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Introduction Revision framework surgeries might be required for unilateral vocal fold paralyses. However, outcomes and indications of revision surgeries have not been adequately documented. For a better understanding of indications for the procedure and to help in achieving better vocal outcomes, we performed a retrospective chart review of patients who underwent revision framework surgeries for unilateral vocal fold paralysis. Objectives This study aimed to present clinical features of patients who underwent revision framework surgeries for the treatment of unilateral vocal fold paralysis. Methods Of the 149 framework surgeries performed between October 2004 and October 2019, 21 revision framework surgeries were performed in 19 patients. Self-assessments by patients using the voice handicap index-10 questionnaire, and objective aerodynamic and acoustic assessments performed pre- and post-operatively were analyzed using the Wilcoxon’s signed-rank test for paired comparisons. Results Undercorrection was indicated as reasons for revision surgeries in all cases. The revision techniques included type I thyroplasty, type IV thyroplasty, and arytenoid adduction, and revision surgeries were completed without any severe complication in all cases. Pre- and post-operative voice handicap index-10 scores were obtained in 12 cases, and other parameters were evaluated in 18 cases. Significant improvements were observed in voice handicap index-10 scores, maximum phonation time, mean flow rate, Current/Direct Current ratio, and pitch perturbation quotient. Conclusion Undercorrection was observed in all patients who underwent revision framework surgeries for unilateral vocal fold paralysis, and the initial assessment and planning are thought to be important in order to avoid revision surgeries. Revision surgeries were performed safely in all cases, and significantly improved vocal outcomes were observed, even after multiple procedures. Revision surgery should be considered for patients with unsatisfactory vocal functions after primary framework surgeries for unilateral vocal fold paralysis.

Purpose: Auditory-perceptual evaluation is essential for the assessment of voice quality. The Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) provides a standardized protocol and assessment form for clinicians to analyze the voice quality and has been adapted into several different languages. The aims of this study were to develop the Japanese version of the CAPE-V and to investigate its reliability and validity. Method: The Japanese CAPE-V consisted of the same three speech contexts (vowels, sentences, and conversation) as developed in the original English version. The sentences were designed according to the concepts of the original version and reviewed by Japanese phoneticians. To validate the usefulness of the Japanese CAPE-V, voices of 173 Japanese-speaking subjects (76 subjects with dysphonia and 97 without voice complaints) were evaluated by five experienced judges, according to the Japanese CAPE-V as well as the GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale. Results: The Japanese CAPE-V provided a high interrater reliability (intraclass correlation coefficients [ICCs] > .85 for all the parameters) as well as a high intrarater reliability (ICCs > .85 for all the parameters). In addition, overall severity, roughness, and breathiness in the Japanese CAPE-V were highly correlated with the corresponding dimensions in the GRBAS scale, having Spearman correlation coefficients greater than .8. Conclusion: This study demonstrated the reliability and validity of the newly developed Japanese CAPE-V as an auditory-perceptual evaluation instrument.

Nivolumab, an anti-programmed cell death-1 monoclonal antibody, is currently used to treat many types of advanced cancers including recurrent and metastatic head and neck cancer. However, there are increasing reports concerning immune-related adverse events related to nivolumab therapy. Here, we report three patients who presented with adrenal insufficiency following nivolumab therapy. Two were diagnosed as having isolated adrenocorticotropic hormone (ACTH) deficiency and one was diagnosed as having primary adrenal insufficiency. All three patients complained of progressive fatigue and appetite loss, so we measured their blood cortisol and ACTH levels and diagnosed them as having adrenal deficiency. Treatment with nivolumab was discontinued for all three patients, and replacement therapy using hydrocortisone was successful after a few days in all cases. Two patients subsequently resumed nivolumab therapy because their general condition had improved. Complaints of fatigue and appetite loss during cancer treatment are common and tend to be regarded as unimportant. Although adrenal insufficiency due to nivolumab is relatively rare, complaints of these symptoms could lead to the detection of adrenal insufficiency at an early stage. The present report highlights the importance of the early recognition of adrenal insufficiency.

Double inferior vena cava (IVC) is known as a variation in which the additional IVC is found on the left side of the abdominal aorta. Their developmental process has been well documented, but the venous development around the lumbosacral region is controversial. In the present double IVC case, the left IVC entered the left renal vein at the L2 level, and the renal veins on each side flowed into the right IVC at the L1 level. The internal and external iliac veins were merged at the S1 level on each side. Besides, a venous communication (3-mm-width) was found horizontally between the internal iliac veins near their origin at the S1 level. It had also an extra narrow branch (1-mm-width), which ran obliquely upward and reached the left IVC at the level of L5. The median sacral artery (MSA) ran at the ventral side of the horizontal communication but at the dorsal side of its extra oblique branch. These results suggest that the oblique branch is a remnant of the anastomosis between the right and left posterior cardinal veins. Furthermore, the horizontal vein corresponds to the sacral venous plexus, suggesting that the anastomosis can be formed between the IVC and sacral venous plexus.

Objectives/hypothesis "Hot potato voice" (HPV) is a thick, muffled voice caused by pharyngeal or laryngeal diseases characterized by severe upper airway obstruction, including acute epiglottitis and peritonsillitis. To develop a method for determining upper-airway emergency based on this important vocal feature, we investigated the acoustic characteristics of HPV using a physical, articulatory speech synthesis model. The results of the simulation were then applied to design a computerized recognition framework using a mel-frequency cepstral coefficient domain support vector machine (SVM). Study design Quasi-experimental research design. Methods Changes in the voice spectral envelope caused by upper airway obstructions were analyzed using a hybrid time-frequency model of articulatory speech synthesis. We evaluated variations in the formant structure and thresholds of critical vocal tract area functions that triggered HPV. The SVMs were trained using a dataset of 2,200 synthetic voice samples generated by an articulatory synthesizer. Voice classification experiments on test datasets of real patient voices were then performed. Results On phonation of the Japanese vowel /e/, the frequency of the second formant fell and coalesced with that of the first formant as the area function of the oropharynx decreased. Changes in higher-order formants varied according to constriction location. The highest accuracy afforded by the SVM classifier trained with synthetic data was 88.3%. Conclusions HPV caused by upper airway obstruction has a highly characteristic spectral envelope. Based on this distinctive voice feature, our SVM classifier, who was trained using synthetic data, was able to diagnose upper-airway obstructions with a high degree of accuracy. Level of evidence 2c Laryngoscope, 129:1301-1307, 2019.

Objectives Auditory-perceptual voice analysis is a standard method for quantifying pathological voice quality, but perceptual ratings are based on subjective evaluations and therefore may vary among examiners. Although many acoustic metrics have been studied for potential use in the objective evaluation of pathological voices, the interpretation of acoustic metrics in individual cases is difficult and the technique is not widely used by clinicians. The aim of this study was to establish standardized methods to discriminate grade, roughness, breathiness, asthenia, strain (GRBAS) scale scores of pathological voices directly using one-dimensional convolutional neural network (1D-CNN) models. Methods We constructed an original dataset utilizing 1,377 voice samples of sustained phonation of the vowel /a/. Each voice sample was rated by three experts according to the GRBAS scale and the median values were used as the correct answer label. We designed an end-to-end 1D-CNN model with a raw voice waveform input having a frame width of 9,600 samples. The models were trained with our original dataset for each GRBAS category individually and the model performance was tested by the five-fold cross validation method. Results The accuracy, F1 score, and quadratic weighted Cohen's kappa for the testing dataset were determined. The metrics for the G scale showed the most balanced model performance, with high accuracy (0.771) and substantial agreement (kappa = 0.710). The model for the R scale had relatively high accuracy (0.765) and F1 score (0.743) with moderate agreement (kappa = 0.536). The accuracy (0.883) and the F1 score (0.865) for the S scale were the highest among the five categories, whereas the Cohen's kappa was the lowest (0.190). Conclusions The end-to-end 1D-CNN models can evaluate overall pathological voice quality with a reliability comparable to human evaluations. The efficiency with which the machine learning models can be trained and evaluated is closely related to the dataset quality.

Summary Objectives We developed a highly accessible acoustic voice analysis system (VArt) using a handheld device running Android operating system. To provide stable and reliable analysis using readily obtainable equipment under unfavorable conditions, we modified the fundamental frequency (F0) extraction algorithm and designed an intuitive user interface representing a new hoarseness index (real-time Ra: Rart ), which is a derivative of harmonics-to-noise ratio developed by Kojima and Shoji ( Ra2 ). Since Rart continues to display analysis results in real time, unlike conventional acoustic analysis, it can be used for evaluation such as during phonosurgery and speech therapy. We evaluated the agreement between the earlier version of acoustic voice analysis software (VA) running on a Windows personal computer and VArt running on a handheld device. Methods F0, Ra2 , and Rart were measured in voice samples of sustained vowel phonation /a/ from 10 healthy volunteers and 22 patients with voice disorders using VA running on a Windows personal computer and VArt running on two types of handheld devices in a sound-treated room or in a medical examination room. Intraclass correlation coefficients were calculated for both systems under both conditions. Results All of the comparisons were highly correlated. Conclusions Measurements obtained using our newly developed VArt were highly consistent with those using VA, indicating high reliability. Moreover, the new system increases the clinical feasibility of acoustic voice analysis.

Objective: Fine-needle aspiration cytology (FNAC) is a valuable diagnostic technique. However, the procedure involves backand-forth motions of a needle within a mass, which can lead to unexpected complications. We have developed a novel device and sampling techniques that use vibration and rotation instead of backand-forth motions. Methods: The new device consists of a vibrating motor fixed to the stopper of a 5 ml syringe with its piston. A 22-gauge needle attached to the 5 ml syringe is used for FNAC. Samples were obtained from resected specimens using the following four procedures: suction only; suction and vibration for 5 seconds; suction and 180° rotation of the syringe; and suction, vibration for 5 seconds, and 180° rotation of the syringe. Samples were also obtained using the conventional technique. The numbers of well-visualized follicular groups on glass slides were counted to compare the amounts of cellular material obtained using the five different procedures. Next, 415 patients with thyroid nodules underwent ultrasound-guided FNAC to evaluate the rate of inadequacy. Results: Sufficient amounts of material were obtained from resected specimens using suction, vibration and rotation, and using the conventional technique. Inadequate thyroid FNAC material was obtained in 12.3% of cases. Conclusions: The new device and sampling techniques for thyroid FNAC collected sufficient amounts of adequate material and allowed safe and precise control of the device. Our device and sampling techniques are expected to be widely used not only for thyroid FNAC sampling but also for sampling from other anatomical sites.

There are two techniques for excising a parotid gland tumor. The first technique is the anterograde approach, and the second is the retrograde approach. Although the anterograde approach has generally been adopted, the retrograde approach may be useful depending on the identification and dissection of the facial nerve and the localization of the tumor. We reviewed 35 patients who were surgically treated with a parotidectomy using the retrograde approach between 2002 and 2012 at Tenri Hospital. We also reviewed the clinical records for evidence of temporary or definitive injury to the facial nerve. In cases where the identification of the main nerve trunk was expected to be difficult, the parotidectomy was performed using the retrograde approach guided by the mandibular branch. In cases where a tumor was located in the marginal region of the parotid gland, the retrograde approach was guided by the mandibular branch or the zygomatic branch. Of the 35 patients, 17 underwent the retrograde approach guided by the mandibular branch and 18 underwent this approach guided by the zygomatic branch. The mean surgical time and amount of bleeding using the retrograde approach were 70.7 minutes and 33.9 g, respectively. Two of the 35 patients in the retrograde group exhibited a temporary facial deficit.

Arteriovenous fistula (AVF), a type of vascular anomaly, is a relatively uncommon disease characterized by abnormal connections between the arterial and venous systems. Recently, remarkable advances in four-dimensional computed tomographic angiography (4D-CTA) have enabled detailed analysis of the hemodynamic features of vascular anomalies, which cannot be achieved by conventional imaging modalities. We report a case of AVF in a 59-year-old female presenting as a right neck mass. Using reconstructed animations from various viewing angles, 4D-CTA could clearly visualize not only a mass but the feeding artery and draining vein from the mass. 4D-CTA was useful for the diagnosis of AVF and to determine the surgical strategy preoperatively. Laryngoscope, 123:2723–2727, 2013

The voice analyzer (VA) software program we developed for quantitatively analyzing voice quality uses zero-cross-picking to find individual basic pitch periods. Two such periods extracted from a voice waveform were analyzed to calculate the acoustic energy of harmonics separately from that of noise components. The program determines the ratio of harmonics to noise (Ra), F0, jitter, shimmer, APQ, and PPQ. Sustained vowel /a/ from 28 subjects without evident vocal problems such as hoarseness and 49 subjects with hoarseness were examined. Average female and male Ra among the nonhoarse were 31.9 dB and 34.4 dB, jitter 0.254% and 0.246%, and shimmer 0.168% and 0.116%. Among those with hoarseness, all parameter scored worse than in the nonhoarse in proportion to auditory impression.

In cases of labyrinthine fistulae, we performed complete removal of the cholesteatoma matrix in a one-stage procedure, resulting in a satisfactory bone conduction (BC) hearing preservation rate. Preoperative evaluation of labyrinthine fistulae using high resolution computed tomography (HRCT) detected 86% of cases, and this contributed to favorable results achieved with the surgical treatment of labyrinthine fistulae. We aimed to review cases of labyrinthine fistulae to summarize their outcomes and establish standards of management.This was a retrospective chart review of 22 patients with labyrinthine fistulae at Kyoto University Hospital from 2001 to 2009. Patient background (age and sex), location and stage of the fistulae, facial nerve status, preoperative and postoperative BC hearing levels, preoperative CT diagnosis, and surgical procedures were analyzed.The incidence rate of the labyrinthine fistulae was 11.2%. All but one patient had labyrinthine fistula due to cholesteatoma. The fistulae were found in the lateral semicircular canal in 17 cases (77%) and in multiple organs in 4 cases (18%). The BC hearing level was preoperatively scaled out in seven cases. Preoperative HRCT scan revealed the presence of fistulae in 19 cases (86%). For all cases of cholesteatoma, the matrix was completely removed in a one-stage procedure and the fistulae were sealed using bone pate, temporal fascia, and temporal bones. Of the 15 cases with residual BC hearing ability, BC hearing was preserved in up to 12 cases. Two cases with postoperative deterioration of BC hearing had stage 4 fistulae in the cochleae.