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Background: Glottic insufficiency, or glottic gap as it is commonly called, is a common cause of dysphonia, producing symptoms of soft voice, decreased projection, and vocal fatigue. The etiology of glottic gap can occur from issues related to muscle atrophy, neurologic impairment, structural abnormalities, and trauma related causes. Treatment of glottic gap can include surgical and behavioral therapies or a combination of the two. When surgery is chosen, closure of the glottic gap is the primary goal. Options for surgical management include injection medialization, thyroplasty, and other methods of medializing the vocal folds. Methods: This manuscript reviews the current literature regarding the options for treatment of glottic gap. Discussion: This manuscript discusses options for treatment of glottic gap, including the indications for temporary and permanent treatment modalities; the differences between the available materials for injection medialization laryngoplasty and how they affect the vibratory function of the vocal folds and vocal outcome; and the evidence that supports an algorithm for treatment of glottic gap. Level of Evidence: 3a-Systematic review of case-control studies.

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INTRODUCTION: The purpose of this study was to develop an evidence-based consensus statement regarding use of laryngeal electromyography (LEMG) for diagnosis and treatment of vocal fold paralysis after recurrent laryngeal neuropathy (RLN). METHODS: Two questions regarding LEMG were analyzed: (1) Does LEMG predict recovery in patients with acute unilateral or bilateral vocal fold paralysis? (2) Do LEMG findings change clinical management in these individuals? A systematic review was performed using American Academy of Neurology criteria for rating of diagnostic accuracy. RESULTS: Active voluntary motor unit potential recruitment and presence of polyphasic motor unit potentials within the first 6 months after lesion onset predicted recovery. Positive sharp waves and/or fibrillation potentials did not predict outcome. The presence of electrical synkinesis may decrease the likelihood of recovery, based on 1 published study. LEMG altered clinical management by changing the initial diagnosis from RLN in 48% of cases. Cricoarytenoid fixation and superior laryngeal neuropathy were the most common other diagnoses observed. CONCLUSIONS: If prognostic information is required in a patient with vocal fold paralysis that is more than 4 weeks and less than 6 months in duration, then LEMG should be performed. LEMG may be performed to clarify treatment decisions for vocal fold immobility that is presumed to be caused by RLN. Muscle Nerve 53: 850-855, 2016.

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OBJECTIVE: The purpose of this study is to establish normative values for the smoothed cepstral peak prominence (CPPS) and its sensitivity and specificity as a measure of dysphonia. STUDY DESIGN: Prospective cohort study. METHODS: Voice samples of running speech were obtained from 835 patients and 50 volunteers. Eight laryngologists and four speech-language pathologists performed perceptual ratings of the voice samples on the degree of dysphonia/normality using an analog scale. The mean of their perceptual ratings was used as the gold standard for the detection of the presence or absence of dysphonia. CPPS was measured using the CPPS algorithm of Hillenbrand, and the cut-off value for positivity that has the highest sensitivity and specificity for discriminating between normal and severely dysphonia voices was determined based on ROC-curve analysis. RESULTS: The cut-off value for normal for CPPS was set at 4.0 or higher, which gave a sensitivity of 92.4%, a specificity of 79%, a positive predictive value of 82.5%, and a negative predictive value of 90.8%. The area under the receiver operating characteristic (ROC) curve was 0.937 (P < 0.05). CONCLUSIONS: CPPS is a good measure of dysphonia, with the normal value of CPPS (Hillenbrand algorithm) of a running speech sample being defined as a value of 4.0 or higher.

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OBJECTIVES: The 585-nm pulsed-dye laser (PDL) is used for in-office treatment of recurrent respiratory papillomatosis (RRP), premalignant/early malignant lesions, vascular lesions, and proliferative lesions of the larynx. Reported advantages of this technique include avoidance of general anesthesia, improved efficiency, lower overall cost, and treatment of the anterior commissure with minimal web formation. Our objective was to review our experience with office-based PDL procedures for laryngeal lesions. STUDY DESIGN: Retrospective review. METHODS: A chart review of patients undergoing office-based PDL procedures of laryngeal lesions from the years 2005 to 2012. RESULTS: Of 33 patients, 32 (97%) tolerated the procedure without complication. One patient experienced an anxiety attack and the procedure was aborted. There were no complications. The following pathologies were treated: vascular lesions (n = 10), RRP (n = 8), granuloma (n = 5), premalignant lesions (n = 5), benign mass (n = 2), amyloidosis (n = 1), and anterior web (n = 1). Six (19%) patients, all with vascular lesions, were treated successfully with the in-office PDL and no operating room (OR) procedures. All six patients reported complete resolution of symptoms at 6 months posttreatment. Twenty-six (81%) patients were treated with a combination of in-office PDL and OR procedures, most commonly for RRP (n = 8). Seventeen patients had complete resolution of their symptoms with in-office PDL and OR procedures. CONCLUSIONS: PDL treatment is a safe, well-tolerated, effective, adjunctive therapy and may function as monotherapy in the treatment of selected laryngeal lesions.

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OBJECTIVES: The objective of this study was to evaluate the factors predictive of postoperative laryngeal nerve paresis (LNP) in patients undergoing thyroid surgery. We also assess the implications of preoperative LNP on postoperative vocal fold status. STUDY DESIGN: Case series with retrospective chart review. METHODS: Charts of 17 patients who underwent thyroid surgery and had pre- and postoperative laryngeal electromyography (LEMG) were reviewed. LEMGs were ordered routinely in all patients undergoing thyroid surgery, not just in those with clinical findings suggestive of paresis. We collected data relating to pre- and postoperative laryngeal and thyroid evaluations and the details of the surgical procedure. We analyzed the prevalence of preoperative LNP and relationship of thyroid diagnoses, size of thyroid mass, and type of surgery performed with respect to the outcome of the LNP. RESULTS: All the 17 patients had a mild to moderate degree of unilateral or bilateral LNP preoperatively. However, only seven (41.2%) had vocal symptoms. After surgery, only five of these seven patients had voice complaints, and there were no patients with voice complaints among the group that had been asymptomatic preoperatively. Thyroid diagnoses included 11 cases of benign disease (64.7%) in which LNP improved in two, worsened in four, and remained the same in five; and six cases of malignant disease (35.3%) in which LNP improved in none, worsened in two, and remained the same in four. Predictors of worsening postoperative LNP on LEMG included the diagnosis of goiter (P=0.0005) and size of mass greater than 5cm (0.032). CONCLUSIONS: This study supports the notion that there is an intrinsic relationship between benign thyroid diseases and LNP that is probably related to local effects of the disease on the laryngeal nerves. All patients with the postoperative diagnosis of goiter worsened, and all patients with the postoperative diagnosis of adenoma showed no change on postoperative electromyography (EMG). Similarly, all patients with the diagnosis of thyroiditis alone improved, and there were no cases of improvement outside this group. Of the six cases of malignancy, four exhibited no change on EMG and only two worsened. The only reliable predictors of worsening paresis postoperatively are mass size greater than 5cm and diagnosis of goiter.

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OBJECTIVE: Vocal fold paresis has a multifactorial etiology and is idiopathic in many individuals. The incidence of thyroid-related neuropathy in the larynx has not been previously described. The purpose of this study was to evaluate the prevalence of previously undiagnosed thyroid disease in patients with laryngeal neuropathy and to compare this prevalence with that in a cohort of patients with a neurotologic neuropathy. STUDY DESIGN AND SETTING: Case series with chart review; tertiary care, otolaryngology practice. SUBJECTS AND METHODS: Charts of 308 consecutive patients with dysphonia and vocal fold paresis and 333 consecutive patients with sensorineural hearing loss, who presented for evaluation during a 3-year period, were reviewed. RESULTS: One hundred forty-six of 308 (47.4%) patients with vocal fold paresis were diagnosed with concurrent thyroid disease, whereas 55 of 333 (16.5%) patients with sensorineural hearing loss were diagnosed with concurrent thyroid disease (P<0.001, Pearson chi-square = 92.896; degrees of freedom = 5). Thyroid diagnoses among those with vocal fold paresis included benign growths (29.9%), thyroiditis (7.8%), hyperthyroidism (4.5%), hypothyroidism (3.6%), and thyroid malignancy (1.6%). CONCLUSIONS: Thyroid abnormalities are more prevalent in patients with dysphonia and vocal fold paresis than in patients with symptomatic sensorineural hearing loss, suggesting a greater association between previously undiagnosed thyroid abnormalities and laryngeal neuropathy than that between neurotologic neuropathy and thyroid disease.

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OBJECTIVES/HYPOTHESIS: The goal of laryngeal framework surgery in patients with unilateral vocal fold paralysis is to improve glottic closure by medializing the paralyzed vocal fold. Type I thyroplasty (Th) and arytenoid adduction (AA) are two of the most commonly performed procedures. Two of the main rationales for performing an AA are to improve closure of the posterior glottis and correct vertical height discrepancy. The purpose of this study was to evaluate if AA with Th yields better posterior glottic closure and vertical height equality than Th alone. STUDY DESIGN: Retrospective. METHODS: Using visual analog scales, three blinded reviewers evaluated glottic closure patterns in patients who underwent Th or Th with AA. Pre- and postoperative videostroboscopic examinations of 45 patients with unilateral vocal fold paralysis, who underwent laryngeal framework surgery, were evaluated. RESULTS: No significant difference was identified in postoperative scores for midmembranous glottis closure (P=0.282), closure just anterior to the vocal processes (P=0.426), respiratory glottis closure (P=0.158), or vertical height discrepancy (P=0.113). CONCLUSIONS: Although larger glottic gaps and vertical height discrepancies may lead some surgeons to predict that an AA is warranted, the usefulness of AA may not always be related to these parameters. Ultimately, voice improvement and not geometry should guide the surgeon's decision making.

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Laryngeal electromyography (LEMG) is a valuable adjunct in clinical management of patients with voice disorders. LEMG is valuable in differentiating vocal fold paresis/paralysis from cricoarytenoid joint fixation. Our data indicate that visual assessment alone is inadequate to diagnose neuromuscular dysfunction in the larynx and that diagnoses based on vocal dynamics assessment and strobovideolaryngoscopy are wrong in nearly one-third of cases, based on LEMG results. LEMG has also proven valuable in diagnosing neuromuscular dysfunction in some dysphonic patients with no obvious vocal fold movement abnormalities observed during strobovideolaryngoscopy. Review of 751 patients suggests that there is a correlation between the severity of paresis and treatment required to achieve satisfactory outcomes; that is, LEMG allows us to predict whether patients will probably require therapy alone or therapy combined with surgery. Additional evidence-based research should be encouraged to evaluate efficacy further.

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Part 1 of this paper compared fiber optic (FO) and distal chip (DC) flexible technologies in the diagnosis of vocal fold masses and mucosal wave abnormalities. Part 2 of this study was designed to evaluate the usefulness of FO and DC flexible imaging in the diagnosis of laryngopharyngeal reflux (LPR) disease. Thirty-four consecutive patients were examined with either FO or DC flexible stroboscopy followed immediately by rigid stroboscopy. Rigid stroboscopy was considered the "gold-standard" for this study. All stroboscopy segments were evaluated by two laryngologists, an otolaryngologist, a laryngology fellow, and an otolaryngology resident for physical findings of LPR using the Reflux Finding Score (RFS) and Posterior Erythema Grade (PE grade). Both flexible systems underrepresented the physical findings of LPR compared to the rigid examination, but the FO system was frequently more accurate than the DC system. For PE grade, agreement with the rigid endoscope was 95% for the FO system and 73% for the DC system. Total RFSs for both flexible systems were significantly different than RFSs from the corresponding rigid examinations (P=0.001). Raters who used the RFS more often were more consistent. More severe PE grade scores correlated well with increasing RFSs. The number of patients diagnosed with LPR (RFS>7) showed that despite differences in the category scores, the FO and DC were almost identical in how much LPR was diagnosed compared with their matched rigid examination. Because both flexible platforms significantly underrepresented reflux signs, we recommend that a rigid laryngeal telescope be used when examining the larynx for signs of LPR. If this is not available, these data suggest that a high-quality FO endoscope may be more accurate than a DC endoscope for most otolaryngologists.

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OBJECTIVES: The laryngeal chemoreflex is a reflexive central apnea, bradycardia, and cardiovascular collapse that occurs in young, maturing mammals in response to exposure of the laryngeal mucosa to acidic and/or organic stimuli. The severity of the laryngeal chemoreflex varies within a species from one animal to another, and in some animals, the response can be fatal. This study seeks to identify those factors that contribute to fatal laryngeal chemoreflex responses when the larynx is stimulated under normoxic conditions, and to define how the normoxic response differs from the hypoxic laryngeal chemoreflex response. STUDY DESIGN: This is a prospective study evaluating the response to laryngeal stimulation of 80 newborn piglets. METHODS: The laryngeal chemoreflex response was elicited from 67 piglets under normoxic conditions. The data were collected from a combination of three separate experimental protocols, each of which included inducing the laryngeal chemoreflex under normoxic conditions as the first step. The physiologic response was recorded with a combination of arterial blood gas, pulse oximetry, blood pressure, and continuous cardiac monitoring. RESULTS: Resumption of respirations occurred when the pCO(2) rose by a mean of 8.34 (Standard Deviation [SD] = 4.8) mmHg, regardless of response severity (ANOVA, P > .05). Moderate (requiring supplemental O(2) for recovery) and profound (fatal) responders had a significantly higher prestimulation pCO(2) (95% confidence interval [CI] 39.8-44.8 mmHg and 40.5-46.4 mmHg, respectively) than did mild (recovery without assistance) responders (95% CI 36.8-40.8 mmHg, ANOVA, P < .05). Baseline pH was statistically significantly different as a function of response severity (95% CI profound: 7.29-7.37, moderate: 7.33-7.38, and mild 7.36-7.39, P < .05). CONCLUSIONS: Accumulation of arterial CO(2) is associated with resumption of respirations during the normoxic laryngeal chemoreflex. The combination of an elevated prestimulation pCO(2) and a low prestimulation pH predicts a profound laryngeal chemoreflex response under normoxic conditions.

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This study was designed to evaluate the usefulness of fiber optic (FO) and distal chip (DC) flexible imaging platforms in the diagnosis of true vocal fold pathology when compared to the gold standard rigid transoral laryngeal telescopic examination. The recorded strobovideolaryngoscopic examinations of 34 consecutive patients were evaluated retrospectively by five raters. All stroboscopy segments were evaluated by two laryngologists, an otolaryngologist, a laryngology fellow, and an otolaryngology resident. Seventeen patients were examined with a high-quality, large-diameter, FO flexible laryngoscope (FO group) and 17 random patients were examined with a DC flexible laryngoscope (DC group). Each patient was also examined using rigid laryngeal videostroboscopy at the same sitting. Examinations of three patients from each group were presented twice to monitor internal consistency. Diagnoses of intrinsic vocal fold pathology made with the flexible laryngoscopes were compared for accuracy to the diagnoses provided using the rigid laryngeal telescope. The ability to make clinical diagnoses via stroboscopy was statistically equivalent with FO technology and DC technology. Rigid examination provided more information than the flexible examination in 27% of the FO examinations and in 32% of the DC examinations. DC technology did not add diagnostic information to the examination when compared to a high-quality, large-diameter, FO endoscope. Rigid endoscopy provides superior images of the true vocal folds and is necessary for precise diagnosis in patients with true vocal fold pathology. Thus, the most cost-effective means of evaluation of voice disorders remains FO flexible endoscopy for dynamic voice assessment and the neurolaryngologic examination followed by rigid stroboscopy for evaluation of the vocal fold edge and mucosal wave. Strobovideolaryngoscopy using high-quality FO or DC flexible equipment should be reserved for patients who cannot tolerate transoral rigid examination, such as children and those with a very strong gag reflex.

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The anatomy and physiology of voice include not only the larynx but also all body systems. The larynx consists of a skeleton, mucosa, intrinsic muscles, and extrinsic muscles. The vocal folds form the oscillator of the vocal tract, the subglottic vocal tract acts as a power source, and the supraglottic vocal tract functions as a resonator. Complex interactions are responsible for voice production.

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A careful and thoughtful history is extremely important in helping to elucidate the cause of a patient's voice complaints. An understanding of the patient's performance and rehearsal environment and demands is also important in guiding the treatment process. A thorough history helps the clinician understand the vocal problem and how to interpret findings on physical examination that may be contributing to the pathophysiology of the vocal complaint.

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Comprehensive physical examination is essential when evaluating patients. Often it includes objective voice assessment and measures along with strobovideolaryngoscopy. In all cases physical examination involves a thorough examination of the ears, nose, throat, neck, posture, cranial nerve function (usually), and assessment of the patient's general (systemic) physical condition. Performance assessment usually should be included for professional voice.

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Laryngeal electromyography (LEMG) evaluates the integrity of the neuromuscular system in the larynx by recording action potentials generated in the laryngeal muscles during voluntary and involuntary contraction. LEMG is particularly useful for helping to differentiate between disorders involving upper motor neurons, lower motor neurons, peripheral nerves, the neuromuscular junction, muscle fibers, and the laryngeal cartilages and joints. LEMG should be considered to be an extension of the physical examination, not an isolated laboratory procedure. A careful history and laryngeal evaluation determine the indication for LEMG and which muscles or muscle groups, in particular, are to be studied. Abnormalities detected by LEMG are always interpreted within the context of the clinical picture.

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There have been many advances in microsurgery for voice professionals over the last three decades. Driven by a greater understanding of the anatomy and physiology of phonation, most of the advances provide greater surgical precision through improved exposure and more delicate instrumentation. Laryngologists who perform laryngoscopic surgery should be familiar with the current state-of-the-art and should use the latest techniques and technology for all voice patients and particularly for voice professionals. Video procedures for surgical management of voice disorders accompany this content online.

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OBJECTIVE: Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It affects as many as 5% of the population over 65 years old, and this number is growing annually due to the aging population. A significant portion of stroke patients that initially survive are faced with the risk of aspiration, as well as quality-of-life issues relating to impaired communication. The goal of this paper is to define the scope of practice in otolaryngology for these patients, and to review pertinent background literature. STUDY DESIGN: Consensus report and retrospective literature review. RESULTS: Otolaryngology involvement in these patients is critical to their rehabilitation, which often requires an interdisciplinary team of specialists. This committee presentation explores epidemiological data regarding the impact of stroke and its complications on hospitalizations. A pertinent review of neuroanatomy as it relates to laryngeal function is also discussed. State-of-the-art diagnostic and therapeutic procedures are presented. CONCLUSION: There is a well-defined set of diagnostic and therapeutic options for laryngeal dysfunction in the stroke patient. SIGNIFICANCE: Otolaryngologists play a critical role in the interdisciplinary rehabilitation team.

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