Stephanie Misono

Objective: Quantifying treatment‐related voice change in adductor laryngeal dystonia (AdLD) is essential for optimizing botulinum neurotoxin (BoNT) therapy, yet clinical practice lacks objective, automated metrics to track response. Counting voice disruptions remains the standard but is labor‐intensive and prone to error. This study evaluated whether pitch strength (PS) and percent vocal creak (%VC) (automated indices of pitch salience and irregular phonation) are sensitive to BoNT‐related changes. We examined whether these metrics capture treatment effects at the group level, and through individual correlations with manual/perceptual severity. Methods: Standardized speech from 16 patients was analyzed for PS, %VC, and two multi‐parametric indices before and 1 month after BoNT. Mixed‐effects models assessed BoNT and task effects. Spearman correlations examined relationships among acoustic, manual, perceptual, and patient‐reported outcomes. Results: Discontinuity counts, patient‐reported outcomes, and perceptual ratings improved post‐BoNT. Changes in PS ( r = −0.83) and %VC ( r = 0.82) strongly correlated with change in disruption frequency. No main BoNT effects or BoNT‐by‐task interactions were observed for PS or %VC. Acoustic Voice Quality Index increased with a small–medium effect ( d = 0.48, p = 0.03). Conclusions: While PS and %VC correlate with changes in disruption frequency and perceptual severity, they did not demonstrate robust group‐level treatment sensitivity. Because diverse acoustic manifestations of AdLD disruptions (e.g., F0 shifts vs. aperiodicity) can obscure improvement in summary metrics, these measures should be interpreted cautiously at the group level. At the individual level, PS and %VC may offer supplemental value for longitudinal monitoring but are not substitutes for manual disruption counts. Level of Evidence: 3.

Objective: To evaluate how subperichondrial mobilization affects implant‐tissue mechanics, glottal configuration, and vibratory behavior in computational simulations of medialization laryngoplasty (ML). Methods: We used a finite‐discrete element method (FDEM) framework to simulate subperichondrial tissue‐cartilage separation and implant insertion in laryngeal models reconstructed from high‐resolution magnetic resonance imaging. Four dissection conditions were evaluated, ranging from no mobilization to increasing dissection length distal to the thyroplasty window. Outcome measures included change in glottal area, vocal fold medial displacement, finite element fracturing along the tissue‐cartilage interface, and estimated vibratory frequency. Results: Increasing dissection length produced increased medial displacement, progressive reductions in glottal area, fewer secondary extensions of the dissection plane during implantation, and higher estimated vibratory frequencies (range: 100.4–120.8 Hz). These findings indicate that subperichondrial tissue mobilization alters implant‐induced force transmission and modifies boundary conditions relevant to vibration. Conclusion: In this first application of FDEM to simulate laryngeal biomechanics in ML, subperichondrial dissection length demonstrated direct effects on model predictions relevant to implant sizing, placement strategy, and anticipated phonatory outcomes. Incorporating tissue mobilization into computational frameworks as a mechanically meaningful variable improves physiological realism and supports future development of subject‐specific surgical planning tools. Level of Evidence: Level V. This study provides preclinical computational evidence using FDEM, supporting and extending clinical observations in ML.

Background: Subglottic stenosis (SGS) is a complex medical condition marked by airway narrowing. Studies implicate gastroesophageal reflux disease as a potential contributing factor for SGS, however the diagnostic standard and pathogenesis are unknown. This study sought to characterize esophageal structure and function in patients with SGS using multimodal diagnostic testing to address gaps in the current understanding of esophageal involvement in this population. Methods: We performed a retrospective single-center review of adults with SGS who underwent esophageal evaluation at a tertiary referral center between January 2014 and June 2024. Patients were included if they had laryngoscopically-confirmed SGS and completed esophageal function test(s) including esophagogastroduodenoscopy (EGD), high-resolution manometry (HRM), esophageal pH testing, and/or barium esophagram. Demographics, SGS characteristics, and esophageal test results were analyzed descriptively. Results: Among 72 patients (mean age 54.3 years; 87.5% female), most (41.7%) had idiopathic SGS. Esophageal symptoms were reported in 91.7% of patients. Abnormal findings were identified by at least one modality in over half of cases: EGD (53.6%, most commonly hiatal hernia), HRM (53.8% abnormal), pH testing (52.9% abnormal acid exposure), and barium esophagram (62.5% abnormal, including dysmotility and intraesophageal reflux). Notably, 58.8% of patients with normal EGD demonstrated abnormalities on subsequent esophageal function testing. Conclusions: Esophageal abnormalities were highly prevalent in patients with SGS. These findings suggest that a low threshold for comprehensive esophageal evaluation is warranted in patients with SGS. Future studies should evaluate whether targeted esophageal interventions improve SGS outcomes.

Objectives: The electronic health record (EHR) has benefits but also adds documentation burden that is not equally shared between academic faculty. We hypothesize that male gender and senior academic rank are associated with decreased EHR burden compared to female and junior faculty. Methods: Demographics from faculty at participating organizations were combined with 3 years of provider efficiency data. Multivariate analyses were performed to evaluate the differences in EHR burden between genders and academic ranks, clustering for otolaryngologist and institution. Results: Forty‐six institutions with 914 otolaryngologists (female, n = 283, 31%) were included for analysis. Median hours per day (h/d) spent in EHR tasks related to outpatient visits were 4.3, 3.5, and 3.4 h/d for female assistant, associate, and full professors, respectively; and 3.4, 2.7, and 2.3 h/d for males, likewise in ascending academic rank. These differences between median h/d in ambulatory time were significant across all six subgroups of gender and academic rank ( p < 0.002). Academic seniority, but not gender, was associated with less time in ambulatory tasks after work and on days without scheduled appointments ( p < 0.002). Males and otolaryngologists with higher academic rank were more likely to receive help with notes and orders ( p < 0.002). Conclusions: For a typical clinic day, female assistant professors in academic otolaryngology spent nearly twice as much time as their male full professor counterparts did in the EHR completing tasks related to ambulatory patient care. The differential likelihood of faculty receiving help with notes and orders may play a role in this disparity. Level of Evidence: 3.

Objective: To compare instrumental swallow assessment findings and diet recommendations in high versus low vagal unilateral vocal fold paralysis (UVFP). Methods: Retrospective review of patients with UVFP who underwent instrumental swallow assessment, September 2019–February 2024. Demographics, Eating Assessment Tool‐10 (EAT‐10) score, flexible laryngoscopy findings, instrumental swallow parameters, diet recommendations, treatment modalities, and posttreatment outcomes were analyzed. Results: Ninety‐six patients were included: 28 (29%) high‐vagal and 68 (71%) low‐vagal UVFP. High vagal UVFP had a higher incidence of premature spillage (57% vs. 13%, p < 0.0001); residue (82% vs. 22%, p < 0.0001), penetration (89% vs. 35%, p < 0.0001), aspiration (50% vs. 22%, p = 0.013), modified diet (61% vs. 16%, p < 0.0001), and behavioral modifications (89% vs. 38%, p < 0.001) compared to low vagal UVFP. Thirty‐one patients (32%) underwent injection laryngoplasty (16 high, 15 low vagal) with similar pretreatment prevalences of premature spillage, penetration, and aspiration, but a higher prevalence of residue in the high vagal group (100% vs. 53%, p = 0.002). Both groups improved posttreatment (high vagal: 63%–19%, p = 0.016; low vagal: 80%–7%, p = 0.001). Conclusion: High vagal UVFP is associated with greater swallowing dysfunction and higher prevalences of diet and behavioral modifications compared to low vagal UVFP. Treated high and low vagal subgroups had similar dysphagia profiles. Injection laryngoplasty improved aspiration, regardless of vagal level, although many patients continued to require behavioral modifications. Future studies are needed to identify predictors of poor functional swallowing outcomes in UVFP. Level of Evidence: 3 .

Objectives: Cross‐sectional associations between voice and psychological factors are known, but changes over time offer opportunities to refine our understanding of their interactions and consider customized treatment options. Study objectives were to measure relationships between voice and psychological factors using ecological momentary assessment and applying (1) group‐level time series analysis and (2) group and (3) individual causal modeling to identify key psychological factors relevant for voice outcomes. Methods: Adults ( N = 32) with primary muscle tension dysphonia completed multiple assessments daily for 10 days. Measures included items from the Voice Handicap Index‐10, voice‐adapted perceived present control scale, items from NIH PROMIS and the NIH Toolkit to assess distress, and the Positive and Negative Affect Scale. Group‐level time series analysis was conducted using dynamic structural equation modeling; causal analysis utilized the Greedy Fast Causal Inference algorithm. Results: In group‐level time series analyses, neither perceived control nor distress predicted subsequent timepoint voice handicap scores. In group‐level causal modeling, anxiety was causal for voice handicap, but perceived control was not. Individual‐level analyses identified various causal factors for voice handicap including perceived control and negative affect, and to a lesser extent, serenity, anxiety, somatic arousal, and stress. Conclusions: Group‐level analyses may obscure important heterogeneity that is identifiable using individual‐level causal analyses. For example, perceived control was not identified as predictive or causal for voice handicap at the group level; but was a salient causal factor for voice handicap in some individuals. Causal modeling using intensive longitudinal datasets offers a potential avenue for individualized treatment approaches. Level of Evidence: 4.

Importance: Voice-related perceived control is the extent to which a person feels they can control their voice condition and/or their response to it. Given the interaction of psychological factors and voice outcomes, an intervention targeting psychological factors may be a helpful adjunct to clinical voice care.Objective: To investigate the feasibility, acceptability, and potential efficacy of a perceived control intervention adapted for adult patients with muscle tension dysphonia and to compare its outcomes with those of a voice education program.Design, Settings, and Participants: This was a pilot randomized clinical trial using mixed methods and including adults with muscle tension dysphonia from academic otolaryngology clinics from July 8, 2018, to December 8, 2019. Participants were randomized to the voice education program or the perceived control intervention, and feasibility and acceptability of both were assessed using quantitative and qualitative measures. Data analyses were performed from October 1, 2023, to March 5, 2024.Main Outcomes and Measures: Voice-related impairment was measured using the Voice Handicap Index-10 (VHI-10). Psychological factors were measured using the voice-related Perceived Present Control Scale, Brief Symptom Inventory-18 (BSI), and Perceived Stress Scale-4. Open-ended participant responses were analyzed following consensual qualitative research methods.Results: In all, 50 participants (mean [SD] age, 51.0 [15.9] years; 34 women [68%]); 27 were randomly assigned to receive the voice education program and 23 were randomly assigned to the perceived control intervention. Forty participants (80%) completed the study, which demonstrated the feasibility of both options. Outcomes of both the perceived control intervention and the voice education program were acceptable. Change in VHI-10 was heterogeneous, modest overall, and similar in the perceived control (−2.44; 95% CI, −4.25 to −0.63) and education (−2.94; 95% CI, −4.12 to −1.76) arms. Perceived control (secondary outcome) was higher, and exploratory outcomes (ie, somatic concerns, depression, anxiety, and perceived stress) were lower overall between pretest and posttest assessments. Qualitative analyses showed an overall decrease in negative voice-related emotions, fatigue, and negative self-image over the course of the perceived control intervention, and an interest in curated information in the voice education program.Conclusions and Relevance: This pilot randomized clinical trial indicates that both the perceived control intervention and voice education program appear promising for further development. Online interventions are of interest to people with voice disorders, and future work may benefit from taking individual differences into account.Trial Registration: ClinicalTrials.gov Identifier: NCT03576365