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Objective(s): To assess the impact of a novel 3D-printed simulation model with Brainlab Image Guidance on enhancing otolaryngology residents' skills and confidence in performing transcervical intralaryngeal injection (TII) compared with conventional training methods., Methods: Utilizing a 3D-printed larynx model derived from computed tomography (CT) scans, this study involved 16 otolaryngology residents divided into two groups for TII training: one with Brainlab Image Guidance (LMIG) and the other without (LM). Pre- and post-training evaluations measured participants' confidence while the Brainlab system measured the accuracy of their needle placements., Results: After training, participants exhibited a significant increase in confidence with an average rise from 1.56 to 2.75 on a 5-point scale. The LMIG group outperformed the LM group in accuracy achieving statistically significant reductions in target distances after training (3.5 mm right, 3.6 mm left). The LMIG also demonstrated a significantly greater increase in procedural confidence over the LM group after training., Conclusion: The TII laryngeal model with Brainlab Image Guidance significantly improves procedural confidence and accuracy among otolaryngology residents, signifying potential advantage over a more conventional training approach. The model's realistic tactile and live instrument positioning feedback augments the process of surgical skill refinement in a controlled, risk-free, simulation environment., Level of Evidence: NA Laryngoscope, 135:763-768, 2025., (© 2024 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: Vocal fold immobility (VFI) is a cause of significant morbidity and mortality in the paediatric population. Laryngoscopy is the current first-line investigation for patients with suspected VFI. Laryngeal ultrasound (LUS) has recently emerged as an alternative method of identifying VFI. Compared to laryngoscopy, LUS is less invasive, does not require anaesthesia, and can be performed by non-otolaryngologists. The objectives of this study are to evaluate LUS as a diagnostic method for the identification of VFI in a cohort of paediatric patients in Aotearoa New Zealand (NZ) and to estimate the frequency of use of LUS in the paediatric population by clinicians around the world., Methods: A retrospective, single-centre cohort study was performed on all paediatric patients who had undergone laryngoscopy and LUS at Starship Children's Health in Auckland, NZ, between 2020 and 2023. An eight-question survey was also developed and distributed to better understand clinicians' use of LUS in their clinical practice to diagnose paediatric VFI globally., Results: Twenty-nine paediatric patients met the inclusion criteria. LUS demonstrated good sensitivity (80.95%) for detecting VFI and increased to 93.33% for the detection of unilateral VFI. Of the 87 respondents to the survey, 41.38% utilise LUS in their clinical practice in the paediatric population. The main barriers to implementation of LUS as identified by non-users were lack of equipment, expertise, and training., Conclusions: These findings support the use of LUS as an accurate diagnostic tool for the detection of unilateral VFI. Further studies in non-surgical populations and in patients with bilateral VFI, as well as standardised guidelines for LUS technique and reporting, are required., (© 2024 The Author(s). Clinical Otolaryngology published by John Wiley & Sons Ltd.)

Aim: To develop a larynx preservation (LP) score model to predict laryngectomy-free survival (LFS) in advanced laryngeal squamous-cell carcinoma (LSCC) with morphological response to neoadjuvant chemotherapy (NAC)., Materials and Methods: In this retrospective study, patients with advanced LSCC were included. All patients were classified into NAC response and non-response groups according RECIST. Arterial and venous phases of standardized iodine concentrations of dual-energy CT were measured in the response group, and the rate of iodine concentration change (ΔNIC%) was calculated by (NICpost-NICpre)/NICpre ×100%. Clinical outcomes between the two groups were analyzed using chi-square test. Univariable and multivariable cox regression analyses were performed to evaluate the independent predictors of LFS in the response group. A risk score was developed based on the hazard ratios from the multivariable analysis., Results: A total of 146 patients were included. 86 patients achieved a response. T stage, N status, and ΔNAIC% were independent predictors of LFS for LSCC patients with NAC morphological response (all, p<0.001). Based on these factors, the established LP risk score model demonstrated an AUC of 0.877 for the 1-year LFS rate and 0.950 for the 2-year LFS rate. Patients with a score ≥6 had a worse LFS (p<0.001) and OS (p=0.001)., Conclusion: A prediction risk score incorporating T stage, N status, and ΔNAIC% shows good predictive effectiveness for LFS in advanced LSCC with morphological response to NAC. It can prevent high-risk patients in the NAC response group from undergoing salvage laryngectomy and improve patient prognosis., Competing Interests: Conflict of interest The authors declare no conflict of interest., (Copyright © 2024 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.)

Purpose: Traditional dissection methods are primarily limited by challenges in identifying minute structures, which can lead to irreversible tissue damage. Anatomical observation of the larynx is particularly challenging in educational and clinical settings owing to its microscopic structures and complex three-dimensional (3D) nature, making it difficult to dissect. Therefore, this study aimed to demonstrate that micro-computed tomography (micro-CT) imaging of the larynx can serve as an effective alternative for educational and clinical purposes, overcoming these limitations., Methods: Three laryngeal specimens were obtained from cadavers, stained with a phosphotungstic acid-based contrast agent, and imaged using enhanced micro-CT. The resulting images were reconstructed in three dimensions, allowing for a detailed 3D observation of the specimens., Results: Phosphotungstic contrast-enhanced micro-CT provided comprehensive anatomical information on laryngeal structures, including muscles, nerves, arteries, and vocal folds., Conclusion: This study demonstrates the high effectiveness of micro-CT in producing detailed structural images of the larynx, enabling 3D observation of even the smallest anatomical structures. These images can be applied in both educational and clinical settings to analyze the human larynx, effectively overcoming the limitations of traditional dissection methods. This approach facilitates the analysis of laryngeal structures that are otherwise difficult to observe with the naked eye., Competing Interests: Declarations. Institutional review board statements: This study was conducted in accordance with the Declaration of Helsinki and was approved by the Institutional Review Board of the Catholic University of Korea (MC22SISI0098). Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: In the pedagogy of classical vocal singing, it can be difficult to determine the human voice fach, especially for the voice of aspiring vocalists. Hence, an objective metric-based system for the determination of the human voice is needed. In the present study, we investigated the anthropological and aerodynamic parameters for 60 professional singers with a professionally confirmed singing range., Methods: Amongst the 60 included professional singers, there were ten participants each for sopranos, mezzo-sopranos, altos (female vocal fach), and tenors, baritones, basses (male vocal fach). Airflow measurements were recorded using spirometry whilst anthropological measurements were taken using CT scans. Appropriate statistical analyses were done using the Mann-Whitney U test and Kruskal Wallis H test with post-hoc tests and Bonferroni correction. p  < 0.05 was considered statistically significant., Results: Soprano singers, who have the highest pitch, were found to be the shortest and least heavy, whilst basses, who have the lowest pitch, were found to be tallest and heaviest amongst the study participants. Furthermore, sopranos had the smallest lung volumes while the basses had the largest lung volumes (raw spirometry measures). However, when normalized ratios were considered, no differences were observed. Finally, laryngeal size showed sexual dimorphism due to developmental changes., Conclusions: A mix of anthropological and aerodynamic measurements may be useful to assist singers and vocal pedagogues to assess and determine voice types before the beginning of their vocal studies.

Background and Objective: Laryngeal Cancer (LC) constitutes approximately one third of head and neck cancers. Detecting early-stage lesions in this anatomical region is crucial for achieving a high survival rate. However, it poses significant diagnostic challenges owing to the varied appearance of lesions and the need for precise characterization for appropriate clinical management. Conventional diagnostic approaches rely heavily on endoscopic examination, which often requires expert interpretation and may be limited by subjective assessment. Deep learning (DL) approaches offer promising opportunities for automating lesion detection, but their efficacy in handling multi-modal imaging data and accurately localizing small lesions remains a subject of investigation. Furthermore, the clinical domain may largely benefit from the deployment of efficient DL methods that can ensure equitable access to advanced technologies, regardless of the availability of resources that can often be limited. In this study, a DL-based approach, named SRE-YOLO, was introduced to provide real-time assistance to less-experienced personnel during laryngeal assessment, by automatically detecting lesions at different scales from endoscopic White Light (WL) and Narrow-Band Imaging (NBI) images., Methods: During the training, the SRE-YOLO integrates a YOLOv8 nano (YOLOv8n) baseline with a Super-Resolution (SR) branch to enhance lesion detection. This last component is decoupled during inference to preserve the low computational demand of the YOLOv8n baseline. The evaluation was conducted on a multi-center dataset, encompassing diverse laryngeal pathologies and acquisition modalities., Results: The SRE-YOLO method improved the Average Precision (AP @IoU=0.5 ) in lesion detection by 5% with respect to the YOLOv8n baseline, while maintaining the inference speed of 58.8 Frames Per Second (FPS). Comparative analyses against state-of-the-art DL methods highlighted the efficacy of the SRE-YOLO approach in balancing detection accuracy, computational efficiency, and real-time applicability., Conclusions: This research underscores the potential of SRE-YOLO in developing efficient DL-driven decision support systems for real-time detection of laryngeal lesions at different scales from both WL and NBI endoscopic data., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Leonardo S. Mattos reports financial support was provided by RAISE, Robotics and AI for Socio-economic Empowerment (ECS00000035). If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Background: Congenital lung malformations (CLMs) are among the rare anomalies that can be diagnosed by bronchoscopy and imaging. They can cause various respiratory symptoms and complications, especially in children with congenital heart disease. This is an interesting case report of a child with a rare combination of congenital anomalies affecting the airway., Case Presentation: We report a case of a 3.5-year-old boy with multiple congenital anomalies and respiratory problems since birth. He had a history of mild autism, developmental delay, and sensitivity to smell and smoke. He presented with hoarseness, shortness of breath, severe coughing, and severe wheezing, which worsened with the flu. He underwent bronchoscopy and other diagnostic tests, which revealed a posterior laryngeal cleft, a tracheal bronchus, and a very narrow distal trachea. He was treated with nebulizers, antibiotics, and serum therapy and showed improvement. This case illustrates a rare combination of airway malformations that require a multidisciplinary approach., Conclusions: We presented a case of rare pulmonary malformations and chronic respiratory symptoms that improved with conventional pharmacotherapy. Increased awareness and understanding of these anomalies among healthcare providers can lead to earlier diagnosis and improved patient outcomes., Competing Interests: Declarations Ethical approval The study was reviewed and approved by the Research Ethics Committees of Kurdistan University of Medical Sciences Medicine. The project was found to be by the ethical principles and the national norms and standards for conducting Medical Research in Iran. Written informed consent to participate in this study was provided by the participant’s legal guardian. Consent for publication Informed consent was obtained from the patient’s parents for the publication of this case report. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Post-mortem computed tomography (PMCT) is routinely used at many forensic institutions to guide the following autopsy and is especially useful for diagnosing fractures. This systematic review aims to investigate the sensitivity and specificity of a PMCT scan in fracture diagnosis of the hyoid-larynx complex (HLC) compared to traditional autopsy in cases involving traumatic neck injuries. We searched PubMed, SCOPUS and Web of Science and included papers with cases n ≥ 3 published between January 2000 and April 2023 reporting on PMCT and autopsy findings of fractures of the HLC. The search provided 259 results of which 10 were included. Overall sensitivity and specificity were 0.70 [0.59; 0.79] and 0.92 [0.80; 0.97] for hyoid bone fractures and 0.80 [0.62; 0.91] and 0.76 [0.63; 0.85] for the thyroid cartilage. The results show great variation, and a large range between studies. These results indicate that PMCT cannot replace autopsy in cases with HLC fractures. Future larger prospective studies are needed, examining fracture details, scan protocols and different slice thicknesses using uniform reporting., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Unilateral vocal fold paralysis (UVFP) presents as incomplete glottal closure and leads to breathy hoarseness. Various treatments, including laryngeal framework surgery (type 1 thyroplasty [TP1] and arytenoid adduction [AA]), have been devised to correct this condition. Ultrahigh-resolution computed tomography (U-HRCT) allows detailed three-dimensional imaging of the larynx, which aids our understanding of vocal fold motion disorders. This study assessed whether U-HRCT is beneficial for correct diagnosis and surgical planning., Methods: The participants were 26 UVFP patients who underwent laryngeal framework surgery (TP1 and/or AA). U-HRCT was used to measure the vocal fold volume (VFV) and level difference (LD). The need to combine AA with TP1 to obtain satisfactory surgical outcomes was evaluated by U-HRCT and various voice function tests., Results: VFV was smaller in paralyzed folds than in unaffected folds. LD correlated strongly with voice parameters and showed high intra-rater and inter-rater reliability. The surgical outcome of the laryngeal framework surgery performed was judged to be excellent for improving voice function. Comparison of LD between the TP1 group and TP1 + AA group indicated that LD is an excellent parameter to determine the need to combine AA with TP1., Conclusion: These findings underscore the value of preoperative U-HRCT, especially LD, in surgical decision-making and afford insights for optimal phonosurgery and individualized intervention. Patients with LD >1.0 mm may benefit from thyroplasty with AA., Level of Evidence: 3 (case-control study) Laryngoscope, 134:4667-4673, 2024., (© 2024 The Author(s). The Laryngoscope published by Wiley Periodicals LLC on behalf of The American Laryngological, Rhinological and Otological Society, Inc.)

Congenital saccular cyst of the larynx is a rare cause of presentation of stridor and respiratory distress in newborns. The clinical presentation of a saccular laryngeal cyst often overlaps with other common causes of stridor, such as laryngomalacia, presenting a diagnostic dilemma for clinicians. We present a case of a term newborn infant referred for evaluation of inspiratory stridor since birth. Microlaryngoscopy and bronchoscopy confirmed the presence of a large cystic mass obstructing the supraglottis. Marsupialisation of the cyst was performed with resolution of stridor, and histopathological examination confirmed the diagnosis of a saccular laryngeal cyst. Our case highlights the importance of considering congenital saccular laryngeal cysts, although rare, in the differential diagnoses of neonatal stridor. Prompt recognition, early endoscopic airway evaluation and surgical intervention are crucial to preventing potentially life-threatening airway obstruction in a newborn presenting with stridor., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

A human laryngeal model, incorporating all the cartilages and the intrinsic muscles, was reconstructed based on MRI data. The vocal fold was represented as a multilayer structure with detailed inner components. The activation levels of the thyroarytenoid (TA) and cricothyroid (CT) muscles were systematically varied from zero to full activation allowing for the analysis of their interaction and influence on vocal fold dynamics and glottal flow. The finite element method was employed to calculate the vocal fold dynamics, while the one-dimensional Bernoulli equation was utilized to calculate the glottal flow. The analysis was focused on the muscle influence on the fundamental frequency (f o ). We found that while CT and TA  activation increased the f o in most of the conditions, TA activation resulted in a frequency drop when it was moderately activated. We show that this frequency drop was associated with the sudden increase of the vertical motion when the vibration transited from involving the whole tissue to mainly in the cover layer. The transition of the vibration pattern was caused by the increased body-cover stiffness ratio that resulted from TA activation., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

The underlying pathophysiological mechanisms of exercise-induced laryngeal obstruction (EILO) remain to be fully established. It is hypothesized that high inspiratory flow rates can exert a force on laryngeal airway walls that contribute to its inward collapse causing obstruction. Computational fluid dynamics (CFD) presents an opportunity to explore the distribution of forces in a patient-specific upper airway geometry. The current study combined exercise physiological data and CFD simulation to explore differences in airflow and force distribution between a patient with EILO and a healthy matched control. Participants underwent incremental exercise testing with continuous recording of respiratory airflow and laryngoscopic video, followed by an MRI scan. The respiratory and MRI data were used to generate a subject-specific CFD model of upper respiratory airflow. In patient with EILO, the posterior supraglottis experiences an inwardly directed net force, whose magnitude increases nonlinearly with larger flow rates, with slight changes in the direction toward the center of the airway. The control demonstrated an outwardly directed force at all regions of the wall, with a magnitude that increases linearly with larger flow rates. A comparison is made between the CFD results and endoscopic visualization of supraglottic collapse, and a very good agreement is found. The current study presents the first hybrid physiological and computational approach to investigate the pathophysiological mechanisms of EILO, with preliminary findings showing great potential, but should be used in larger sample sizes to confirm findings. NEW & NOTEWORTHY The current study is the first to use a hybrid combined computational fluid dynamics (CFD) and exercise physiology approach to investigate pathophysiology in exercise-induced laryngeal obstruction (EILO). The hybrid methodology is a promising approach to explore the pathophysiological mechanisms underlying the condition. Notable differences occur in the distribution of airflow and wall forces between the EILO and control participants, which align with symptoms and visual observations.

Background: Cervical injuries are important complications of near-hanging, which is defined as self-injury by hanging if the patient survives at admission. Previous studies have reported that complicated cervical injuries due to near-hanging are uncommon. The primary aim of this study was to evaluate whether cervical imaging can be safely omitted for near-hanging patients who are alert and have no abnormal neck symptoms or signs., Methods: This was a retrospective observational study to investigate the prevalence of cervical injuries among hospitalized near-hanging patients between April 2014 and June 2023. The primary outcome was the prevalence of any complicated cervical injuries, which included laryngeal fractures, laryngeal deviations, spinal cord injuries, cervical spine fractures, and blunt cerebrovascular injuries. The primary aim of this study was to determine the primary outcome among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs., Results: During the study period, a total of 63 near-hanging patients were hospitalized. Of these, 11 patients (18%) with normal levels of consciousness and no neck symptoms or signs at admission were included. The median age of the patients was 37 years (IQR 27 to 53); 5 (45%) were women, and none had cardiac arrest at the scene. For the primary outcome, no complicated cervical injuries (0%; 95% CI, 0% to 27%) occurred among the small number of near-hanging patients who had normal levels of consciousness and no abnormal neck symptoms or signs at admission., Conclusions: There were no cases of complicated cervical injuries among near-hanging patients with normal levels of consciousness and no abnormal neck symptoms or signs. Further prospective multicenter studies are warranted to investigate whether cervical imaging can be safely omitted in assessments of these patients., Competing Interests: Declaration of competing interest None of authors have financial relationships with any organizations that might have an interest in this work or other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: A comprehensive understanding of how vocal tract dimensions vary among different types of loud voice productions has not yet been fully formed. This study aims to expand the existing knowledge on the topic., Methods: Three trained professional singers together practiced the vocal techniques underlying Opera and Kulning singing styles for one hour and, afterwards, phonated using these techniques on vowel [iː] at pitch C5 (523 Hz), while their vocal tracts were scanned via MRI. One of the participants also produced the samples in the Edge vocal mode using [ɛː]. Several dimensional vocal tract measurements were calculated from the MRIs. Spectral analysis was conducted on the filtered audio recorded during the MRI., Results: The Operatic technique demonstrated a lower larynx, a larger tongue-palate distance, and larger epilaryngeal and pharyngeal tube diameters compared to Kulning. Edge showed the highest laryngeal position, narrowest pharynx and epilarynx tubes, and the least forward-tilted larynx out of the styles studied. The spectra of Opera and Kulning showed a dominant first harmonic, while in Edge, the second harmonic was the strongest., Conclusions: The results shed light on the magnitude of vocal tract changes necessary for genre-typical vocal projection. This information can be pedagogically helpful., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: Surface reconstructions from laryngoscopic videos have the potential to assist clinicians in diagnosing, quantifying, and monitoring airway diseases using minimally invasive techniques. However, tissue movements and deformations make these reconstructions challenging using conventional pipelines., Methods: To facilitate such reconstructions, we developed video frame pre-filtering and featureless dense matching steps to enhance the Alicevision Meshroom SfM pipeline. Time and the anterior glottic angle were used to approximate the rigid state of the airway and to collect frames with different camera poses. Featureless dense matches were tracked with a correspondence transformer across subsets of images to extract matched points that could be used to estimate the point cloud and reconstructed surface. The proposed pipeline was tested on a simulated dataset under various conditions like illumination and resolution as well as real laryngoscopic videos., Results: Our pipeline was able to reconstruct the laryngeal region based on 4, 8, and 16 images obtained from simulated and real patient exams. The pipeline was robust to sparse inputs, blur, and extreme lighting conditions, unlike the Meshroom pipeline which failed to produce a point cloud for 6 of 15 simulated datasets., Conclusion: The pre-filtering and featureless dense matching modules specialize the conventional SfM pipeline to handle the challenging laryngoscopic examinations, directly from patient videos. These 3D visualizations have the potential to improve spatial understanding of airway conditions., (© 2024. CARS.)

Background: Bleeding incidents during percutaneous dilatational tracheostomy are concerning, and most cases occur in patients with unrecognized and unanticipated anatomical variations in the vascular anatomy. However, the extent of this variation remains unclear. To address this knowledge gap, our study aimed to comprehensively map laryngeal vascular anatomy in a cohort of adult patients., Methods: Ultrasound assessments of the soft tissue in the neck were performed, spanning from the thyroid cartilage to the third tracheal ring and extending 2 cm laterally on both sidesperformed. We subdivided this area into 12 zones comprising four medial and eight lateral sections. A pre-planned form was used to document the presence of arteries or veins in each zone. The results are reported as odds ratios, 95% CIs, and corresponding P values., Results: Five-hundred patients were enrolled from August 14, 2023, to November 13, 2023, at the University Hospital of Padua. Arteries and veins were identified in all investigated zones (varying from a minimum of 1.0%-46.4%). The presence of invessels progressively increased from the cricothyroid membrane to the third tracheal ring and from the midline to the paramedian laryngeal area., Conclusions: Given the prevalence of arteries and veins, particularly in areas where tracheostomies are commonly performed, we strongly advocate for routine ultrasound assessments before such procedures are performed.

Objective: The epiglottis plays an integral role in the swallowing mechanism and is also implicated as an obstruction site in obstructive sleep apnea (OSA). The underlying causes of epiglottic collapse during sleep remain unclear. This study aimed to investigate the cognitive functions using the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) and the neurophysiological and anatomical factors using videofluoroscopic swallowing studies (VFSS). We compared patients with OSA exhibiting epiglottic collapse to those without, assessing differences in anatomical or neurophysiological characteristics., Methods: The study included 12 patients with epiglottic collapse (Epi-group) and 68 without (non-Epi group), all undergoing overnight polysomnography (PSG), drug-induced sleep endoscopy (DISE), LOTCA, and VFSS. Oral transit time (OTT), pharyngeal delay time (PDT), and pharyngeal transit time (PTT) were considered as neurophysiological traits, and laryngeal elevation length (LE) as anatomical trait, and were measured across various test diets (10 ml of liquid, soft, or solid)., Results: The study comprised 80 individuals, 57 men and 23 women, with no significant age, sex, body mass index or PSG parameters between groups, or DISE findings, with the exception of epiglottic collapse. Swallowing metrics from VFSS were normal, with no differences in OTT, PDT, PTT, or LOTCA scores. Notably, patients with epiglottic collapse showed a greater laryngeal elevation when swallowing soft and solid foods (p = 0.025 and p = 0.048, respectively)., Conclusions: Patients with epiglottic collapse do not exhibit neurophysiological or cognitive impairments when compared to non-Epi group. However, the Epi-group displayed a significantly increased laryngeal elevation length. This suggests that anatomical factors may have a more substantial role in the development of epiglottic collapse than neurophysiological factors., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Large neck circumference and displacement of the trachea due to pathology increase the risk of failed identification of the cricothyroid membrane and cricothyroidotomy. We investigated whether ultrasound aids in the successful identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea., Methods: We developed silicone neck models that were suitable for both palpation and ultrasonography and where the trachea deviated laterally from the midline to either side. After reading a book chapter and participating in a 25-minute lecture and a 15- to 23-minute hands-on demonstration and rehearsal of ultrasonography for identification of the cricothyroid membrane, anesthesiologists and anesthesiology residents randomly performed identification with either ultrasound or palpation on 1 of 2 neck models., Results: We included 57 participants, of whom 29 and 28 were randomized to palpation and ultrasound, respectively. Correct identification of the cricothyroid membrane was achieved by 21 (75.0%) vs 1 (3.5%) of participants in the ultrasound versus palpation groups (risk ratio [RR], 21.8 [95% confidence interval {CI}, 3.1-151.0]). The tracheal midline position in the sagittal plane was identified correctly by 24 (85.7%) vs 16 (55.2%) of participants in the ultrasound versus palpation groups (RR, 1.6 [95% CI, 1.1-2.2])., Conclusions: Identification of the cricothyroid membrane in a model of an obese neck with midline deviation of the trachea was more often successful with ultrasound compared to palpation. Our study supports the potential use of ultrasound before induction of anesthesia and airway management in this group of patients, and it may even be applied in emergency situations when ultrasound is readily available. Further studies in human subjects should be conducted., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 International Anesthesia Research Society.)

Background: Gossypiboma, a retained surgical sponge with a foreign body reaction, is an unusual but serious complication seen in open abdominal surgeries. It is exceptionally rare following head and neck surgeries. Here, we present a case of Gossypiboma of the upper airway following tracheostomy., Case Presentation: A 32-year-old male presented with stridor and difficulty breathing one-month post-tracheostomy after a severe head injury following a road traffic accident. A neck radiograph was unremarkable, and a computed tomography (CT) scan of the neck showed a well-defined homogenous curvilinear membrane extending from the hypopharynx to the upper trachea. Bronchoscopic evaluation of the larynx and upper trachea revealed a retained surgical sponge, which was retrieved. The patient's breathing improved drastically post intervention., Conclusion: Gossypiboma may go undetected in radiographs and may also present atypically as a homogenous membrane on a CT scan of the neck. Though rare, retained surgical items can have profound medicolegal and professional consequences on physicians. Hence, a strong clinical suspicion and vigilance for gossypiboma is necessary for patients presenting with respiratory distress post-tracheostomy., (© 2024. The Author(s).)

To determine the diagnostic bias between clinical and forensic radiology in cases of nonfatal hanging and determine and describe typical underreported imaging findings. In a retrospective, single-center study, all patients admitted for attempted suicide with near-hanging or fatal hanging between January 2008 and December 2020 who received CT or MRI of head and neck were reviewed and missed findings in the original report were documented. A binary regression with disagreement as dependent variable was fitted for the imaging modality, fatality, age, and sex. A total of 123 hanging incidents were retrospectively analyzed. The vast majority (n = 108; 87.8%) had attempted suicide with a nonfatal outcome. Fatal outcome occurred in 15 (12.0%). The extra- and intracranial injuries documented on CT and MRI scans were laryngeal (n = 8; 6.5%), soft tissue (n = 42; 34.1%), and vascular injuries (n = 1; 0.8%). Intracranial pathology was evident on 18 (14.6%) scans. Disagreement occurred in 36 (29.3%) cases and represented 52 (69.2%) of all cases with a radiological finding. Disagreement was strongly associated with fatality (OR: 2.7-44.9.4, p = 0.0012). In most cases, nonfatal hangings cause no or only minor injuries. Fatal cases are associated with a greater probability of missed minor imaging findings. This suggests that findings deemed clinically irrelevant are probably not reported in such severe emergency cases. This association indicates that minor abnormalities are underreported when major pathologies are evident on imaging in victims of strangulation., (© 2023. The Author(s).)

Grading laryngeal squamous cell carcinoma (LSCC) based on histopathological images is a clinically significant yet challenging task. However, more low-effect background semantic information appeared in the feature maps, feature channels, and class activation maps, which caused a serious impact on the accuracy and interpretability of LSCC grading. While the traditional transformer block makes extensive use of parameter attention, the model overlearns the low-effect background semantic information, resulting in ineffectively reducing the proportion of background semantics. Therefore, we propose an end-to-end network with transformers constrained by learned-parameter-free attention (LA-ViT), which improve the ability to learn high-effect target semantic information and reduce the proportion of background semantics. Firstly, according to generalized linear model and probabilistic, we demonstrate that learned-parameter-free attention (LA) has a stronger ability to learn highly effective target semantic information than parameter attention. Secondly, the first-type LA transformer block of LA-ViT utilizes the feature map position subspace to realize the query. Then, it uses the feature channel subspace to realize the key, and adopts the average convergence to obtain a value. And those construct the LA mechanism. Thus, it reduces the proportion of background semantics in the feature maps and feature channels. Thirdly, the second-type LA transformer block of LA-ViT uses the model probability matrix information and decision level weight information to realize key and query, respectively. And those realize the LA mechanism. So, it reduces the proportion of background semantics in class activation maps. Finally, we build a new complex semantic LSCC pathology image dataset to address the problem, which is less research on LSCC grading models because of lacking clinically meaningful datasets. After extensive experiments, the whole metrics of LA-ViT outperform those of other state-of-the-art methods, and the visualization maps match better with the regions of interest in the pathologists' decision-making. Moreover, the experimental results conducted on a public LSCC pathology image dataset show that LA-ViT has superior generalization performance to that of other state-of-the-art methods.

Timely and complete laryngeal closure is critical for a successful swallow. Researchers have studied laryngeal closure, including true vocal cords (TVC) closure, closure of the arytenoids to the epiglottis base (laryngeal vestibule closure), and epiglottic inversion, but the most commonly available imaging tools have limitations that do not allow the study of these components individually. Swallowing computerized tomography (CT) has enabled three-dimensional dynamic visualization and quantitative evaluation of swallowing events providing a unique view of swallowing-related structures and their motion. Using CT, TVC closure can be visualized and evaluated on any plane or cross-section without being obscured by of laryngeal vestibule closure or epiglottis inversion. The current review summarizes the results of five papers evaluating the effects of bolus consistency and volume, posture, and age on TVC closure. The combined results of these studies suggest that TVC closure is responsive to oral sensory input based on bolus consistency and size and can be modulated in response to conditions perceived to increase the risk of airway invasion. These results are meaningful for dysphagia rehabilitation as it suggests that interventions to improve TVC closure are likely to enhance airway protection., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Imaging of the larynx and hypopharynx is frequently requested to assess the extent of neoplasms beyond the field of view of endoscopic evaluation. The combination of optical and cross-sectional imaging allows tumors to be classified according to AJCC/UICC guidelines. A thorough understanding of laryngeal and hypopharyngeal anatomy is crucial to guide the radiological eye along the possible pathways of the spread of diseases and to guide differential diagnoses. Computed tomography (CT) has been the first cross-sectional imaging technique used to evaluate the larynx and hypopharynx; its spatial resolution combined with volumetric capability and the use of injectable contrast medium made CT the working horse in the assessment of neoplastic and inflammatory diseases. In the last two decades, magnetic resonance (MR) supported CT in the most challenging cases, when the optimal contrast resolution due to the multisequence portfolio is needed to assess the neoplastic involvement of laryngeal cartilages, paraglottic space(s), and extra laryngeal spread. The aim of this paper is to give a comprehensive radiological overview of larynx and hypopharynx complex anatomy, combining in vivo images, anatomical sections, and images of ex vivo specimens., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: There are different parts of a battery of voice assessments to assess voice functions and voice quality. The objective assessment of voice quality using acoustics is recommended and two measurements such as the Acoustic Voice Quality index, 03.01 (AVQI) and the Acoustic Breathiness Index (ABI) are leading in this domain. The purpose of this study was to verify the validity between these two acoustic measurements and other dimensions of the voice assessments (the Voice Handicap Index-10 (VHI-10) and the laryngeal imaging evaluation of the larynx and vocal folds)., Methods: We used a retrospective database of 150 participants (37 vocally healthy participants and 113 dysphonic patients). To test the validity between the acoustic measurements and the other voice assessments the concurrent validity and diagnostic precision were analyzed using Pearson correlation coefficient and the receiver operating characteristic (ROC) statistics with likelihood ratios., Results: The VHI-10 score presented moderate-significant correlations with the AVQI and the ABI, r= 0.477, P < 0.001 (r 2 = 0.228) and r= 0.426, P < 0.001 (r 2 =0.181), respectively. The larynx alteration presented low-significant correlations with the AVQI (r= 0.362, P < 0.001, r 2 = 0.131), and ABI (r= 0.371, P < 0.001, r 2 = 0.138), respectively. The area under the curve (AUC) of ROC was almost reasonable ranging from 0.701 to 0.737; except between ABI and VHI-10 (AUC= 0.689). The highest AUC was between the AVQI and VHI-10 at a threshold of 2.10; the highest specificity was between the ABI and VHI-10 at a threshold of 3.77. However, the lowest sensitivity was between ABI and VHI-10 while the lowest specificity was between the laryngeal diagnosis and the ABI., Conclusion: AVQI and ABI presented significantly lower concurrent validity and diagnostic precision when the reference is not the auditory-perceptual judgment of voice quality. However, AVQI seems to be for some validity aspects a more reasonable classifier of vocal handicap and laryngeal alteration than ABI. Both AVQI and ABI values can broaden their range of assessment for the clinical user, thus showing more relationships between the individual voice examination methods., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Objective: Calibrated horizontal-plane measurements from laryngeal images could contribute significantly to refining evidence-based practice and developing patient-specific models and precision-medicine approaches. Laser-projection endoscopes can address the need for direct calibrated measures; however, these systems are not widely available. This study presents the framework for an alternative indirect horizontal-plane calibration approach., Method: A spatial attribute of a common object, a distinct characteristic that is maintained across images, may be used as a scale for the normalization of other spatial measurements. The outcome of this indirect approach could be used for absolute measurements (eg, in units of mm) or relative measurements (eg, percent change), depending on the information that is available from the common attribute. The required conditions of a common attribute for achieving a valid calibration outcome were studied. Three conditions were derived: registration accuracy of the common attribute, size consistency of the common attribute, and similarity in the vertical distance between the region of interest (ROI) (eg, vocal fold) and the common attribute. Any common attribute satisfying these three conditions was called proper and would result in a valid indirect calibration outcome. Three tests were presented for evaluating the properness of a common attribute. A data-driven statistical method was presented that can evaluate the registration accuracy of a common attribute. The second test used variation in calibrated lengths of a common attribute under different phonatory configurations for evaluating the size consistency condition. Finally, the effect of differences between vertical distances of the ROI and the common attribute was mathematically tested and quantified. The application of the proposed framework for indirect calibration was demonstrated using a pre existing dataset with a vocal fold as the ROI and four different common attributes (vocal fold length, vocal fold width, blood vessel on the vocal fold, and blood vessel on nearby tissue)., Results: The proposed registration-accuracy test was able to detect and eliminate instances of common attributes with low accuracies. The analysis suggested that among the studied four common attributes, the vocal fold length had the highest (ie, best) registration accuracy; however, the vocal fold length exhibited the lowest (ie, worst) size consistency. The analysis also suggested that, among the studied attributes, the vocal fold width offered the best trade-off among the three conditions and, hence, was a proper common attribute for calibrating spatial aspects of the vocal folds (length, displacement of edges, velocity, etc)., Conclusion: Indirect calibration is a feasible alternative for calibration of laryngeal endoscopic images, given a proper common attribute is selected. Future work is needed to systematically evaluate the effects of various phonatory conditions on the characteristics of common attributes., Competing Interests: Conflict of interest Drs. Robert Hillman and Daryush Mehta have a financial interest in InnoVoyce LLC, a company focused on developing and commercializing technologies for the prevention, diagnosis, and treatment of voice-related disorders. Dr. Hillman's and Dr. Mehta's interests were reviewed and are managed by Massachusetts General Hospital and Mass General Brigham in accordance with their conflict-of-interest policies., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

In most cases, the superior laryngeal artery (SLA) branches from the superior thyroid artery, which, in turn, leaves the external carotid artery. Few dissection studies found previously that the SLA could originate from the lingual artery. We report here probably the first evidence of such a rare anatomical variation found unilaterally in a retrospectively evaluated by computed tomography angiography adult male case. The left SLA left a suprahyoid coil of the lingual artery and continued over the greater hyoid horn to enter the larynx through the thyrohyoid membrane. On both sides, thyroid foramina were found, but only the right one used for the entry of the right SLA. Therefore, the rare SLA origin from the lingual artery can be documented on computed tomography angiograms, which could help during preoperative evaluations and prevent unwanted surgical complications., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Endoscopy is the gold standard for characterizing pediatric airway disorders, however, it is limited for quantitative analysis due to lack of three-dimensional (3D) vision and poor stereotactic depth perception. We utilize structure from motion (SfM) photogrammetry, to reconstruct 3D surfaces of pathologic and healthy pediatric larynges from monocular two-dimensional (2D) endoscopy. Models of pediatric subglottic stenosis were 3D printed and airway endoscopies were simulated. 3D surfaces were successfully reconstructed from endoscopic videos of all models using an SfM analysis toolkit. Average subglottic surface error between SfM reconstructed surfaces and 3D printed models was 0.65 mm as measured by Modified Hausdorff Distance. Average volumetric similarity between SfM surfaces and printed models was 0.82 as measured by Jaccard Index. SfM can be used to accurately reconstruct 3D surface renderings of the larynx from 2D endoscopy video. This technique has immense potential for use in quantitative analysis of airway geometry and virtual surgical planning., (© 2024 American Academy of Otolaryngology–Head and Neck Surgery Foundation.)

Purpose of Review: Laryngeal cancer (LC) is a highly aggressive malignancy of the head and neck and represents about 1-2% of cancer worldwide.Treatment strategies for LC aim both to complete cancer removal and to preserve laryngeal function or maximize larynx retention.Predicting with high precision response to induction chemotherapy (IC) is one of the main fields of research when considering LC, since this could guide treatment strategies in locally advanced LC., Recent Findings: Radiomics is a noninvasive method to extract quantitative data from the whole tumor using medical imaging. This signature could represent the underlying tumor heterogeneity and phenotype.During the last five years, some studies have highlighted the potential of radiomics in the pretreatment assessment of LC, in the prediction of response to IC, and in the early assessment of response to radiation therapy. Although these represent promising results, larger multicentric studies are demanded to validate the value of radiomics in this field., Summary: The role of radiomics in laryngeal preservation strategies is still to be defined. There are some early promising studies, but the lack of validation and larger multicentric studies limit the value of the papers published in the literature and its application in clinical practice., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Even without diseases that cause dysphagia, physiological swallowing function declines with age, increasing the risk of aspiration. This study analyzed age-related changes in laryngeal movement in older adults. The study population consisted of 10 volunteers in their 80s and six in their 20s. A videofluoroscopic study of 3 and 10 mL barium swallows was performed laterally using a digital fluorographic. The recorded images were retrieved to a personal computer and analyzed frame-by-frame using video analysis software. The movement of the larynx during swallowing, barium's pharyngeal transit time (PTT), and laryngeal elevation delay time (LEDT) were analyzed. Results were compared between the 20s and 80s age groups using statistical analyses. The PTT was shorter in the 20s than in the 80s age group. The PTT was significantly longer in the 80s group than in the 20s for both 3 and 10 mL barium swallows. LEDT in the 80s was statistically significantly longer than that in the 20s for the 10 ml barium. No statistically significant differences were found; however, there was a tendency for the 80s group to have more types of laryngeal movement velocity peaks. In this study, LEDT was prolonged in the 80s with 10 ml barium swallowing than in the 20s. Two peak patterns of laryngeal elevation during swallowing were observed. The velocity peaks showed a two-peak pattern when the patients were in their 80s and when the barium volume was tested at 10 mL. Our results suggest that aging's effect on swallowing relates to laryngeal elevation., (© 2023. The Author(s), under exclusive licence to The Society of The Nippon Dental University.)

Background: Fibre-optic laryngoscopy is still widely used in daily clinical practice; however, high-definition laryngoscopy using narrow band imaging could be more reliable in characterising pharyngeal and laryngeal lesions., Methods: Endoscopic videos were assessed in a tertiary referral hospital by 12 observers with different levels of clinical experience. Thirty pairs of high-definition laryngoscopy with narrow band imaging and fibre-optic laryngoscopy videos were judged twice, with an interval of two to four weeks, in a random order. Inter- and intra-observer reliability, sensitivity and specificity were calculated in terms of detecting a malignant lesion and a specific histological entity, for beginners, trained observers and experts., Results: Using high-definition laryngoscopy with narrow band imaging, inter-observer reliability for detecting malignant lesions increased from moderate to substantial in trained observers and experts (high-definition laryngoscopy with narrow band imaging κ = 0.66 and κ = 0.77 vs fibre-optic laryngoscopy κ = 0.51 and κ = 0.56, for trained observers and experts respectively) and sensitivity increased by 16 per cent., Conclusion: Inter-observer reliability increased with the level of clinical experience, especially when using high-definition laryngoscopy with narrow band imaging.

Real-time magnetic resonance imaging (rtMRI) is a technique that provides high-contrast videographic data of human anatomy in motion. Applied to the vocal tract, it is a powerful method for capturing the dynamics of speech and other vocal behaviours by imaging structures internal to the mouth and throat. These images provide a means of studying the physiological basis for speech, singing, expressions of emotion, and swallowing that are otherwise not accessible for external observation. However, taking quantitative measurements from these images is notoriously difficult. We introduce a signal processing pipeline that produces outlines of the vocal tract from the lips to the larynx as a quantification of the dynamic morphology of the vocal tract. Our approach performs simple tissue classification, but constrained to a researcher-specified region of interest. This combination facilitates feature extraction while retaining the domain-specific expertise of a human analyst. We demonstrate that this pipeline generalises well across datasets covering behaviours such as speech, vocal size exaggeration, laughter, and whistling, as well as producing reliable outcomes across analysts, particularly among users with domain-specific expertise. With this article, we make this pipeline available for immediate use by the research community, and further suggest that it may contribute to the continued development of fully automated methods based on deep learning algorithms., (© 2023. The Author(s).)

We report a case of extramedullary plasmacytoma of the larynx that was eradicated by radiotherapy; however, 8 years later, the disease had progressed to multiple myeloma. A mid -60s Japanese woman presented with a right-sided arytenoid mass in the larynx who underwent biopsy at another hospital. Based on the biopsy results, the patient was diagnosed with extramedullary plasma cell tumour and was referred to the Department of Otorhinolaryngology at our hospital. She received radiotherapy (50.4 Gy) and the laryngeal tumour was eradicated. Positron emission tomography/CT (PET-CT) revealed no abnormal accumulation in the larynx or whole body. After radiotherapy, the department of otorhinolaryngology, in consultation with Ddepartment of haematology performed follow-ups using laryngoscope, blood examination and PET-CT. Five years after the end of radiotherapy, the patient had no local recurrence or transition to multiple myeloma. However, 8 years later, blood examination and PET-CT revealed multiple myeloma. Laryngoscopy did not reveal any recurrent laryngeal tumour. Therefore, chemotherapy for multiple myeloma was administered at the department of haematology. Three months after the initiation of chemotherapy, the accumulation had disappeared in PET-CT. Three years have passed since chemotherapy initiation. At present, no recurrence or metastasis was observed in the larynx or whole body., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Videofluoroscopic swallow studies (VFSS) provide dynamic assessment of the phases of swallowing under fluoroscopic visualization and allow for identification of abnormalities in the process, such as laryngeal penetration and aspiration. While penetration and aspiration both reflect degrees of swallowing dysfunction, the predictive potential of penetration for subsequent aspiration is not fully elucidated in the pediatric population. As a result, management strategies for penetration vary widely. Some providers may interpret any depth or frequency of penetration as a proxy for aspiration and implement various therapeutic interventions (e.g., modification of liquid viscosity) to eliminate penetration episodes. Some may recommend enteral feeding given the presumed risk of aspiration with penetration, even when aspiration is not identified during the study. In contrast, other providers may advise continued oral feeding without modification even when some degree of laryngeal penetration is identified. We hypothesized that the depth of penetration is associated with the likelihood of aspiration. Identification of predictive factors for aspiration following laryngeal penetration events has significant implications for selection of appropriate interventions. We performed a retrospective cross-sectional analysis of a random sample of 97 patients who underwent VFSS in a single tertiary care center over a 6 month period. Demographic variables including primary diagnosis and comorbidities were analyzed. We examined the association between aspiration and degrees of laryngeal penetration (presence or absence, depth, frequency) across diagnostic categories. Infrequent and shallow penetration events of any type of viscosity were less likely to be associated with aspiration event(s) during the same clinical encounter regardless of diagnosis. In contrast, children with consistent deep penetration of thickened liquids invariably demonstrated aspiration during the same study. Our findings show that shallow, intermittent laryngeal penetration of any viscosity type on VFSS was not consistent with clinical aspiration. These results provide further evidence that penetration-aspiration is not a uniform clinical entity and that nuanced interpretation of videofluoroscopic swallowing findings is necessary to guide appropriate therapeutic interventions., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Image enhancement systems are important diagnostic tools in the detection of laryngeal pathologies. This study aimed to compare three different image enhancement systems: professional image enhancement technology, Image1 S and narrow-band imaging., Method: Using the three systems, 100 patients with laryngeal lesions were investigated using a flexible and a 30° rigid endoscope. The lesions were diagnosed by three experts and classified using the Ni classification. The findings were compared., Results: Lesions classified as 'benign' were histopathologically confirmed in 50 per cent of patients, malignant lesions were confirmed in 41 per cent and recurrent respiratory papillomatosis were confirmed in 9 per cent. There was no significant difference between the experts' assessments of each image enhancement system., Conclusion: The three systems give comparable results in the detection of laryngeal lesions. With two additional systems, more users can perform image-enhanced endoscopy, resulting in a broadly available tool that can help to improve oncological assessment.

Laryngeal air cyst (laryngocele) is a rare disease that is an abnormal cystic expansion of the deep structures of the laryngeal ventricle. They can be accompanied by serious complaints, such as shortness of breath, difficulty breathing during exercise, as well as at rest with large cysts. Computed tomography is the most effective method for determining the type, localization and degree of laryngocele. Although surgical treatment is considered the method of choice in cases of laryngeal air cyst, the approach significantly depends on the size of the lesion.

We present a case of a preterm neonate with a type IV laryngo-tracheo-oesophageal cleft, an uncommon congenital malformation, resulting from the failure of separation of the trachea and the oesophagus during fetal development, often associated with other deformities as well. Data in the literature shows that the long-term morbidity from the entity has declined over the last decades, even though prognosis remains unfavourable for types III and IV. This report emphasizes the complex issues neonatologists are faced with, when treating neonates with this rare disorder in the first days of life, what will raise suspicion of this rare medical entity, and that direct laryngoscopy/bronchoscopy finally depicts the exact extension of the medical condition. At the same time extensive evaluation for coexisting congenital anomalies should be performed. For all the above reasons, these neonates should be treated in specialized tertiary pediatric centers for multidisciplinary prompt management, which may improve, the outcome.

The white-eared opossum (Didelphis albiventris) is a Neotropical marsupial that occurs in the Brazilian territory. The larynx is an important organ of vocalization in mammals, although, other laryngeal functions are more fundamental for survival of mammals than phonation. The anatomical knowledge of respiratory structures is pivotal for a better understanding of the species. Thus, this study aimed to examine the larynx of the white-eared opossum by gross anatomy, computed tomography and histological description. For this, 10 adult (six females and four males) white-eared opossums (D. albiventris) were used. The white-eared opossum larynx was formed by epiglottis, thyroid, cricoids and arytenoid cartilages and a corniculate process. There is a similarity between the larynx of this marsupial and those reported in other wild mammals, regarding the number of cartilages and their location. Histologically, the epiglottis consisted of elastic cartilage and thyroid, cricoid and arytenoid cartilages were composed of hyaline cartilage. The epiglottis protruded rostrally into the nasal part of the pharynx, above the soft palate, and this is probably a marsupial characteristic as the fact that the thyroid and cricoid cartilages were ventrally fused. The hyoid apparatus was similar to that of other animals, with the same bony constitution, but with a greatly reduced stylohyoid bone. Histologically, the larynx was similar to those of other species such as koala, armadillo, crab-eating foxes and giant anteaters. The knowledge of the larynx morphology is important for the anatomical features of the species and clinical and surgical procedures, such as endotracheal intubation., (© 2023 Wiley-VCH GmbH. Published by John Wiley & Sons Ltd.)

Background and Purpose: Diagnostic CT of the larynx is historically performed with a protocol that combines a standard neck CT with dedicated imaging through the larynx. Multichannel CT scanners, however, allow high-resolution reformatted images of the larynx to be created directly from the initial neck acquisition data. The purpose of this study was to determine whether reformatted laryngeal images derived from a standard neck CT acquisition provide information comparable with that of separate dedicated high-resolution laryngeal images., Materials and Methods: The CT protocol for suspected laryngeal masses at our institution consists of a standard neck acquisition followed by a second acquisition focused on the larynx. We enrolled 200 patients who had undergone this protocol for a suspected laryngeal mass. Two head and neck radiologists independently reviewed each of the 200 scans twice. In one session, the entire scan was available, while in the other session, only images derived from the standard neck acquisition were available. The main outcome variable was the frequency of discrepant tumor staging between the interpretation sessions. No pathologic reference standard was used., Results: Radiologist A had discrepant staging in 45 of the 200 scans (23%; 95% CI, 17%-29%). Radiologist B had discrepant staging in 42 of the 200 scans (21%; 95% CI, 16%-27%). Fifty-three of the 87 discrepancies (61%) reflected improper downstaging of the laryngeal tumor on standard images alone, while the other 34 (39%) had improper upstaging on standard images alone., Conclusions: Reformatted images from our institution's standard neck CT acquisition were less accurate than dedicated images of the larynx for analysis of laryngeal tumor extension. Focused images of the larynx were needed to optimize interpretation., (© 2023 by American Journal of Neuroradiology.)

Purpose: Acute traumatic osseous and cartilaginous injuries to the larynx are rare injuries presenting to the emergency department. Despite the low reported incidence, laryngeal trauma carries a high morbidity and mortality. The purpose of this study is to identify fracture and soft tissue injury patterns in laryngeal trauma and explore associations with patient demographics, mechanisms of injury, urgent airway and surgical intervention., Methods: A retrospective review of patients with laryngeal injury who underwent multidetector computed tomography (MDCT) imaging was performed. The CT findings of laryngeal and hyoid fracture location, fracture displacement, and soft tissue injuries were recorded. Clinical data including patient demographics, mechanisms of injury, frequency of airway and surgical intervention were also recorded. Correlation of imaging characteristics with patient demographics, mechanism of injury and interventions were assessed for statistical significance using χ 2 and Fisher's exact tests., Results: The median patient age was 40 years old with a strong male predominance. The most common mechanisms of injury included motor vehicle collisions and penetrating gunshot wounds. Thyroid cartilage fractures were the most common fracture type. Findings of fracture displacement and airway hematoma had a higher correlation with requiring urgent airway management., Conclusion: Radiologists' early recognition and prompt communication of laryngeal trauma to the clinical service is important to reduce associated morbidity and mortality. Displaced fractures and laryngeal hematomas should be promptly conveyed to the clinical service as they are associated with more complex injuries and higher rates of urgent airway management and surgical intervention., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

The messa di voce (MdV), which consists of a continuous crescendo and subsequent decrescendo on one pitch is one of the more difficult exercises of the technical repertoire of Western classical singing. With rising lung pressure, regulatory adjustments both on the level of the glottis and the vocal tract are required to keep the pitch stable. The dynamic changes of vocal tract dimensions with the bidirectional variation of sound pressure level (SPL) during MdV were analyzed by two-dimensional real-time magnetic resonance imaging (25 frames/s) and synchronous audio recordings in 12 professional singer subjects. Close associations in the respective articulatory kinetics were found between SPL and lip opening, jaw opening, pharynx width, uvula elevation, and vertical larynx position. However, changes in vocal tract dimensions during plateaus of SPL suggest that perceived loudness could have been varied beyond the dimension of SPL. Further multimodal investigation, including the analysis of sound spectra, is needed for a better understanding of the role of vocal tract resonances in the control of vocal loudness in human phonation., (© 2023 Acoustical Society of America.)

Objective: To localize structural laryngeal lesions within digital flexible laryngoscopic images and to classify them as benign or suspicious for malignancy using state-of-the-art computer vision detection models., Study Design: Cross-sectional diagnostic study SETTING: Tertiary care voice clinic METHODS: Digital stroboscopic videos, demographic and clinical data were collected from patients evaluated for a structural laryngeal lesion. Laryngoscopic images were extracted from videos and manually labeled with bounding boxes encompassing the lesion. Four detection models were employed to simultaneously localize and classify structural laryngeal lesions in laryngoscopic images. Classification accuracy, intersection over union (IoU) and mean average precision (mAP) were evaluated as measures of classification, localization, and overall performance, respectively., Results: In total, 8,172 images from 147 patients were included in the laryngeal image dataset. Classification accuracy was 88.5 for individual laryngeal images and increased to 92.0 when all images belonging to the same sequence (video) were considered. Mean average precision across all four detection models was 50.1 using an IoU threshold of 0.5 to determine successful localization., Conclusion: Results of this study showed that deep neural network-based detection models trained using a labeled dataset of digital laryngeal images have the potential to classify structural laryngeal lesions as benign or suspicious for malignancy and to localize them within an image. This approach provides valuable insight into which part of the image was used by the model to determine a diagnosis, allowing clinicians to independently evaluate models' predictions., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Introduction: This study aimed to compare ultrasonography (US) measurements of the upper airway to computerized tomography (CT) measurements. Our study's primary outcome is to research the accuracy of US measurements in the evaluation of upper airway diameters when CT is taken as the gold standard; the secondary outcome is to determine the time required to obtain US measurements., Methods: This prospective study included patients ≥18 years old that had undergone thoracic or neck CT due to current clinical necessity. The US measurement for each patient was performed by two researchers with different levels of experience, both of whom were blinded to each other and the CT measurements. Measurements were obtained from the vocal cords and subglottic region. The duration of the US performance was also recorded., Results: The US and CT measurements were obtained from 94 patients. Concordance between US and CT measurements was found in the Bland-Altman analysis, with a mean -0.05 mm difference for vocal cord diameter and -1.2 mm for subglottic diameter. The intra-class correlation coefficients (ICC) between the CT and US measurements were 0.993, and 0.609 for vocal cord and subglottic diameter measurements, respectively. The ICC between US performers was 0.992 for vocal cord diameter and 0.959 for subglottic diameter. The US's mean time for vocal cord diameter measurement was 38 ± 23 s, and the mean time for subglottic diameter measurement was 49 ± 30 s., Conclusion: The concordance between US and CT measurements is high and the measurements of different practitioners with different experience levels are compatible with each other., Competing Interests: Declaration of Competing Interest All authors have no conflicts of interest to declare., (Copyright © 2023 Elsevier Inc. All rights reserved.)

The larynx is an essential organ in mammals with three primary functions - breathing, swallowing, and vocalizing. A wide range of disorders are known to impair laryngeal function, which results in difficulty breathing (dyspnea), swallowing impairment (dysphagia), and/or voice impairment (dysphonia). Dysphagia, in particular, can lead to aspiration pneumonia and associated morbidity, recurrent hospitalization, and early mortality. Despite these serious consequences, existing treatments for laryngeal dysfunction are largely aimed at surgical and behavioral interventions that unfortunately do not typically restore normal laryngeal function, thus highlighting the urgent need for innovative solutions. To bridge this gap, we have been developing an experimental endoscopic approach to investigate laryngeal dysfunction in murine (i.e., mouse and rat) models. However, endoscopy in rodents is quite challenging due to their small size relative to current endoscope technology, anatomical differences in the upper airway, and the necessity for anesthesia to optimally access the larynx. Here, we describe a novel transoral laryngoscopy approach that permits close-up, unobstructed video imaging of laryngeal motion in mice and rats. Critical steps in the protocol include precise anesthesia management (to prevent overdosing that abolishes swallowing and/or risks respiratory distress-related mortality) and micromanipulator control of the endoscope (for stable video recording of laryngeal motion by a single researcher for subsequent quantification). Importantly, the protocol can be performed over time in the same animals to study the impact of various pathological conditions specifically on laryngeal function. A novel advantage of this protocol is the ability to visualize airway protection during swallowing, which is not possible in humans due to epiglottic inversion over the laryngeal inlet that obstructs the glottis from view. Rodents therefore provide a unique opportunity to specifically investigate the mechanisms of normal versus pathological laryngeal airway protection for the ultimate purpose of discovering treatments to effectively restore normal laryngeal function.

Oblique orientation of vocal cord demands strict compliance, by technicians and clinicians, to the recommended parallel plane CT scan of larynx. Repercussions of non-compliance has never been investigated before. We aimed to observe influence of non-parallel vocal cord plane CT scan on qualitative and quantitative glottic parameters, keeping parallel plane CT as a standard for comparison. Simultaneous identification of potential suboptimal imaging sequelae as a result of unformatted CT plane was also identified. In this study we included 95 normal adult glottides and retrospectively analyzed their anatomy in two axial planes, non-parallel plane ① and parallel to vocal cord plane ②. Qualitative (shape, structures at glottic level) and quantitative (anterior commissure ACom, vocal cord width VCw, anteroposterior AP, transverse Tr, cross-sectional area CSA) glottic variables were recorded. Multivariate statistical analysis was used to predict pattern and their impact on glottic anatomy. Plane ① displayed supraglottic features in glottis; adipose (90.5%) and split thyroid laminae (70.6%). Other categorical variables: atypical shape, submental structures and multilevel vertebral crossing were also in majority. All glottic dimensions varied significantly between two planes with most in ACom (-5.8mm) and CSA (-15.0 mm2). In contrast, plane ② manifested higher VCw (>73%), Tr (66.3%), CSA (64.2%) and AP (44.2%) measurements. On correlation analysis, variation in ACom, CSA, Tr was positively associated with VC or plane obliquity (p<0.05). This variability was more in obese and short necked subjects. Change in one parameter also modified other significantly i.e., ACom versus AP and CSA versus Tr. Results indicated statistically significant change in subjective and objective anatomical parameters of glottis on non-application of appropriate CT larynx protocol for image analysis hence highlighting importance of image reformation., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Khan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

The endoscopic examination of subepithelial vascular patterns within the vocal fold is crucial for clinicians seeking to distinguish between benign lesions and laryngeal cancer. Among innovative techniques, Contact Endoscopy combined with Narrow Band Imaging (CE-NBI) offers real-time visualization of these vascular structures. Despite the advent of CE-NBI, concerns have arisen regarding the subjective interpretation of its images. As a result, several computer-based solutions have been developed to address this issue. This study introduces the CE-NBI data set, the first publicly accessible data set that features enhanced and magnified visualizations of subepithelial blood vessels within the vocal fold. This data set encompasses 11144 images from 210 adult patients with pathological vocal fold conditions, where CE-NBI images are annotated using three distinct label categories. The data set has proven invaluable for numerous clinical assessments geared toward diagnosing laryngeal cancer using Optical Biopsy. Furthermore, given its versatility for various image analysis tasks, we have devised and implemented diverse image classification scenarios using Machine Learning (ML) approaches to address critical clinical challenges in assessing laryngeal lesions., (© 2023. Springer Nature Limited.)

Background: The objective of this study was to assess the performance and application of a self-developed deep learning (DL) algorithm for the real-time localization and classification of both vocal cord carcinoma and benign vocal cord lesions., Methods: The algorithm was trained and validated upon a dataset of videos and photos collected from our own department, as well as an open-access dataset named "Laryngoscope8"., Results: The algorithm correctly localizes and classifies vocal cord carcinoma on still images with a sensitivity between 71% and 78% and benign vocal cord lesions with a sensitivity between 70% and 82%. Furthermore, the best algorithm had an average frame per second rate of 63, thus making it suitable to use in an outpatient clinic setting for real-time detection of laryngeal pathology., Conclusion: We have demonstrated that our developed DL algorithm is able to localize and classify benign and malignant laryngeal pathology during endoscopy., (© 2023 The Authors. Head & Neck published by Wiley Periodicals LLC.)

Objective: Surgical simulation training in residents has declined due to the limited exposure to cadaveric specimens. Three-dimensional (3D)-printing technology is rapidly taking an important role in different medical areas, especially in surgical specialties. It provides an alternative for resident simulation practices and for developing surgical skills before exposure to real settings. The elaboration of the thyroid window in the medialization laryngoplasty procedure requires high technical precision and experience for better outcomes., Methods: The computer-based 3D reconstruction model was created using computed tomograph scan images from a standard larynx. The final model was created using a deposition modeling 3D printing technique with polylactic acid filament. The model was tested for surgical simulation practice in three otolaryngology residency programs in Bogotá, Colombia., Results: The model had similar anatomic detail and it was considered very useful, safe, and relevant for surgical simulation., Conclusions: 3D printed models are a cost-effective alternative for resident training., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)

Introduction: Qualitative laryngoscopy belongs to a diagnostic routine. Nevertheless, quantitative morphometric measurements of laryngeal structures remain challenging. This study aimed to introduce a special laser projection device that can facilitate computer-assisted digitalized analysis and provide important quantitative information for diagnostics and treatment planning., Materials and Methods: The laryngeal images were captured with our device, which contained two parallel laser beams in order to provide the scaling reference. The maximum length of the vocal fold during respiration and vibration (phonation), vocal width at midpoint, total fold area, maximum cross-sectional area of the glottic space, and maximum vocal fold angle were determined and calculated. These parameters were analyzed and compared on the basis of age, sex, body height, body weight and body mass index., Results: A total of 87 subjects were enrolled in this study, comprising 39 males and 48 females. The age range for all subjects was 21 to 80 years old. The maximum value of the glottic area and vocal angle showed no significant gender difference. Both the respiration and vibration vocal fold length was significantly longer in males than in females. The vocal width revealed no gender difference, but the fold area during both respiration and phonation was significantly larger in men than in women. As for the respiration-to-vibration ratio of the vocal length, there was a trend, but without statistical significance (P = 0.06), toward a higher length compression ratio in men than in women. Meanwhile, age was found to have a strong relationship with vocal width during phonation. The width of vibration vocal fold decreased with aging significantly., Conclusion: Our innovative module can provide reference parameters, which makes it possible to directly estimate the objective absolute values of relevant laryngeal structures. Our non-invasive approach can be used during routine laryngoscopy and the findings easily documented. In future, we can extend its clinical application to measure subtle laryngeal or hypopharyngeal changes, which are difficult to objectively quantify., (Copyright © 2021 The Voice Foundation. Published by Elsevier Inc. All rights reserved.)