Publications by authors named "Michael M Johns"

158 Publications

Cricothyroid Muscle Botulinum Toxin Chemodenervation to Treat Recalcitrant High-Pitched Functional Dysphonia in an Adult Male.

J Voice 2022 Jul 15. Epub 2022 Jul 15.

USC Voice Center, USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck Medicine of USC, Los Angeles, California. Electronic address:

Introduction: Functional dysphonia occurs in the absence of structural or neurologic laryngeal abnormalities with various manifestations including aphonia and inappropriate vocal pitch. Voice therapy is the first-line treatment, and literature on treatment options for functional dysphonia unresponsive to voice therapy is limited.

Methods: Retrospective medical records review and report of a case.

Results: We report a unique case of an adult male with recalcitrant high-pitched functional dysphonia of adult-onset that was successfully treated with a single cricothyroid muscle botulinum toxin (Botox) chemodenervation injection.

Conclusion: Cricothyroid muscle botulinum toxin chemodenervation can be an effective treatment for recalcitrant functional dysphonia.
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http://dx.doi.org/10.1016/j.jvoice.2022.06.014DOI Listing
July 2022

Safety of Platelet-Rich Plasma Subepithelial Infusion for Vocal Fold Scar, Sulcus, and Atrophy.

Laryngoscope 2022 Jul 13. Epub 2022 Jul 13.

USC Voice Center, Department of Otolaryngology-Head & Neck Surgery, University of Southern California, Los Angeles, California, U.S.A.

Objective: To demonstrate the safety profile of platelet-rich plasma (PRP) as an injectable therapeutic for the treatment of vocal fold scarring and atrophy.

Methods: Preliminary report on a prospective clinical trial of patients with vocal fold scar or atrophy undergoing unilateral vocal fold subepithelial infusion with autologous PRP. Enrolled patients underwent four subepithelial injections spaced 1 month apart. Adverse events were assessed peri and post-injection at each session. Patient-reported outcomes were collected at every visit using the Voice Handicap Index-10 (VHI-10) and Vocal Fatigue Index (VFI) questionnaires.

Results: Twelve patients underwent unilateral vocal fold injection with autologous PRP prepared according to Eclipse PRP® system protocol. Forty-three injections were performed using a peroral or percutaneous approach. An average of 1.57 ± 0.4 cc (range 0.6-2.0 cc) injectate was used. All patients tolerated the procedure without difficulty or peri-procedural complications. The average duration of follow-up was 3.6 ± 1.8 months. No significant inflammatory reactions or adverse events were seen to date. There was statistically significant improvement in patient-reported outcomes at the 3 month follow up (n = 9) follow-up (mean ΔVHI-10 = 10.8, p < 0.001, mean ΔVFI = 18.9, p = 0.01, t test, paired two sample for means, two-tail). All nine patients who completed the series of four injections subjectively (yes/no) reported they were satisfied with the results.

Conclusion: This prospective study cohort demonstrated a favorable safety profile, with no adverse events or peri-procedural complications. Subjective improvements in vocal quality and reduction in vocal fatigue need to be clinically correlated with further study.

Level Of Evidence: 4 Laryngoscope, 2022.
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http://dx.doi.org/10.1002/lary.30288DOI Listing
July 2022

Artificial Intelligence and Laryngeal Cancer: From Screening to Prognosis: A State of the Art Review.

Otolaryngol Head Neck Surg 2022 Jul 5:1945998221110839. Epub 2022 Jul 5.

Department of Otolaryngology-Head and Neck Surgery, Sean Parker Institute for the Voice, Weill Cornell Medical College, New York, New York, USA.

Objective: This state of the art review aims to examine contemporary advances in applications of artificial intelligence (AI) to the screening, detection, management, and prognostication of laryngeal cancer (LC).

Data Sources: Four bibliographic databases were searched: PubMed, EMBASE, Cochrane, and IEEE.

Review Methods: A structured review of the current literature (up to January 2022) was performed. Search terms related to topics of AI in LC were identified and queried by 2 independent reviewers. Citations of selected studies and review articles were also evaluated to ensure comprehensiveness.

Conclusions: AI applications in LC have encompassed a variety of data modalities, including radiomics, genomics, acoustics, clinical data, and videomics, to support screening, diagnosis, therapeutic decision making, and prognosis. However, most studies remain at the proof-of-concept level, as AI algorithms are trained on single-institution databases with limited data sets and a single data modality.

Implications For Practice: AI algorithms in LC will need to be trained on large multi-institutional data sets and integrate multimodal data for optimal performance and clinical utility from screening to prognosis. Out of the data types reviewed, genomics has the most potential to provide generalizable models thanks to available large multi-institutional open access genomic data sets. Voice acoustic data represent an inexpensive and accurate biomarker, which is easy and noninvasive to capture, offering a unique opportunity for screening and monitoring of LA, especially in low-resource settings.
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http://dx.doi.org/10.1177/01945998221110839DOI Listing
July 2022

Comparison of Treatment for Recurrent Respiratory Papillomatosis at a Public County Versus Private Academic Hospital.

J Voice 2022 Feb 20. Epub 2022 Feb 20.

Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California. Electronic address:

Objective: To compare patient, disease and treatment characteristics of patients treated for recurrent respiratory papillomatosis (RRP) at a public county versus a private hospital.

Methods: A retrospective cohort study was conducted of adult patients undergoing treatment for RRP at a tertiary-care academic center (TAC, n = 48) versus public safety net hospital (PSNH, n = 14), both staffed by the same Otolaryngology providers.

Results: There was no difference between cohorts in age, gender, medical comorbidities, history of juvenile-onset presentation, or history of prior treatment at a different institution. PSNH patients were more likely to be Hispanic/Latino, primarily speak Spanish, have public or no insurance, and reside in a zip code with lower median income compared with TAC patients. Despite living significantly closer to the hospital, PSNH patients were more likely than TAC patients to present with respiratory symptoms (50% versus 20.8%, P = 0.04), and exhibit more than one involved laryngeal subsite at their first surgical intervention (78.6% versus 27.1%, P = 0.001). They also had high rates of referral for otolaryngologic care via the emergency department (42.9%) rather than outpatient specialty referral (35.7%) and were more likely than TAC patients to require urgent intervention (21.4% versus 2.1%, P = 0.03). There was no difference in time interval from first clinic visit to procedure date or total number of treatments.

Conclusions: PSNH patients present with more severe and symptomatic RRP disease compared with TAC patients. This finding may be related to sociodemographic disparities leading to poorer access in care.
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http://dx.doi.org/10.1016/j.jvoice.2022.01.019DOI Listing
February 2022

Does Vocal Fatigue Negatively Affect Low Vocal Range in Professional, Female Opera Singers? A Survey Study and Single-Subject Pilot Study.

J Voice 2022 Jan 16. Epub 2022 Jan 16.

USC Thornton School of Music, University of Southern California, Los Angeles, California.

Objective: 1. To survey how vocal fatigue manifests itself in the vocal range of a sample of professional, female opera singers. 2. To assess laryngeal videostroboscopic changes of one professional, female opera singer before and after extended operatic singing.

Methods: Survey study: 296 professional, female opera singers were recruited to participate in an anonymous research survey querying the temporary impact of vocal fatigue in professional, female opera singers. 46.3% of participants described themselves as singing mainstage roles at large, A-level opera houses. Singers were asked to report where in their vocal range they experienced the effects of vocal fatigue and could choose more than one response. Single-subject study: One professional, female opera singer (the author) underwent two laryngeal videostroboscopic exams pre and post vocal loading. The exams were evaluated and compared independently by two blinded laryngologists.

Results: The results of the survey found that 42.9% of the total responses from professional, female opera singers indicated a temporary impact on the lower middle range (≈C4-F4) as a result of vocal fatigue. 36.5% of participants experienced a temporary impact on their lowest range (≈below C4) and 19.6% reported a temporary impact on their higher range due to vocal fatigue. The results of the single-subject study showed reduced glottal closure pattern in the postloading, lower middle range, head voice condition.

Conclusions: A large proportion (64.9%) of the professional, female opera singers surveyed reported increased difficulty navigating their lower middle range and/or lowest range after extended operatic singing. These results support the single-subject study, which found that after vocal loading, there was a decrease in glottal competence while singing in head voice in the lower middle range.
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http://dx.doi.org/10.1016/j.jvoice.2021.12.005DOI Listing
January 2022

The Role of Educational Podcast Use Among Otolaryngology Residents.

Ann Otol Rhinol Laryngol 2022 Jan 13:34894211072996. Epub 2022 Jan 13.

Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA.

Objective: Medical podcasts are becoming increasingly available; however, it is unclear how these new resources are being used by trainees or whether they influence clinical practice. This study explores the preferences and experiences of otolaryngology residents with otolaryngology-specific podcasts, and the impact of these podcasts on resident education and clinical practice.

Methods: An 18-question survey was distributed anonymously to a representative junior (up to post-graduate year 3) and senior (post-graduate year 4 or greater) otolaryngology residents at most programs across the US. Along with demographic information, the survey was designed to explore the preferences of educational materials, podcast listening habits and motivations, and influence of podcasts on medical practice. Descriptive statistics and student -tests were used to analyze the results.

Results: The survey was distributed to 198 current otolaryngology residents representing 94% of eligible residency programs and was completed by 73 residents (37% response rate). Nearly 3-quarters of respondents reported previous use of otolaryngology podcasts, among which 83% listen at least monthly. Over half of residents changed their overall clinical (53%) and consult (51%) practice based on podcast use. Residents rank-ordered listening to podcasts last among traditional options for asynchronous learning, including reading textbooks and watching online videos.

Conclusions: While other asynchronous learning tools remain popular, most residents responding to this survey use podcasts and report that podcasts influence their clinical practice. This study reveals how podcasts are currently used as a supplement to formal otolaryngology education. Results from the survey may inform how medical podcasts could be implemented into resident education in the future.
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http://dx.doi.org/10.1177/00034894211072996DOI Listing
January 2022

Laryngologists' Reported Decision-Making in Presbyphonia Treatment.

J Voice 2021 Nov 21. Epub 2021 Nov 21.

UAB Voice Center, Department of Otolaryngology, University of Alabama at Birmingham, Hapner, Birmingham, Alabama. Electronic address:

Objective: Decision-making regarding behavioral versus procedural intervention in the treatment of presbyphonia has not been well defined. The study objective was to survey laryngologists' reported practice patterns and decision-making in presbyphonia.

Methods: All laryngology faculty in U.S. academic medical centers with residency programs were recruited to complete an anonymous 29-item survey regarding decision-making in presbyphonia treatment. The survey included 5 sections: demographics, first-line treatment distribution, factors that drive decision-making toward procedural intervention, treatment progression if first-line treatment is insufficient, durable treatment.

Results: Of 153 laryngologists surveyed, 89 responded (58%). Voice therapy (VT) was the most often reported first-line treatment, with 57% of respondents indicating the majority of their patients receive VT initially. Most respondents (83%) indicated they occasionally use procedural intervention as first-line treatment. Factors driving first-line procedural intervention were severe glottal insufficiency (87%), high occupational/social voice demands (76%), voice not stimulable for change (73%), difficulty attending VT (70%), severe dysphonia (65%), and dysphagia (61%). The majority of respondents indicated the following do not affect their decision to pursue procedural intervention: patient age (88%); medical comorbidities (63%); patient's desire for a "quick fix" (55%); patient-reported outcome measures (51%). Most respondents (81%) use trial injection augmentation before durable treatment. Of durable treatments, bilateral thyroplasty was preferred (71%), followed by CaHA (15%) and lipoinjection (11%).

Conclusions: This study is the first to our knowledge to examine factors that influence decision-making in presbyphonia treatment. While VT remains the most frequent first-line treatment, study results better inform decision-making regarding first-line procedural intervention.
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http://dx.doi.org/10.1016/j.jvoice.2021.10.008DOI Listing
November 2021

Recent Laryngology Fellowship Graduates: Where Are They Now?

Ann Otol Rhinol Laryngol 2022 Sep 8;131(9):979-986. Epub 2021 Oct 8.

Department of Otolaryngology-Head and Neck Surgery, Voice and Swallowing Center, Loma Linda University, Loma Linda, CA, USA.

Objectives: Over the past 30 years laryngology fellowships have grown in number and diversity. This study investigated the career trajectories of recent laryngology fellowship graduates with the purpose of informing residents considering fellowship.

Study Design: Cross-sectional survey.

Setting: Academic medical center.

Methods: The directors of all 27 US laryngology fellowships that graduated/recruited fellows from 2010 to 2019 were contacted, and a list of former fellows was compiled. A short survey was administered in person or via email or phone. Additional data was gathered through internet searches.

Results: One hundred eighty-three fellows were identified having completed American laryngology fellowships between 2010 and 2019 (100M:83F). Fifteen percent now practice internationally and 68% are in academic practice. A higher proportion of women than men enter laryngology fellowship after otolaryngology residency. One hundred twenty-nine fellows responded to our survey. Two-thirds of former fellows report current participation in laryngology research. Seventy-two percent of former fellows are still in their first job after fellowship and 53% believe they have their ideal practice. Women were more likely to enter academics than men after laryngology fellowship. Responders were overwhelmingly satisfied with their fellowship experience, with 95% saying they would choose to pursue fellowship training again.

Conclusions: Most former laryngology fellows enter academia, contribute to laryngology research, practice away from their training institution, and believe they have found their ideal practice. The results of this study may be useful to residents considering fellowship training, centers considering establishing laryngology fellowships, and practices recruiting fellowship graduates.
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http://dx.doi.org/10.1177/00034894211049574DOI Listing
September 2022

Pulmonary Function Tests May Better Predict Dyspnea-Severity in Patients with Subglottic Stenosis Compared to Clinician-Reported Stenosis.

Ann Otol Rhinol Laryngol 2022 Jul 8;131(7):791-796. Epub 2021 Sep 8.

Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA.

Objective: Patients with subglottic stenosis (SGS) present with varied degree of breathing complaints. The dyspnea index (DI) is a 10-question patient-reported outcome measure designed to measure the severity of upper airway obstruction. We set out to determine whether pulmonary function tests or clinician-reported degree of stenosis best predicted DI scores.

Methods: Thirty patients with SGS were retrospectively reviewed over a 6-year period. One visit from each patient was included. Data including peak expiratory flow rate (PEFR), body-mass index (BMI), clinician-reported degree of stenosis, and DI scores were reviewed. Multiple linear regression was performed to determine how degree of stenosis and PEFR % predicted the variation in DI score.

Results: PEFR % better predicted DI scores compared to degree of stenosis (partial correlation -0.32 vs 0.17). After stepwise elimination, PEFR % remained in the regression and was significantly associated with DI scores ([1, 29] = 9.38,  = .005). BMI did not demonstrate a linear relationship with DI scores and was not included in the regression ( = -.02). The PEFR % unstandardized coefficient was -0.25 (95% CI: -0.42 to -0.08,  = .005). The model predicts that a 4% increase in the PEFR % results in a 1-point decrease in the DI score (95% CI: -1.68 to -0.32).

Conclusion: This study suggests that pulmonary function tests may be a better in-office measure to substantiate the severity of symptoms in patients with SGS.
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http://dx.doi.org/10.1177/00034894211045266DOI Listing
July 2022

Perceptions of Vocal Performance Impairment in Singers with and without Hearing Loss.

J Voice 2021 Jul 24. Epub 2021 Jul 24.

Department of Otolaryngology - Head and Neck Surgery, USC Voice Center, Tina and Rick Caruso, University of Southern California, Los Angeles, California. Electronic address:

Introduction: It is well understood that hearing plays an important role in accurate vocal production. Singers in particular rely on auditory cues and auditory feedback to reproduce specific pitch contours. Therefore, even mild hearing loss may have a detrimental effect on a singer's ability to perform. This study investigates the effect of hearing loss on self-reported vocal production in singers, specifically in the domains of pitch matching, pitch maintenance, vowel production, and dynamic control as well as the effect of hearing loss on vocal handicap.

Methods: An 18-item electronic self-report survey was distributed to the members of the National Association of Teachers of Singing and to the Voice Foundation. Data collected included demographics, the Singing Voice Handicap Index-10 (SVHI-10), and a series of closed and open-ended questions. Demographic variables, variables related to the SVHI-10, and variables related to the newly introduced survey were included in a hierarchical regression analysis to determine significant relationships.

Results: Among 206 eligible participants, 37 individuals reported a voice problem, 58 reported hearing loss, and 19 reported concurrent hearing loss and a voice problem. Among males, there were no significant differences between hearing impaired and normal hearing singers in reported pitch matching, pitch maintenance, dynamic control, and vowel matching when those with voice problems were excluded and included. However, in females, when singers with voice problems were excluded, there was a significant difference between hearing impaired and normal hearing singers in pitch matching (P = 0.38). Additionally, when singers with voice problems were included in the female subset, significant differences emerged between the hearing impaired and normal hearing singers in areas of pitch matching (P = 0.01) and vowel matching (P = 0.02). Further, controlling for gender, when excluding voice problems, there was a significant difference between the SVHI-10 scores of normal hearing (mean = 9.03) and hearing impaired participants (mean = 11.30, P = 0.02). This difference continued to be significant when including those with voice problems (normal hearing mean = 9.97, hearing impaired mean=14.1, P <0.0001). Additionally, individuals with hearing impairments were more likely to report higher perceived vocal handicap scores as reflected on the SVHI-10 than normal hearing respondents (P = 0.002). Other factors associated with higher likelihood of SVHI-10 score include older age (P = 0.008), having a voice problem (P <0.0001), and being paid to sing within the past six months (P = 0.001).

Conclusion: When controlling for voice problems, singers with hearing impairments subjectively did not perceive that they performed less accurately on pitch matching, pitch maintenance, dynamic control, and vowel matching, yet they scored higher on the SVHI-10 indicating vocal handicap. Further study is needed to characterize the relationship between perceived and measured vocal accuracy in singers with hearing loss.
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http://dx.doi.org/10.1016/j.jvoice.2021.06.021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9365312PMC
July 2021

Aerosol Generation During Laryngology Procedures in the Operating Room.

Laryngoscope 2021 12 2;131(12):2759-2765. Epub 2021 Jul 2.

Tina and Rick Caruso Department of Otolaryngology - Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A.

Objective: Severe acute respiratory syndrome coronavirus-2 spreads through respiratory fluids. We aim to quantify aerosolized particles during laryngology procedures to understand their potential for transmission of infectious aerosol-based diseases.

Study Design: Prospective quantification of aerosol generation.

Methods: Airborne particles (0.3-25 μm in diameter) were measured during live-patient laryngology surgeries using an optical particle counter positioned 60 cm from the oral cavity to the surgeon's left. Measurements taken during the procedures were compared to baseline concentrations recorded immediately before each procedure. Procedures included direct laryngoscopy with general endotracheal anesthesia (GETA), direct laryngoscopy with jet ventilation, and carbon dioxide (CO ) laser use with or without jet ventilation, all utilizing intermittent suction.

Results: Greater than 99% of measured particles were 0.3 to 1.0 μm in diameter. Compared to baseline, direct laryngoscopy was associated with a significant 6.71% increase in cumulative particles, primarily 0.3 to 1.0 μm particles (P < .0001). 1.0 to 25 μm particles significantly decreased (P < .001). Jet ventilation was not associated with a significant change in cumulative particles; when analyzing differential particle sizes, only 10 to 25 μm particles exhibited a significant increase compared to baseline (+42.40%, P = .002). Significant increases in cumulative particles were recorded during CO laser use (+14.70%, P < .0001), specifically in 0.3 to 2.5 μm particles. Overall, there was no difference when comparing CO laser use during jet ventilation versus GETA.

Conclusions: CO laser use during laryngology surgery is associated with significant increases in airborne particles. Although direct laryngoscopy with GETA is associated with slight increases in particles, jet ventilation overall does not increase particle aerosolization.

Level Of Evidence: 3 Laryngoscope, 131:2759-2765, 2021.
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http://dx.doi.org/10.1002/lary.29729DOI Listing
December 2021

Targeted Wellness Initiatives Are Most Effective for Reducing Otolaryngology Resident Burnout.

Ear Nose Throat J 2021 Apr 13:1455613211009139. Epub 2021 Apr 13.

USC Caruso Department of Otolaryngology, Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA.

Objective: Investigate the effect of a targeted wellness program on burnout in Otolaryngology residents.

Methods: Residents and faculty collaboratively developed a program aimed at improving resident wellness. Program implementation began in July of 2018 and after 1 year, residents evaluated the program's effects on burnout. We used the Maslach Burnout Inventory (MBI) and a Likert scale to evaluate the effects of the program.

Results: After 1 year of the resident wellness program, the MBI results showed an increase in the number of residents in the "engaged" category and a decrease in those rated as "burnout." Residents rated favorably initiatives grouped into the following themes: time away from work, faculty engaging with residents outside of the hospital environment, efforts to enhance residents' self-efficacy, fostering a positive culture among residents, and providing easy access to physical activity. The majority of initiatives were targeted to the "culture of wellness" domain, as defined by the Stanford Well MD framework. Our program targeted to a lesser extent the other 2 domains, "efficiency of practice" and "personal resilience."

Conclusion: After 1 year, the wellness program resulted in a trend toward improving burnout. Future efforts should be focused on targeting the multidimensional drivers of burnout as defined by established wellness frameworks. Realizing new stressors brought on by the COVID-19 pandemic will also be an area of active effort and research.
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http://dx.doi.org/10.1177/01455613211009139DOI Listing
April 2021

Flexible Versus Rigid Laryngoscopy: A Prospective, Blinded Comparison of Image Quality.

J Voice 2021 Mar 25. Epub 2021 Mar 25.

Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California. Electronic address:

Objective: To compare flexible distal-chip laryngoscopy (FDL) and rigid telescopic laryngoscopy (RTL) in image quality and diagnostic ability.

Study Design: Prospective cohort study; blinded comparison.

Methods: Eighteen normal adult subjects were recruited to undergo both FDL and RTL and normalized videos were recorded. Three blinded laryngologists compared the videos for color fidelity, illumination, resolution, and vascularity, and indicated superiority with FDL, RTL, or no difference. Raters also reported if an abnormality was seen and in which video it was better visualized. Videos for two subjects were repeated to assess intra-rater reliability, making 20 video comparisons across 3 raters for a total of 60 ratings. Differences in responses were analyzed via Mann-Whitney U and Pearson Χ. Inter-rater reliability was assessed via Fleiss' kappa, and intra-rater reliability was assessed via percent agreement.

Results: RTL was rated superior in all categories of image quality (47 vs 5 vs 8, P < 0.01; 47 vs 7 vs 6, P < 0.01; 51 vs 5 vs 4, P<0.01; 44 vs 9 vs 7, P < 0.01, respectively). An abnormality was seen 33 times with both modalities and 6 times with RTL only. When seen with both modalities, visualization was superior in RTL compared with FDL (29 vs 4, P <0.01).

Conclusions: There was significant superiority of RTL in all categories of image quality, with slight inter-rater agreement for color fidelity, resolution, and vascularity. RTL was also significantly better for visualization of abnormalities. These findings suggest superior image quality in RTL compared with FDL, but further research is required to determine if this difference is clinically significant.
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http://dx.doi.org/10.1016/j.jvoice.2021.02.010DOI Listing
March 2021

Association of Social Determinants of Health with Time to Diagnosis and Treatment Outcomes in Idiopathic Subglottic Stenosis.

Ann Otol Rhinol Laryngol 2021 Oct 25;130(10):1116-1124. Epub 2021 Feb 25.

Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, CA, USA.

Objectives: To examine whether social determinants of health (SDH) factors are associated with time to diagnosis, treatment selection, and time to recurrent surgical intervention in idiopathic subglottic stenosis (iSGS) patients.

Methods: Adult patients with diagnosed iSGS were recruited prospectively (2015-2017) via clinical providers as part of the North American Airway Collaborative (NoAAC) and via an online iSGS support community on Facebook. Patient-specific SDH factors included highest educational attainment (self-reported), median household income (matched from home zip code via U.S. Census data), and number of close friends (self-reported) as a measure of social support. Main outcomes of interest were time to disease diagnosis (years from symptom onset), treatment selection (endoscopic dilation [ED] vs cricotracheal resection [CTR] vs endoscopic resection with adjuvant medical therapy [ERMT]), and time to recurrent surgical intervention (number of days from initial surgical procedure) as a surrogate for disease recurrence.

Results: The total 810 participants were 98.5% female, 97.2% Caucasian, and had a median age of 50 years (IQR, 43-58). The cohort had a median household income of $62 307 (IQR, $50 345-$79 773), a median of 7 close friends (IQR, 4-10), and 64.7% of patients completed college or graduate school. Education, income, and number of friends were not associated with time to diagnosis via multivariable linear regression modeling. Univariable multinominal logistic regression demonstrated an association between education and income for selecting ED versus ERMT, but no associations were noted for CTR. No associations were noted for time to recurrent surgical procedure via Kaplan Meier modeling and Cox proportional hazards regression.

Conclusions: Patient education, income, and social support were not associated with time to diagnosis or time to disease recurrence. This suggests additional patient, procedure, or disease-specific factors contribute to the observed variations in iSGS surgical outcomes.
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http://dx.doi.org/10.1177/0003489421995283DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8762607PMC
October 2021

Platelet-Rich Plasma for Vocal Fold Scar: A Preliminary Report of Concept.

J Voice 2021 Jan 12. Epub 2021 Jan 12.

USC Voice Center, Tina and Rick Caruso Department of Otolaryngology - Head and Neck Surgery, University of Southern California, Los Angeles, California. Electronic address:

Introduction: Vocal fold atrophy and scar can lead to loss of normal superficial lamina propria, negatively affecting the vibratory function of the vocal fold. These changes can lead to dysphonia, vocal fatigue, decreased volume, and altered pitch. Treatment options for these conditions are limited. Platelet-rich plasma (PRP) consists of platelets, growth factors, and cytokines derived from the patient's own blood and is believed to activate tissue regeneration. The purpose of this study was to review the technical aspects of collecting PRP and injecting it into the vocal fold injection - based on our initial experience with this procedure.

Case: A patient with vocal fold scar was identified and enrolled in an ongoing prospective clinical trial study of a series of 4 monthly subepithelial vocal fold PRP injections, which was temporarily halted due to the COVID-19 pandemic. Patient underwent a single injection of autologous PRP into the left vocal fold. There were no adverse events during the study period. Subjective improvement in voice was noted at 1 month after injection with subsequent return to baseline over the next 4 months. Videostroboscopy performed on postinjection day 1 and day 7 and demonstrated no concerning exam changes. Compared to the preinjection baseline, the patient-reported voice-handicap index-10 (VHI-10) and voice catastrophization index were similar at 4 months following injection (20 to 20 and 4 to 3, respectively). Independent perceptual analysis of voice showed improvement at 4 months postinjection, compared to baseline consensus auditory-perceptual evaluation of voice 60 to 44.

Conclusions: This preliminary report was part of a prospective trial investigating the use of PRP to treat vocal fold atrophy and scar. This work highlights the technical considerations for injecting PRP into the vocal fold. Planned prospective enrollment in this study will help to validate the safety and efficacy of PRP injections.
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http://dx.doi.org/10.1016/j.jvoice.2020.12.040DOI Listing
January 2021

Respiratory Particle Emission During Voice Assessment and Therapy Tasks in a Single Subject.

J Voice 2020 Oct 22. Epub 2020 Oct 22.

USC Voice Center, USC Caruso Department of Otolaryngology - Head and Neck Surgery at Keck Medicine of USC, University of Southern California, Los Angeles, California. Electronic address:

Introduction: SARS-CoV-2 is transmitted via respiratory particles. Respiratory particle emission is impacted by manner of breathing and voicing, as well as intersubject variability. Assessment and treatment of voice disorders may include tasks that increase respiratory particle emission beyond typical breathing and speaking. This could increase the risk of disease transmission via respiratory particles.

Methods: Respiratory particle emission was measured during a single-subject, repeated measures clinical simulation of acoustic and aerodynamic assessment and voice therapy tasks. An optical particle sizer was used to measure particle count (1-10 μm in diameter). Assessment and therapy tasks were completed in three conditions: (1) 15 cm from the device, (2) 1 m from the device, and (3) 1 m from the device with the subject wearing a surgical mask.

Results: Condition 1 generated the highest particle count, with a median of 5.1 (13) additional particles above baseline, which was statistically significant (U = 381.5, P= 0.002). In condition 1, therapy and acoustic tasks combined produced more particles compared to the baseline and speech tasks, with a median difference of 6.5 additional particles per time point (U = 309.0, P= 0.002). This difference was not significant for conditions 2 and 3. Peak particle generation occurred in specific phonatory tasks, which was most pronounced in condition 1. Voice therapy tasks during condition 1 generated the highest peaks of normalized total particles with classical singing and expiratory muscle strength training. There was a significant difference in the amount of particle generation between condition 1 and 2, with a median difference of 5.2 particles (U = 461.0, P= 0.002). The particle count difference between conditions 2 and 3 was 2.1 (U = 282.0, P= 0.292), and this difference was not significant. The normalized total particles were assessed over time for each condition. For all conditions, there was no significant accumulation of particles.

Conclusions: For a single subject, production of voice assessment and therapy tasks combined resulted in an increased number of respiratory particles compared to speech and baseline (1-10 μm). EMST and classical singing generated the greatest concentration of particles. Respiratory particle counts were higher at 15 cm from the particle sizer compared to 1 m from the particle sizer, suggesting that physical distancing may reduce immediate clinician exposure to respiratory particles. Particle concentration did not accumulate over time.
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http://dx.doi.org/10.1016/j.jvoice.2020.10.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7582043PMC
October 2020

Effect of Vitamin B12 Injection on the Vocal Performance of Professional Singers: A Randomized, Double-blind, Placebo-Controlled, Crossover Trial.

JAMA Otolaryngol Head Neck Surg 2021 01;147(1):9-15

USC Voice Center, Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles.

Importance: One-third of singers and vocal professionals report experiencing a benefit from empirical vitamin B12 injections for improvement of mild singing-related symptoms (eg, reduced stamina, vocal fatigue, and effort). However, there is no objective evidence to support or refute these claims.

Objective: To assess the presence and magnitude of the effect of empirical vitamin B12 injection on the vocal performance of singers.

Design, Setting, And Participants: A randomized, double-blind, placebo-controlled, crossover trial was conducted from November 7, 2017, to November 30, 2018, at an academic voice center among 20 active adult singers without dysphonia but with mild vocal symptoms. Individuals with known or suspected vitamin B12 deficiency or active or recent vitamin B12 treatment were excluded. Analysis was on a per-protocol basis.

Interventions: Participants were randomized to receive an intramuscular (deltoid) injection of either vitamin B12 (1000 μg of cyanocobalmin) or placebo (0.9% sodium chloride). After a washout period of at least 4 weeks, participants were crossed over to receive the opposite injection. Both the investigators and participants were blinded to the order of injections.

Main Outcomes And Measures: The participants completed the Singing Voice Handicap Index-10 (SVHI-10), the Voice Fatigue Index (VFI), and the Evaluation of the Ability to Sing Easily (EASE) before each injection and at intervals of 1 hour, 3 hours, 24 hours, 72 hours, and 1 week after the injection. The primary time point assessment was 72 hours after injection, and the SVHI-10 score was the primary outcome measure.

Results: Twenty singers (10 men; median age, 22 years [range, 19-42 years]) were enrolled. The improvements after either placebo or vitamin B12 injections were comparable to each other. At 72 hours after the vitamin B12 injection, the median difference in the SVHI-10 score was 1 (95% CI, -1 to 2) compared with 3 (95% CI, 0-4) after placebo. The median difference between differences at 72 hours between placebo and vitamin B12 injections were 1.5 (95% CI, -2 to 5) for the SVHI-10, 1 (95% CI, -9 to 9) for the VFI, and -1 (95% CI, -3 to 2) for the EASE. The improvements after both injections failed to reach the estimated minimal clinically important difference. Of the 20 participants, 4 (20%) reached the estimated minimal clinically important difference in their SVHI-10 score after 72 hours for both vitamin B12 and placebo injections.

Conclusions And Relevance: This randomized, double-blind, placebo-controlled, crossover trial found that after empirical vitamin B12 injection to improve mild voice-related symptoms, the improvement in self-reported voice measures in singers shows no meaningful difference compared with placebo.

Trial Registration: ClinicalTrials.gov Identifier: NCT03437824.
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http://dx.doi.org/10.1001/jamaoto.2020.4026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7662483PMC
January 2021

A Novel Approach to Vocal Fold Mucous Retention Cysts: Awake KTP Laser-Assisted Marsupialization.

J Voice 2022 Jul 22;36(4):570-573. Epub 2020 Aug 22.

USC Voice Center, Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California.

Vocal fold mucous retention cysts are an important etiology of dysphonia and have classically been treated via microsurgical excision under general anesthesia. We present four cases that were treated with a novel technique of awake potassium-titanyl-phosphate laser-assisted marsupialization under local anesthesia. Reasons for in-office treatment included older age, medical comorbidities, and desire to avoid surgery/general anesthesia. No recurrences were observed and all patients had improved vocal quality, with a mean reduction in Voice Handicap Index-10 of 12.5. Hence, awake potassium-titanyl-phosphate laser treatment exhibits potential as a modality for addressing vocal fold mucous retention cysts in select patients with favorable outcomes.
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http://dx.doi.org/10.1016/j.jvoice.2020.07.028DOI Listing
July 2022

COVID-19 After Effects: Concerns for Singers.

J Voice 2022 07 6;36(4):586.e7-586.e14. Epub 2020 Aug 6.

Janette Ogg Voice Research Center, Shenandoah Conservatory, Winchester, VA, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jvoice.2020.07.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7409791PMC
July 2022

Development of In-Office Laryngeal Nerve Conduction Studies: Computed Tomography and Cadaveric Study.

Laryngoscope 2021 07 22;131(7):1566-1569. Epub 2020 Aug 22.

Tina and Rick Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California, U.S.A.

Objectives/hypothesis: In-office recurrent laryngeal nerve conduction studies (NCSs) are a technique that can potentially provide information about laryngeal innervation. NCS is essential in the management of other neuropathies including carpal tunnel syndrome and spinal cord injury. We hypothesize that laryngeal NCS may have similar utility in managing patients with vocal fold paralysis, atrophy, and neurodegenerative disease. NCSs are technically challenging because they require transcervical stimulation of the recurrent laryngeal nerve (RLN). This study combines radiographic data with cadaveric dissection to describe the anatomic parameters for optimal RLN stimulation.

Study Design: Radiographic and Cadaveric Study.

Methods: Fifty computed tomography scans were reviewed to determine the dimensions for ideal needle electrode placement. These values were compared to measurements from 12 fresh human cadaveric neck dissections. Ultrasound imaging was utilized in select cases. The neck was dissected to assess the accuracy of electrode placement.

Results: Radiographically, the mean transcervical depth to the RLN was 33.2 mm ± 8.3 mm in males versus 29.4 mm ± 9.4 mm in females. The working space between the lateral trachea and carotid artery was 15.3 mm ± 3.6 mm on the right and 14.1 mm ± 2.9 mm on the left. After placement of stimulating electrodes into the cadaveric neck, the electrode tips were consistently within 8 mm of the RLN. Ultrasound guidance improved placement accuracy of the stimulating electrode.

Conclusions: Laryngeal NCSs can provide detailed and objective information about laryngeal innervation that could dramatically improve the management of various neuropathies. In-office NCSs require technical precision, and this study describes anatomic factors that may affect the feasibility of performing this technique.

Level Of Evidence: NA Laryngoscope, 131:1566-1569, 2021.
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http://dx.doi.org/10.1002/lary.29021DOI Listing
July 2021

The Effect of Unilateral Hearing Protection on Vocal Intensity With Varying Degrees of Background Noise.

J Voice 2021 Nov 30;35(6):886-891. Epub 2020 Apr 30.

Department of Speech and Hearing Science, University of Illinois at Urbana-Champaign, Champaign, Illinois. Electronic address:

Introduction: The Lombard effect (LE) is a phenomenon in which speakers adjust their vocal production by raising the volume in noisy environments. As a result, the LE can create problems of vocal strain, fatigue and potential injury.

Objectives: This study aims to examine the difference in vocal intensity output in subjects wearing unilateral hearing protection versus no hearing protection in the presence of background noise.

Methods: Each subject was seated inside a sound booth wearing a head-mounted microphone. Subjects were asked to read an excerpt from "The Rainbow Passage" while various levels of background noise were played: 50, 60, 70, and 80 dBA (Multitalker Babble). Each noise level was played while the subject was with and without unilateral ear protection (Optime 98 Earmuff [3M]) in random order. The earmuff has a noise reduction rating of 25 dB. After each reading of the text, subjects were asked to rate communication disturbance, vocal clarity, and discomfort during talking using a 10 cm visual analogue scale.

Results: The LE is reduced from 0.38 dB/dB to 0.29 dB/dB with unilateral ear occlusion. However, self-perception of disturbance, clarity and comfort were not affected by unilateral occlusion, only by noise level.

Conclusions: Unilateral hearing protection reduces the LE and may protect against phonotrauma when speaking in an environment with loud background noise.
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http://dx.doi.org/10.1016/j.jvoice.2020.03.019DOI Listing
November 2021

Idiopathic Ulcerative Laryngitis: A National Survey of Academic Laryngologists.

J Voice 2021 Nov 26;35(6):892-900. Epub 2020 Apr 26.

Caruso Department of Otolaryngology - Head and Neck Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California. Electronic address:

Objectives: Idiopathic ulcerative laryngitis (IUL) is a rare disorder characterized by ulceration in the mid-membranous portions of the vocal folds. The etiology and optimal management of this condition are poorly understood. We aimed to survey laryngologists on their experiences with managing IUL in order to better understand the diagnosis and treatment of this unusual condition.

Methods: An online survey was sent to 149 laryngologists practicing at academic institutions in the United States. Survey questions assessed respondents' professional backgrounds and clinical experiences with IUL. Individual responses were tallied and calculated as percentages of total responses.

Results: A total of 96 out of 149 academic laryngologists completed the survey, leading to an overall response rate of 64.4%. All respondents reported that they had encountered IUL in practice, including 56.3% who reported having seen 1-10 cases, 22.9% reporting 11-20 cases, and 20.8% reporting greater than 20 cases over their careers. Dysphonia (99.0%) and cough (84.4%) were the two co-occurring primary presenting symptoms reported. Most base diagnosis on laryngeal videostroboscopy (93.8%). Fungal/bacterial cultures and operative biopsy had been performed by approximately 30% of respondents with occasional candidiasis reported but otherwise negative or nonspecific results. Common therapies used were empiric: antireflux therapy (91.7%), modified voice rest (91.7%), and oral steroids (80.2%). Among survey respondents with experience managing more than 10 cases of IUL, many found complete voice rest (60.0%), oral steroids (55.9%), behavioral cough suppression (46.7%), and modified voice rest (46.3%) to be at least moderately effective treatment options. Resolution of symptoms was most commonly reported to occur over the course of 1-3 months (59.4%) and recurrences were seen not very often or never (85.4%). However, permanent sequelae were common, including vocal fold stiffness (89.6%) and dysphonia (81.3%).

Conclusions: IUL is a rare disorder of unknown etiology. Diagnosis is typically made with laryngeal videostroboscopy and spontaneous resolution occurs over 1-3 months. Laryngologists commonly treat empirically with antireflux therapy, voice rest, antimicrobials, and oral steroids. While no empiric treatment appears to be highly effective for the management of IUL, complete or modified voice rest, oral steroids, and behavioral cough suppression may be the most effective of the currently available options. Further research is necessary to improve the understanding and optimal management of IUL.
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http://dx.doi.org/10.1016/j.jvoice.2020.04.009DOI Listing
November 2021

Pilot Evaluation of Community-Based Vocal Health Screenings.

J Voice 2021 Jul 29;35(4):666.e1-666.e5. Epub 2020 Jan 29.

USC Voice Center, Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, California. Electronic address:

Introduction: Community-based health fairs can help identify at-risk populations, improve health literacy, and facilitate access to medical services. No community-based screenings specifically targeting vocal health were identified in the literature. The purpose of this study is to compare the results of community-based vocal health screenings across two populations: a group of community members with unknown risk of voice problems, and a group of actors belonging to a profession with a known increased risk of voice problems.

Methods: Vocal health screenings were conducted at two free, community-based health fair events in the Los Angeles area. One was open to the public, and one was organized specifically for actors who are members of the Screen Actors Guild-American Federation of Television and Radio Artists. A total of 142 community members (94 nonactors and 48 actors) were administered a questionnaire on current vocal health and voice-related quality of life indices (Vocal Handicap Index-10, Vocal Fatigue Index), followed by review and discussion with a laryngologist or a speech pathologist trained in assessment and treatment of voice disorders.

Results: A significantly higher percentage of actors (55.1%) reported current voice problems than nonactors (33.0%; χ = 7.122, df = 1, P = 0.008). Additionally, as measured by the Vocal Fatigue Index 2 subscale, actors reported a greater amount of perceived pain with phonation than the nonactors. Despite over half of the actors reporting current voice concerns, only 7% reported having sought medical advice regarding these concerns.

Conclusions: The results of this study suggest that vocal health screenings can help identify persons with voice complaints. However, in order to determine if vocal health screenings help close prevalence-presentation gap and are useful to both medical professionals and participants, more research is needed.
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http://dx.doi.org/10.1016/j.jvoice.2019.12.018DOI Listing
July 2021

Flexible versus rigid laryngoscopy: A randomized crossover study comparing patient experience.

Laryngoscope 2020 11 6;130(11):2663-2666. Epub 2020 Jan 6.

Caruso Department of Otolaryngology-Head and Neck Surgery, University of Southern California, Los Angeles, Los Angeles, California, U.S.A.

Objectives: To compare flexible distal-chip laryngoscopy (FDL) versus rigid telescopic laryngoscopy (RTL) in regard to examinees' pain level, comfort, satisfaction, and preference, and to evaluate the clinician's assessment of the examinees' experience with both exam types.

Study Design: Randomized crossover study.

Methods: Twenty-three normal adult subjects were recruited to undergo both FDL and RTL; the initial exam type was randomized. Subjects and clinicians completed corresponding questionnaires after each exam. Differences in participant characteristics and questionnaire scores between the two exam types were assessed via Pearson χ and paired t tests, respectively.

Results: Overall, participants reported that FDL was more uncomfortable than RTL (4.22 vs. 2.91, P = .003) and scored higher on the pain scale for FDL compared to RTL (2.91 vs. 1.70, P = .006). However, there was no significant difference in number of participants who preferred FDL versus RTL (10 [43%] vs. 13 [57%]). Poor correlation was seen between clinicians' assessment of participants' discomfort and actual reported discomfort for FDL (2.70 vs. 4.22, P = .001).

Conclusions: Subjects undergoing FDL experience greater discomfort and pain compared to RTL, but do not demonstrate a differential preference of exam. Overall, clinicians underestimate the discomfort of patients undergoing FDL, but participants maintain high satisfaction with both exams nonetheless.

Level Of Evidence: 1 Laryngoscope, 130:2663-2666, 2020.
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http://dx.doi.org/10.1002/lary.28491DOI Listing
November 2020

Comparative Treatment Outcomes for Patients With Idiopathic Subglottic Stenosis.

JAMA Otolaryngol Head Neck Surg 2020 01;146(1):20-29

Vanderbilt Center for Quantitative Sciences, Vanderbilt-Ingram Cancer Center, Nashville, Tennessee.

Importance: Surgical treatment comparisons in rare diseases are difficult secondary to the geographic distribution of patients. Fortunately, emerging technologies offer promise to reduce these barriers for research.

Objective: To prospectively compare the outcomes of the 3 most common surgical approaches for idiopathic subglottic stenosis (iSGS), a rare airway disease.

Design, Setting, And Participants: In this international, prospective, 3-year multicenter cohort study, 810 patients with untreated, newly diagnosed, or previously treated iSGS were enrolled after undergoing a surgical procedure (endoscopic dilation [ED], endoscopic resection with adjuvant medical therapy [ERMT], or cricotracheal resection [CTR]). Patients were recruited from clinician practices in the North American Airway Collaborative and an online iSGS community on Facebook.

Main Outcomes And Measures: The primary end point was days from initial surgical procedure to recurrent surgical procedure. Secondary end points included quality of life using the Clinical COPD (chronic obstructive pulmonary disease) Questionnaire (CCQ), Voice Handicap Index-10 (VHI-10), Eating Assessment Test-10 (EAT-10), the 12-Item Short-Form Version 2 (SF-12v2), and postoperative complications.

Results: Of 810 patients in this cohort, 798 (98.5%) were female and 787 (97.2%) were white, with a median age of 50 years (interquartile range, 43-58 years). Index surgical procedures were ED (n = 603; 74.4%), ERMT (n = 121; 14.9%), and CTR (n = 86; 10.6%). Overall, 185 patients (22.8%) had a recurrent surgical procedure during the 3-year study, but recurrence differed by modality (CTR, 1 patient [1.2%]; ERMT, 15 [12.4%]; and ED, 169 [28.0%]). Weighted, propensity score-matched, Cox proportional hazards regression models showed ED was inferior to ERMT (hazard ratio [HR], 3.16; 95% CI, 1.8-5.5). Among successfully treated patients without recurrence, those treated with CTR had the best CCQ (0.75 points) and SF-12v2 (54 points) scores and worst VHI-10 score (13 points) 360 days after enrollment as well as the greatest perioperative risk.

Conclusions And Relevance: In this cohort study of 810 patients with iSGS, endoscopic dilation, the most popular surgical approach for iSGS, was associated with a higher recurrence rate compared with other procedures. Cricotracheal resection offered the most durable results but showed the greatest perioperative risk and the worst long-term voice outcomes. Endoscopic resection with medical therapy was associated with better disease control compared with ED and had minimal association with vocal function. These results may be used to inform individual patient treatment decision-making.
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http://dx.doi.org/10.1001/jamaoto.2019.3022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6824232PMC
January 2020

Service supply chains for population health: Overcoming fragmentation of service delivery ecosystems.

Learn Health Syst 2019 Apr 5;3(2):e10186. Epub 2019 Feb 5.

Center for Complex Systems & Enterprises Stevens Institute of Technology Hoboken New Jersey.

Introduction: Population health involves integration of health, education, and social services to keep a defined population healthy, to address health challenges holistically, and to assist with the realities of being mortal. The fragmentation of the US population health delivery system is addressed. The impacts of this fragmentation on the treatment of substance abuse in the United States are considered. Innovations needed to overcome this fragmentation are proposed.

Approach: Treatment capacity issues, including scheduling practices, are discussed. Costs of treatment and lack of treatment are considered. Models of integrated care delivery are reviewed. Potential innovations from systems science, behavioral economics, and social networks are considered. The implications of these innovations are discussed in terms of information technology (IT) systems and governance.

Conclusions: Enormous savings are possible with more integrated treatment. Based on a range of empirical findings, it is argued that investments of these resources in integrated delivery of care have the potential to dramatically improve health outcomes, thereby significantly reducing the costs of population health.
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http://dx.doi.org/10.1002/lrh2.10186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6508805PMC
April 2019

Trends in Diagnostic Flexible Laryngoscopy and Videolaryngostroboscopy Utilization in the US Medicare Population.

JAMA Otolaryngol Head Neck Surg 2019 Aug;145(8):716-722

Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine, University of Southern California, Los Angeles.

Importance: Diagnostic flexible laryngoscopy (DFL) is the second-most reimbursed procedure by Medicare in otolaryngology. However, the economic trends of this procedure on a population level are unknown.

Objective: To describe national- and state-level DFL and videolaryngostroboscopy (VLS) utilization and payment trends from 2000 to 2016 in the Medicare population.

Design, Setting, And Participants: This population-based, cross-sectional study of all Medicare beneficiaries from 2000 through 2016 found that at the national level the total absolute number of DFLs performed in the US Medicare population increased by 87% from 344 183 to 645 172 services, whereas total absolute payments for DFLs made by Medicare concurrently increased by 41% from $38 720 243 to $54 499 071. Rates of DLS and VLS categorized as Current Procedural Terminology (CPT) code 31575 and 31579, respectively. Analysis was carried out between November 18, 2018 and December 18, 2018.

Exposures: Diagnostic flexible laryngoscopy and VLS.

Main Outcomes And Measures: The DFL and VLS utilization rates, payments, and reimbursement rate trends were analyzed by year and state. Utilization was assessed for physician characteristics, including specialty and credentials.

Results: Nationally from 2000 to 2016 in the Medicare population, DFL utilization per Medicare enrollee increased 30% from 0.0087 to 0.0110 and payment per enrollee decreased 2% from $0.98 to $0.96, whereas VLS utilization and payment per enrollee both increased at least 300% during the same time period, with VLS procedure per enrollee and payment per enrollee increasing by 382% from 0.00028 to 0.0013 and 301% from $0.05 to $0.22, respectively. There was a weak correlation between reimbursement and utilization per enrollee for both DFL (r = 0.23; 95% CI, 0.12-0.34) and VLS (r = 0.26; 95% CI, 0.14-0.37) performed from 2012 to 2016. In 2016, the mean (SD) payment per DFL was $85.14 ($7.95), ranging from $65.45 in Puerto Rico to $104.82 in Washington, DC, a 1.6-fold difference. For VLS, there was a 2-fold difference between the lowest-reimbursing state, Maine ($92.20) and the highest, New York ($182.96). All US dollar values were uniformly adjusted for inflation to 2018 dollar values. Most DFLs in 2016 were performed by otolaryngologists (93.6%).

Conclusions And Relevance: The DFL utilization rates remained stable compared with VLS in the Medicare population from 2000 to 2016. There was a decrease in both DFL and VLS payments per procedure in the same time period and also weak correlations between reimbursement and utilization. Practice patterns and reimbursement varied geographically across the United States, though VLS exhibited significantly higher variation than DFL at the state level.
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http://dx.doi.org/10.1001/jamaoto.2019.1190DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6587150PMC
August 2019

The rising rate of nonsmokers among laryngeal carcinoma patients: Are we facing a new disease?

Laryngoscope 2020 03 15;130(3):E108-E115. Epub 2019 May 15.

Department of Otolaryngology-Head and Neck Surgery, Kaplan Medical Center, Rehovot, and the Hebrew University, Jerusalem, Israel.

Objectives/hypothesis: Laryngeal squamous cell carcinoma (SCC) is strongly associated with tobacco smoking. With the rising awareness of tobacco's adverse health effects, we have witnessed a global decrease in tobacco use. Nevertheless, laryngeal SCC remains prevalent and includes a subset of patients lacking the traditional risk factors.

Study Design: A two-center retrospective cohort.

Methods: Medical records of patients diagnosed with laryngeal SCC between 2009 and 2016 were reviewed. Data collected included demographics, smoking status, and tumor site. Patients who have never smoked were designated as nonsmokers.

Results: The study included 330 patients with laryngeal SCC, of whom 75 (22.7%) were nonsmokers; this rate was relatively similar for each of the two institutions independently (21.9% and 25%). There were 285 patients with glottic SCC and 45 with supraglottic SCC. All nonsmoking patients in this cohort had glottic SCC, representing 26.3% (75/285) of the glottic SCC cases. The rate of female patients was significantly higher among nonsmokers. Of the patients with glottic SCC, females represented 25.3% (19/75) of the nonsmokers compared with 12.4% (26/210) of the smokers (P = .008). Mean age at diagnosis was 60.2 ± 17.5 years for nonsmoking glottic SCC patients and 63.6 ± 12.4 years for smokers (P = .280). However, nonsmokers demonstrated a distinct age distribution pattern. Nonsmoking females with glottic SCC demonstrated a bimodal age distribution pattern; 73.7% (14/19) were age <40 years or >75 years at diagnosis.

Conclusions: The rate of laryngeal SCC in nonsmokers is higher than what has previously been reported, representing a growing proportion, and may suggest a shift in etiology. Knowing that laryngeal SCC in nonsmokers predominantly affects the glottis, and that females and age extremities are more vulnerable, the traditional screening paradigm should be revised.

Level Of Evidence: 4 Laryngoscope, 130:E108-E115, 2020.
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http://dx.doi.org/10.1002/lary.28067DOI Listing
March 2020

Guest Editorial.

Authors:
Michael M Johns

Ear Nose Throat J 2018 Dec;97(12):386

USC Caruso Department of Otolaryngology-Head and Neck Surgery University of Southern California Los Angeles.

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http://dx.doi.org/10.1177/014556131809701201DOI Listing
December 2018
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