Faculty Bibliography

OBJECTIVE: Vocal fold hematoma is traditionally managed with a period of voice rest, in the order of weeks, to allow natural resolution. This study is designed to examine the efficacy and safety of a number of hemoglobin-avid (vascular) lasers when used in the setting of acute vocal fold hematoma. METHODS: Venous blood drawn from 4 white rabbits was used to create an array of subepithelial hematomas in the buccal cavities of each animal. Laser energy from 1 of 3 different lasers (532-nm pulsed potassium titanyl phosphate [KTP], 532-nm diode KTP, and 940-nm diode laser) was applied to each of the test hematomas at varying energy levels. Hematoma sites were photographed at days 0, 1, 5, 7, 9, and 12. Two animals were sacrificed on day 7 and the remainder on day 12. Histological evaluation of collateral tissue damage and residual hematoma was performed on biopsy specimens. RESULTS: Macroscopic and microscopic ulceration at laser-treated sites was mostly resolved by day 7. Inflammatory cell infiltrate was present in laser-treated and hematoma-only sites. Laser-treated samples showed alterations in vascularity. CONCLUSION: Hemoglobin-avid lasers may be beneficial in accelerating subepithelial hematoma resolution with a favorable tissue damage profile.

OBJECTIVES/HYPOTHESIS: Recent data have suggested that in-office potassium titanyl phosphate (KTP) laser treatment for benign vocal fold lesions yields significant reduction in lesion size with favorable effects on both mucosal wave and glottic closure. However, these previous studies omitted voice-related outcomes. We sought to compliment these previous data with voice-related outcomes in a cohort of patients undergoing KTP ablation of vocal fold polyps. STUDY DESIGN: Retrospective outcomes study. METHODS: Voice Handicap Index (VHI)-10 and acoustic measures were reviewed for 31 consecutive patients with benign vocal fold polyps treated with in-office KTP laser surgery. All data were analyzed statistically via a mixed model fit to analyze the data from each of three clinical visits. RESULTS: Across all patients, the mean VHI-10 scores decreased at first follow-up from 19.7 to 9.7 (P < .0001). At subsequent follow-up visits, the VHI-10 scores remained stable (mean, 8.3). This shift in VHI scores was accompanied by favorable improvements in both noise-to-harmonic ratio and speaking fundamental frequency in both males and females. CONCLUSIONS: In-office KTP ablation of vocal fold polyps had a favorable effect on patient-reported handicap as determined by the VHI-10. This treatment also slightly altered physiologic measures of voice; however, these measures did not achieve statistical significance. LEVEL OF EVIDENCE: 4. Laryngoscope, 2013.

OBJECTIVES/HYPOTHESIS: To provide insight into the demographics and vocal habits of current Broadway musical theater performers. STUDY DESIGN: Prospective, Questionnaire. METHODS: Adult musical theater performers in Broadway Productions as defined by the League of American Theater Producers and the Actors' Equity Association were asked to complete a survey collecting demographic information, vocal health and habits, alcohol, tobacco, and drug use and information regarding their level of vocal comfort and threshold to miss performances based on their voice. Data were subjected to descriptive and statistical analysis based on sex and role type (lead vs ensemble). RESULTS: One hundred thirty-five performers completed the survey from seven actively running shows. Ensemble members were younger and had not been in the business as long as performers in lead roles. Over 25% of respondents had been diagnosed with a vocal injury, yet the number of days missed per year due to voice problems was relatively low (1.7-4.7). Across all respondents, only approximately 54.8% reported consistently warming up before a performance and 7.4% reported consistently cooling down afterward. Nearly 91% of respondents reported regular alcohol consumption and tobacco use was 10.4%; 23.0% reported illicit drug use. CONCLUSIONS: This study marks the first time that vocal health has been addressed in this elite group of vocal professionals. The performer's low self-reported numbers of missed days is interesting particularly given that they appear to participate in harmful vocal health activities at the same rate as the general public.

Tongue strength is reduced in patients treated with chemoradiotherapy for oral/oropharyngeal cancer. Tongue strengthening protocols have resulted in improved lingual strength and swallowing in healthy individuals, as well as in patients following a neurological event. However, no studies have examined the efficacy of tongue strengthening exercises on tongue strength, swallowing, and quality of life (QOL; Head and Neck Cancer Inventory) in patients treated with chemoradiotherapy. A randomized clinical trial examined the effects of a tongue strengthening programme paired with traditional exercises vs. traditional exercises alone. Dependent variables included tongue strength, swallowing, and QOL in a group of patients with oral and oropharyngeal cancer treated with primary radiotherapy with or without chemotherapy. Differences with regard to tongue strength and oropharyngeal swallow efficiency (OPSE) were not observed within or between groups. QOL in the eating and speech domains improved following treatment in both groups. However, the experimental group demonstrated greater impairment in QOL in the social disruption domain following treatment, whereas the control group demonstrated a slight improvement in functioning. Tongue strengthening did not yield a statistically significant improvement in either tongue strength or swallowing measures in this patient cohort. Patient compliance and treatment timing may be factors underlying these outcomes.

OBJECTIVE/HYPOTHESIS: Currently, no clinical standards exist with regard to antireflux medications in the perioperative period for patients undergoing surgery for benign vocal fold lesions. The present study sought to determine the clinical yield of these medications on operative outcomes in patients who underwent surgical treatment for benign vocal fold lesions. STUDY DESIGN: Retrospective, outcomes study. METHODS: Medical records were reviewed from a single surgeon database between January 2011 and June 2012 to quantify outcomes in patients taking antireflux medications compared with subjects not taking medications at the time of surgery. Voice Handicap Index (VHI)-10 and Reflux Symptom Index (RSI) scores were the primary dependent variables. The t test analyses were conducted to compare VHI-10 and RSI scores. Additional multivariate regression analyses were conducted to evaluate medication effects on VHI and RSI, adjusting for potential confounds. RESULTS: A total of 51 patients met inclusion criteria. Of these patients, 12 (23.5%) were using antireflux medication(s) at the time of surgery and 39 (76.5%) were not. The mean shifts in VHI-10 and RSI after surgery for the antireflux therapy (ART) group were -14.75 and -7.5, respectively. For the non-antireflux therapy (non-ART) group, mean DeltaVHI-10 and DeltaRSI values were -9.87 and -5.05, respectively. Both t test and regression analyses confirmed no statistical difference between the ART and non-ART groups for both DeltaVHI-10 and DeltaRSI. Additional regression analysis revealed a positive correlation between preoperative RSI score and DeltaRSI score. CONCLUSION: Antireflux medications did not significantly alter postoperative outcomes in this preliminary cohort of patients.

IMPORTANCE Current approaches to the diagnosis and subsequent management of specific voice disorders vary widely among primary care physicians (PCPs). In addition, sparse literature describes current primary care practice patterns concerning empirical treatment for vocal disorders. OBJECTIVE To examine how PCPs manage patients with dysphonia, especially with regard to laryngopharyngeal reflux. DESIGN, SETTING, AND PARTICIPANTS Prospective, questionnaire-based study by an academic laryngology practice among academic PCPs from all major US geographic regions. MAIN OUTCOMES AND MEASURES A 16-question web-based survey, distributed via e-mail, concerning management and possible empirical treatment options for patients with dysphonia. RESULTS Of 2441 physicians who received the e-mail broadcast, 314 (12.9%) completed the survey. Among those who completed the survey, 46.3% were family practitioners, 46.5% were trained in internal medicine, and 7.2% identified as specialists. Among all respondents, 64.0% preferred to treat rather than immediately refer a patient with chronic hoarseness (symptoms persisting for >6 weeks) of unclear origin. Reflux medication (85.8%) and antihistamines (54.2%) were the most commonly selected choices for empirical treatment. Most physician respondents (79.2%) reported that they would treat chronic hoarseness with reflux medication in a patient without evidence of gastroesophageal reflux disease. CONCLUSIONS AND RELEVANCE Most PCPs who responded to our survey report empirically treating patients with chronic hoarseness of unknown origin. Many physician respondents were willing to empirically prescribe reflux medication as primary therapy, even when symptoms of gastroesophageal reflux disease were not present. These data suggest that PCPs strongly consider reflux a common cause of dysphonia and may empirically treat patients having dysphonia with reflux medication before referral.

OBJECTIVE/HYPOTHESIS: Glucocorticoids (GCs) are commonly used in the treatment of laryngeal disorders despite the absence of clear guidelines regarding their use. We sought to assess clinical practice patterns regarding GC use for various vocal fold diseases and to ascertain factors underlying the selection of particular GCs for different vocal fold pathology. STUDY DESIGN: Prospective, survey. METHODS: A web-based 20-question survey querying clinical indications for GC use and other factors influencing decision making in GC administration was distributed to 5280 otolaryngologists via e-mail using a commercially available database. RESULTS: The overall response rate for the survey was 4% (212/5280). Of the respondents, 99% reported GCs to be valuable in their practice. Previous experience/results, familiarity, and use in practice (68%, 54%, and 37%, respectively) were the most commonly cited reasons for choosing a particular GC; pharmacokinetic profile and academic literature were infrequently cited reasons. Fifty-four percent of respondents were more likely to prescribe GCs for vocal performers compared with other patients. Additionally, most respondents stated that the potential for side effects only occasionally prevented GC utilization. CONCLUSIONS: GC prescription practices vary greatly among otolaryngologists. Drug choice appears to be driven primarily by clinician preference and personal experience rather than by specific pharmacologic or physiologic rationale. These findings likely reflect the current lack of well-constructed studies in the laryngology literature to guide GC selection and administration for benign disorders of the larynx and highlight an important potential area for future studies.

OBJECTIVES: We undertook to provide data regarding temporal measurements of swallow function obtained by dynamic magnetic resonance imaging in a midsagittal plane and to compare these values to normative fluoroscopy data. METHODS: Seventeen healthy female volunteers with no swallowing complaints underwent turbo-fast low-angle-shot magnetic resonance imaging with a 3-T scanner while swallowing liquid and pudding boluses delivered via syringe. Ninety sequential images were acquired with a temporal resolution of 113 ms per frame for each swallow. The imaging was performed in the midsagittal plane. The analyses focused on oral and pharyngeal transit times. RESULTS: All subjects tolerated the protocol without complaints or adverse events. The mean (+/- SD) oral transit times for liquids and pudding were measured as 0.25 +/- 0.09 second and 0.25 +/- 0.13 second, respectively. This difference was not statistically significant (p = 0.74). The mean pharyngeal transit times for liquids and pudding were measured as 0.84 +/- 0.16 second and 1.11 +/- 0.21 seconds, respectively. This difference achieved statistical significance (p < 0.0001). The intrarater and inter-rater reliabilities for the measurements were excellent. CONCLUSIONS: This sequence provided a high degree of temporal resolution of deglutition in the midsagittal plane. Furthermore, the temporal measurements acquired with dynamic magnetic resonance imaging were reliable and were relatively consistent with those of previous studies done with videofluoroscopy.

OBJECTIVES/HYPOTHESIS: To describe a novel conduction study of the laryngeal nerves, including normal values and abnormal findings. STUDY DESIGN: Prospective nonrandomized. METHODS: Seventeen healthy adult volunteers, as well as three patients with clinically identified laryngeal neuropathy, underwent low-level brief electrical stimulation of the laryngeal mucosa by means of a wire inserted via a transnasal flexible laryngoscope. Bilateral hookwire electrodes recorded the result in the laryngeal adductor muscles. RESULTS: This study yields an early response ipsilateral to the side of stimulation (LR1), which is uniform and consistent (right = 13.2 +/- 0.80 msec; left = 15.2 +/- 1.20 msec), and late bilateral responses (ipsilateral LR2 [LR2i] and contralateral LR2 [LR2c]), which exhibit greater variation in latency and morphology (right LR2i = 50.5 +/- 3.38 msec; left LR2i = 52.2 msec; right LR2c = 50.7 +/- 4.26; left LR2c = 50.6 +/- 4.07). Findings in abnormal patients differ significantly from normal, consistent with the distribution of neuropathy. CONCLUSIONS: We describe a novel, clinically applicable conduction study of laryngeal nerves. Normative electrodiagnostic values and variations of the reflex responses of the laryngeal adductor muscles in response to irritative stimulation of the laryngeal mucosa (Laryngeal Closure Reflex) are proposed. By enabling the determination of electrophysiological parameters of the superior laryngeal and recurrent laryngeal branches of cranial nerve X (CN X), this procedure, which is used as an adjunct to laryngeal electromyography, may provide earlier and more accurate information regarding the extent and grade of nerve injury. Because injury grade relates directly to prognosis, the information derived from this test may have clinical relevance in determining optimal treatment. LEVEL OF EVIDENCE: 4. Laryngoscope, 123:2202-2208, 2013.