclear potential improvement, not understanding the purpose of therapy, and concern that it would be too hard. In multivariate analysis, factors associated with greater likelihood of attending VT included shorter travel distance, age (40-59 years), and being seen in an academic practice. Conclusions Most patients reported plans to attend VT as recommended. Patients who intended to attend VT reported different considerations in their decision making from those who did not plan to attend. These findings may inform patient counseling and efforts to increase access to voice care.

Thyroplasty with arytenoid adduction, a combined procedure for treatment of unilateral vocal fold paralysis, is typically performed under local anesthesia with sedation to allow for intraoperative voice assessment. However, the need for patient immobility and suppression of laryngeal responses to surgical manipulation can make sedation-analgesia challenging. We describe our first 26 consecutive cases undergoing thyroplasty and arytenoid adduction with a standardized technique consisting of a combination of general anesthesia with tracheal intubation followed by sedation-analgesia. Most patients (69 %) were women, with age of 53 ± 15 years (mean ± SD). Neck surgery was the cause of vocal fold paralysis in 50 % of patients. Initially, general anesthesia was maintained with desflurane and remifentanil with dexmedetomidine added just before tracheal extubation. During the sedation-analgesia phase, patients received infusions of remifentanil and dexmedetomidine. Duration of general anesthesia and sedation-analgesia phases was 162 ± 68.2 and 79 ± 18.3 min, respectively. Mean (SD) wake-up time was 8.0 ± 4.0 min after desflurane discontinuation. Extubation occurred without coughing, bucking, or agitation in 96 % of patients. All the patients were able to phonate appropriately and remained comfortable after emergence. This technique allowed improved surgical conditions with reduced patient discomfort and may be advantageous for other laryngeal and neck surgeries in which intraoperative patient feedback is required.

Objectives: (1) To develop an automated algorithm to analyze electroglottographic (EGG) signal in continuous dysphonic speech, and (2) to identify EGG waveform parameters that correlate with the auditory-perceptual quality of strain in the speech of patients with adductor spasmodic dysphonia (ADSD)., Study Design: Software development with application in a prospective controlled study., Methods: EGG was recorded from 12 normal speakers and 12 subjects with ADSD reading excerpts from the Rainbow Passage. Data were processed by a new algorithm developed with the specific goal of analyzing continuous dysphonic speech. The contact quotient, pulse width, a new parameter peak skew, and various contact closing slope quotient and contact opening slope quotient measures were extracted. EGG parameters were compared between normal and ADSD speech. Within the ADSD group, intra-subject comparison was also made between perceptually strained syllables and unstrained syllables., Results: The opening slope quotient SO7525 distinguished strained syllables from unstrained syllables in continuous speech within individual subjects with ADSD. The standard deviations, but not the means, of contact quotient, EGGW50, peak skew, and SO7525 were different between normal and ADSD speakers. The strain-stress pattern in continuous speech can be visualized as color gradients based on the variation of EGG parameter values., Conclusions: EGG parameters may provide a within-subject measure of vocal strain and serve as a marker for treatment response. The addition of EGG to multidimensional assessment may lead to improved characterization of the voice disturbance in ADSD., (Copyright © 2016 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Individuals with larynx (vocal folds) impaired have problems in controlling their glottal vibration, producing whispered speech with extreme hoarseness. Standard automatic speech recognition using only acoustic cues is typically ineffective for whispered speech because the corresponding spectral characteristics are distorted. Articulatory cues such as the tongue and lip motion may help in recognizing whispered speech since articulatory motion patterns are generally not affected. In this paper, we investigated whispered speech recognition for patients with reconstructed larynx using articulatory movement data. A data set with both acoustic and articulatory motion data was collected from a patient with surgically reconstructed larynx using an electromagnetic articulograph. Two speech recognition systems, Gaussian mixture model-hidden Markov model (GMM-HMM) and deep neural network-HMM (DNN-HMM), were used in the experiments. Experimental results showed adding either tongue or lip motion data to acoustic features such as mel-frequency cepstral coefficient (MFCC) significantly reduced the phone error rates on both speech recognition systems. Adding both tongue and lip data achieved the best performance.

The terms used to describe vocal fold motion impairment are confusing and not standardized. This results in a failure to communicate accurately and to major limitations of interpreting research studies involving vocal fold impairment. We propose standard nomenclature for reporting vocal fold impairment. Overarching terms of vocal fold immobility and hypomobility are rigorously defined. This includes assessment techniques and inclusion and exclusion criteria for determining vocal fold immobility and hypomobility. In addition, criteria for use of the following terms have been outlined in detail: vocal fold paralysis, vocal fold paresis, vocal fold immobility/hypomobility associated with mechanical impairment of the crico-arytenoid joint and vocal fold immobility/hypomobility related to laryngeal malignant disease. This represents the first rigorously defined vocal fold motion impairment nomenclature system. This provides detailed definitions to the terms vocal fold paralysis and vocal fold paresis.

Objectives: To assess perspectives of patients with voice problems and identify factors associated with the likelihood of referral to voice therapy via the CHEER (Creating Healthcare Excellence through Education and Research) practice-based research network infrastructure., Study Design: Prospectively enrolled cross-sectional study of CHEER patients seen for a voice problem (dysphonia)., Setting: The CHEER network of community and academic sites., Methods: Patient-reported demographic information, nature and severity of voice problems, clinical diagnoses, and proposed treatment plans were collected. The relationship between patient factors and voice therapy referral was investigated., Results: Patients (N = 249) were identified over 12 months from 10 sites comprising 30 otolaryngology physicians. The majority were women (68%) and white (82%). Most patients reported a recurrent voice problem (72%) and symptom duration >4 weeks (89%). The most commonly reported voice-related diagnoses were vocal strain, reflux, and benign vocal fold lesions. Sixty-seven percent of enrolled patients reported receiving a recommendation for voice therapy. After adjusting for sociodemographic and other factors, diagnoses including vocal strain/excessive tension and vocal fold paralysis and academic practice type were associated with increased likelihood of reporting a referral for voice therapy., Conclusions: The CHEER network successfully enrolled a representative sample of patients with dysphonia. Common diagnoses were vocal strain, reflux, and benign vocal fold lesions; commonly reported treatment recommendations included speech/voice therapy and antireflux medication. Recommendation for speech/voice therapy was associated with academic practice type., (© American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.)

Vocal folds are used as sound sources in various species, but it is unknown how vocal fold morphologies are optimized for different acoustic objectives. Here we identify two main variables affecting range of vocal fold vibration frequency, namely vocal fold elongation and tissue fiber stress. A simple vibrating string model is used to predict fundamental frequency ranges across species of different vocal fold sizes. While average fundamental frequency is predominantly determined by vocal fold length (larynx size), range of fundamental frequency is facilitated by (1) laryngeal muscles that control elongation and by (2) nonlinearity in tissue fiber tension. One adaptation that would increase fundamental frequency range is greater freedom in joint rotation or gliding of two cartilages (thyroid and cricoid), so that vocal fold length change is maximized. Alternatively, tissue layers can develop to bear a disproportionate fiber tension (i.e., a ligament with high density collagen fibers), increasing the fundamental frequency range and thereby vocal versatility. The range of fundamental frequency across species is thus not simply one-dimensional, but can be conceptualized as the dependent variable in a multi-dimensional morphospace. In humans, this could allow for variations that could be clinically important for voice therapy and vocal fold repair. Alternative solutions could also have importance in vocal training for singing and other highly-skilled vocalizations.

Objectives/hypothesis: To test the hypothesis that subligamental cordectomy produces superior acoustic outcome than subepithelial cordectomy for early (T1-2) glottic cancer that requires complete removal of the superficial lamina propria but does not involve the vocal ligament., Study Design: Computer simulation., Methods: A computational tool for vocal fold surgical planning and simulation (the National Center for Voice and Speech Phonosurgery Optimizer-Simulator) was used to evaluate the acoustic output of alternative vocal fold morphologies. Four morphologies were simulated: normal, subepithelial cordectomy, subligamental cordectomy, and transligamental cordectomy (partial ligament resection). The primary outcome measure was the range of fundamental frequency (F0 ) and sound pressure level (SPL). A more restricted F0 -SPL range was considered less favorable because of reduced acoustic possibilities given the same range of driving subglottic pressure and identical vocal fold posturing., Results: Subligamental cordectomy generated solutions covering an F0 -SPL range 82% of normal for a rectangular vocal fold. In contrast, transligamental and subepithelial cordectomies produced significantly smaller F0 -SPL ranges, 57% and 19% of normal, respectively., Conclusion: This study illustrates the use of the Phonosurgery Optimizer-Simulator to test a specific hypothesis regarding the merits of two surgical alternatives. These simulation results provide theoretical support for vocal ligament excision with maximum muscle preservation when superficial lamina propria resection is necessary but the vocal ligament can be spared on oncological grounds. The resection of more tissue may paradoxically allow the eventual recovery of a better speaking voice, assuming glottal width is restored. Application of this conclusion to surgical practice will require confirmatory clinical data., Level of Evidence: N/A., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To investigate the effect of stretch-and-flow voice therapy on vocal function and handicap., Study Design: Randomized controlled trial., Methods: Participants with primary muscle tension dysphonia were randomly assigned to experimental or control groups. Experimental participants received vocal hygiene education followed by 6 weeks of stretch-and-flow voice therapy. Control participants received vocal hygiene education only. Outcome variables consisted of a measure of vocal handicap (Voice Handicap Index [VHI]), maximum phonation time, s/z ratio, and acoustic measures. All measures were obtained at baseline prior to treatment and within 2 weeks posttreatment or at the end of the control period. The pre- to posttreatment measurement change (delta Δ) was applied to statistical analyses., Results: A multivariate analysis of variance revealed significant group differences in pre-to-post changes on measures of VHI, maximum phonation time, and cepstral peak prominence (CPP) in connected speech and vowels (P = 0.003, 0.013, 0.025, and 0.017 respectively), with a significant reduction of VHI (Cohen's d = 1.6), increase in maximum phonation time (Cohen's d = 1.2), increase of CPP in connected speech (Cohen's d = 1.2), and increase of CPP in vowels (Cohen's d = 1.1) in the experimental group compared to the control group., Conclusions: This preliminary small sample randomized controlled trial found significantly greater improvement in vocal handicap, maximum phonation time, and acoustic measures of vocal function after participants received stretch-and-flow voice therapy compared to participants receiving vocal hygiene education alone. Additional research incorporating larger samples will be needed to confirm and further investigate these findings., Level of Evidence: 1b., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: To investigate the efficacy of stretch-and-flow voice therapy as a primary physiological treatment for patients with hyperfunctional voice disorders., Study Design: Prospective case series., Methods: Participants with a diagnosis of primary muscle tension dysphonia or phonotraumatic lesions due to hyperfunctional vocal behaviors were included. Participants received stretch-and-flow voice therapy structured once weekly for 6 weeks. Outcome variables consisted of two physiologic measures (s/z ratio and maximum phonation time), an acoustic measure (cepstral peak prominence [CPP]), and a measure of vocal handicap (voice handicap index [VHI]). All measures were obtained at baseline before treatment and within 2 weeks posttreatment., Results: The s/z ratio, maximum phonation time, sentence CPP, and VHI showed statistically significant (P < 0.05) improvement through therapy. Effect sizes reflecting the magnitude of change were large for s/z ratio and VHI (d = 1.25 and 1.96 respectively), and moderate for maximum phonation time and sentence CPP (d = 0.79 and 0.74, respectively)., Conclusions: This study provides supporting evidence for preliminary efficacy of stretch-and-flow voice therapy in a small sample of patients. The treatment effect was large or moderate for multiple outcome measures. The data provide justification for larger, controlled clinical trials on the application of stretch-and-flow voice therapy in the treatment of hyperfunctional voice disorders., (Copyright © 2015 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives/hypothesis: The relationship between patient-reported vocal handicap and clinician-rated measures of vocal dysfunction is not understood. This study aimed to determine if a correlation exists between the Voice Handicap Index-10 (VHI-10) and the Voice Functional Communication Measure rating in the National Outcomes Measurement System (NOMS)., Study Design: Retrospective case series., Methods: Four hundred and nine voice evaluations over 12 months at a tertiary voice center were reviewed. The VHI-10 and NOMS scores, diagnoses, and potential comorbid factors were collected and analyzed., Results: For the study population as a whole, there was a moderate negative correlation between the NOMS rating and the VHI-10 (Pearson r = -0.57). However, for a given NOMS level, there could be considerable spread in the VHI-10. In addition, as the NOMS decreased stepwise below level 4, there was a corresponding increase in the VHI-10. However, a similar trend in VHI-10 was not observed for NOMS above level 4, indicating the NOMS versus VHI-10 correlation was not linear. Among diagnostic groups, the strongest correlation was found for subjects with functional dysphonia. The NOMS versus VHI-10 correlation was not affected by gender or the coexistence of a psychiatric diagnosis., Conclusions: A simple relationship between VHI-10 and NOMS rating does not exist. Patients with mild vocal dysfunction have a less direct relationship between their NOMS ratings and the VHI-10. These findings provide insight into the interpretation of patient-perceived and clinician-rated measures of vocal function and may allow for better management of expectations and patient counseling in the treatment of voice disorders., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To develop a vocal fold scarring model using an ablative laser in the rabbit as a platform for testing bioengineered therapies for missing or damaged lamina propria., Study Design: Prospective controlled animal study., Methods: An optimal laser energy level was first determined by assessing the depths of vocal fold injury created by a Holmium:YAG laser at various energy levels on fresh cadaveric rabbit larynges. The selected energy level was then used to create controlled unilateral injuries in vocal folds of New Zealand white rabbits, with the contralateral folds serving as uninjured controls. After 4 weeks, the larynges were harvested and subjected to excised-larynx phonation with high-speed imaging and immunohistochemical staining for collagen types I and III, elastin, and hyaluronic acid (HA) with quantitative histological analysis., Results: A total of 1.8 joules produced full-thickness injury of the lamina propria without extensive muscle injury. After 4 weeks, the injured vocal folds vibrated with reduced amplitude (P = 0.036) in excised-larynx phonation compared to normal vocal folds. The injured vocal folds contained a higher relative density of collagen type I (P = 0.004), higher elastin (P = 0.022), and lower HA (P = 0.030) compared to normal controls. Collagen type III was unchanged., Conclusions: With its potential for higher precision of injury, this laser vocal fold scarring model may serve as an alternative to scarring produced by cold instruments for studying the effects of vocal fold lamina propria bioengineered therapies., (© 2014 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: 1) To test whether alteration of the vocal fold medial surface contour can improve phonation and 2) to demonstrate that implant material properties affect vibration even when implantation is deep to the vocal fold lamina propria., Study Design: Induced phonation of excised human larynges., Methods: Thirteen larynges were harvested within 24 hours postmortem. Phonation threshold pressure (PTP) and flow (PTF) were measured before and after vocal fold injections using either calcium hydroxylapatite (CaHA) or hyaluronic acid (HA). Small-volume injections (median, 0.0625 mL) were targeted to the inferomedial aspect of the thyroarytenoid muscle. Implant locations were assessed histologically., Results: The effect of implantation on PTP was material dependent. CaHA tended to increase PTP, whereas HA tended to decrease PTP (Wilcoxon test, P = .00013 for onset). In contrast, the effect of implantation on PTF was similar, with both materials tending to decrease PTF (P = .16 for onset). Histology confirmed implant presence in the inferior half of the vocal fold vertical thickness., Conclusions: Taken together, these data suggested the implants may have altered the vocal fold medial surface contour, potentially resulting in a less convergent or more rectangular glottal geometry as a means to improve phonation. An implant with a closer viscoelastic match to vocal fold cover is desirable for this purpose, as material properties can affect vibration even when the implant is not placed within the lamina propria. This result is consistent with theoretical predictions and implies greater need for surgical precision in implant placement and care in material selection., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: To create a high-resolution three-dimensional (3D) reconstruction of a case of cricoarytenoid subluxation and perform quantitative analysis to understand its anatomy and functional consequence., Study Design: Computational, with image processing and analysis., Methods: High-resolution axial computed tomography images of the larynx of a patient with an anteriorly subluxed arytenoid were processed with custom MATLAB routines to create a versatile 3D reconstruction. The geometries of the subluxed and nonsubluxed arytenoids were quantitatively compared., Results: The anteriorly subluxed arytenoid has an inferoposteriorly displaced vocal process (VP), resulting in an elongated and inferiorly positioned vocal fold. The paradoxical posterior displacement of the VP with elongation of the vocal fold has not been described previously. Quantitative analysis reveals significant rotational components and a unidirectional translational component in anterior arytenoid subluxation., Conclusions: Quantitative 3D analysis yielded insight into the biomechanics of anterior arytenoid subluxation. Subluxation in this case appeared to involve more pure rotational than translational motion. Overrocking of the subluxed arytenoid can produce paradoxical elongation of the involved vocal fold., (Copyright © 2012 The Voice Foundation. Published by Mosby, Inc. All rights reserved.)