Unilateral vocal fold paralysis (UVFP) occurs due to neurologic dysfunction that arises anywhere along the course of the vagus or recurrent laryngeal nerve (RLN). Patients most commonly experience dysphonia and varying degrees of dysphagia and dyspnea. The most common causes of UVFP include iatrogenic (i.e. thyroid, cardiac, or esophageal surgery), tumors/masses along the course of the vagus or RLN, and idiopathic. Initial evaluation includes a careful history, voice assessment, and laryngeal examination. Adjunctive tests can include computed tomography scans of the neck/chest and laryngeal electromyography. Depending on the severity of the patient’s symptoms and goals for rehabilitation, treatment options encompass observation, speech therapy, injection augmentation, and surgery. This review will provide valuable insight for both junior and senior Otolaryngology residents as they learn to manage these patients during residency and beyond.

This review contains 13 figures, 5 tables, and 80 references

Keywords: Unilateral vocal fold paralysis, general laryngeal anatomy, injection augmentation, type I thyroplasty, arytenoid adduction, laryngeal reinnervation 

Laryngotracheal stenosis (LTS) can occur secondary to narrowing or collapse of the upper airway. This chapter highlights the etiologies, workup, and management for LTS, specifically looking at subglottic, tracheal, and laryngeal stenosis. There are several etiologies for stenosis including trauma, intubation, tracheotomy tube placement, and autoimmune disease. Careful attention to the underlying causes of LTS guides the appropriate workup and treatment. Advances in in-office endoscopy and procedures have improved the ability to visualize the stenosis, biopsy tissue, and treat the stenosis in the awake patient. For tracheal and subglottic narrowing, open resection and anastomosis is sometimes necessary, and this chapter addresses important technical and post-operative considerations. Finally, this chapter addresses the challenges associated with laryngeal stenosis, with particular attention to the workup and surgical treatments for posterior glottic stenosis (PGS).

This review contains 12 figures, 3 videos, 3 tables, and 36 references

Key Words: laryngeal stenosis, subglottic stenosis, tracheal stenosis, dyspnea, laryngotracheal stenosis, posterior glottic stenosis

Upper aerodigestive tract trauma is rare occurrence, but can have devastating consequences. Immediate complications including airway compromise can be life threatening and complicate resuscitative efforts. Long-term sequelae can significantly affect a patient’s quality of life by limiting one’s ability to breathe, phonate, and/or swallow. This review provides an overview of upper aerodigestive trauma, where many of these injuries occur concomitantly, but this text is divided into three main categories of: laryngeal framework, upper aerodigestive perforation, and adult caustic ingestion. The initial management of these injuries can be reflexive and mundane, but also are frequently nuanced and challenging, where personal experiences in management of these patients results in mastery. 

This review contains 9 figures, 4 tables and 82 references. 

Keywords: Laryngeal trauma, laryngeal facture, esophageal perforation, caustic ingestion

A functional swallow involves the neuromuscular coordination of ingestion and digestion of food.  Dysphagia is the term for abnormal swallowing, a discoordination of respiration, phonation, and digestion. Swallowing disorders can describe a simple abnormal sensation of swallow or a complex disorder leading to aspiration pneumonia. The most common cause of mortality and morbidity in dysphagia patients is aspiration pneumonia. Additional complications include malnutrition and dehydration. The prevalence of oropharyngeal dysphagia is up to 40% in adults over 65 and increases to 60% in institutionalized elderly. Oropharyngeal dysphagia is common after stroke, Parkinson’s disease, and other neurologic disorders. Patients in high-risk groups and patients with signs and symptoms of dysphagia should be diagnosed appropriately to determine underlying cause and aspiration risk. This chapter will focus on dysphagia due to pharyngeal phase disorders and their diagnosis and treatments. 

This review contains 6 figures, 4 videos, 5 tables and 49 references.

Key Words: dysphagia, swallowing, Zenker diverticulum, modified barium swallow, videofluoroscopic swallowing study, FEES, transnasal esophagoscopy, esophagram 

Since the early 1990s, the consequences of extra-esophageal reflux in the larynx have been recognized to be related to a variety of laryngeal symptoms with certain endoscopic manifestations. The paper by Dr. Koufman described various types of laryngeal injury which were attributed to extra-esophageal reflux also known as laryngopharyngeal reflux (LPR). The mechanism of injury was postulated to be a consequence of acid refluxate as well as from pepsin. Since that time there has been a surge of literature devoted to the topic of LPR seeking to refine its diagnosis, elucidate its pathophysiology, and treat its symptoms and sequelae. Our goal in this chapter is to provide a balanced, evidence-based framework for identifying LPR and providing treatment while balancing the benefits versus the risks of overtreatment and escalating therapy.

This review contains 13 figures, 7 tables and 49 references.

Key Words: LPR, GERD, PPI, RSI, TLESR

The larynx is critical to performing complex tasks of airway protection, phonation, respiration, and deglutition. Various focal and systemic neurologic disorders impact the larynx, causing deficits that lead to dysfunction in voice, speech, breathing, and swallowing function. The most common hyperfunctional neurolaryngeal disorders include spasmodic dysphonia (laryngeal dystonia), essential vocal tremor, and muscle tension dysphonia. Some hypofunctional neurolaryngeal disorders include parkinsonian disorders, neuromuscular junction diseases, and myopathies. A multidisciplinary approach involving evaluation by neurologists, voice-trained otolaryngologists and speech-language pathologists is often key to diagnosis and treatment of these challenging and sometimes lifelong disorders. Botulinum toxin injection into the laryngeal musculature is currently the gold-standard treatment for both spasmodic dysphonia and vocal tremor. However, much research is being conducted to advance less invasive and more definitive medical and surgical treatment interventions.

This review contains 3 figures, 11 videos, 5 audio files, 6 tables and 29 references

Keywords: laryngeal neurophysiology, laryngeal dystonia, adductor spasmodic dysphonia, abductor spasmodic dysphonia, essential vocal tremor, hyperfunctional voice disorders, hypofunctional voice disorders, botulinum toxin injection

Total laryngectomy is a common method of disease treatment and control for advanced larynx cancers. Salvage laryngectomy may also be utilized in setting of failed laryngeal preservation attempts, or in the setting of non-functional larynx. The significant changes in anatomy and function following total laryngectomy can cause apprehension from patients, specifically as it pertains to speaking and communication. The ability to speak and communicate effectively with others is a significant part of a patient’s quality of life. The understanding that a patient will no longer have the ability to speak post-operatively can cause distress and concern for both patients and their families. Since the first laryngectomy was performed, efforts have been made through development of voice rehabilitation techniques to improve a patient’s quality of life following surgery. The primary methods for communication following laryngectomy include external and internal sound sources. Proper selection and implementation of these communication devices can facilitate the return to usual activities of daily living following total laryngectomy.

This review contains 23 figures, 4 tables and 21 references.

Key Words: total laryngectomy, voice prosthesis, tracheoesophageal puncture, stoma, electrolarynx, communication, alaryngeal speech

According to the 2013 American Society of Anesthesiology Practice Guidelines for Management of the Difficult Airway, a term “difficult airway” refers to clinical situations in which a likelihood of 1) difficulty with patient cooperation or consent, 2) difficult mask ventilation, 3) difficult supraglottic airway placement, 4) difficult laryngoscopy, 5) difficult intubation, and/or 6) difficult surgical airway is high. Several considerations are important when approaching each individual clinical scenario. An airway management plan should include patient-specific and situation-specific factors that take into account findings of bedside airway evaluation, prior history of intubations, the acuity of the situation requiring intubation, and the level of airway obstruction. The following module provides an overview of these factors along with a brief introduction to specific clinical situations in which some airway management strategies are more suitable.^1,2

This review contains 10 figures, 7 tables and 32 references

Key words: Difficult airway, intubation, LEMON score, High-Flow Nasal Cannula Oxygenation, THRIVE

Presbylarynx refers to age-related structural changes of the vocal folds that include muscle atrophy, reduced neuromuscular control, loss of superficial lamina propria layer, and reduced pliability. The changes result in thin and bowed vocal folds, increased vocal effort requirements, breathy voice, change in habitual pitch, and strain. The primary treatment options are voice therapy focused on strengthening breath support and the intrinsic muscles of the larynx, and optimization of resonance; injection augmentation of the vocal folds; and type I thyroplasty. Functional dysphonia is defined as change in voice quality in the absence of structural or neurological abnormalities of the larynx. Muscle tension dysphonia (MTD) is a subtype of functional voice disorders and involves laryngeal muscle tension imbalance due to excessive or dysregulated activation resulting often in strained or breathy voice. MTD can be divided into primary (psychological etiology or vocal misuse) and secondary (compensatory for organic laryngeal pathology). The mainstay of treatment for MTD is voice therapy, along with medical or surgical treatment of the underlying vocal pathology in secondary MTD. Mutational falsetto, or puberphonia, is a functional voice disorder where a high-pitched, pre-adolescent voice fails to transition to the lower pitch of adulthood.

This review contains 5 figures, 7 tables, 4 videos and 10 references

Key Words: Presbylarynx, Injection augmentation, Type I thyroplasty, Primary muscle tension dysphonia, Secondary muscle tension dysphonia, Muscle tension patterns, Manual circumlaryngeal therapy, Functional dysphonia, Mutational falsetto  

Benign laryngeal lesions represent a diverse set of pathologies whose clinical presentation may range from no symptoms to dyspnea and/or dysphonia. Flexible fiberoptic laryngoscopy and videolaryngostroboscopy are important in distinguishing
different types of lesions, and management and treatment are dependent on the identification of these lesions, as they have different etiologies. Some lesions such as vocal fold nodules and polyps are primarily phonotraumatic and may benefit from
speech therapy and vocal hygiene as initial approaches. Vocal fold cysts and benign tumors may benefit from microlaryngeal approaches, while capillary ectasias, polypoid corditis, laryngoceles, saccular cysts, and papilloma may benefit from laser therapy. Vocal fold granulomas may arise from various etiologies such as intubation, traumatic behaviors, or reflux. Polypoid corditis arises from smoking. This review is intended to provide an overview of the variety of lesions that encompass non-malignant laryngeal lesions that is both suitable for junior and senior residents.

This review contains 12 figures, 5 tables, and 64 references

Keywords: Benign laryngeal lesions, Laryngocele, Polyp, Cyst, Polypoid Corditis, Papilloma

Esophageal disorders are an underrecognized class of pathology that can often contribute to issues faced by otolaryngologists. Complaints stemming from these conditions range from globus sensation, cough and throat clearing to odynophagia, dysphonia and dysphagia. An understanding of esophageal physiology, anatomy and pathophysiology is essential for management of patients’ symptoms.  A wise clinician must use the tools of esophageal fluoroscopy, manometry, pH testing and esophagoscopy to evaluate a patient’s concerns while minimizing unnecessary testing. While common findings such as gastroesophageal reflux disease, candidiasis and esophageal strictures often contribute to patients’ symptoms, clinicians must be knowledgeable about less common diagnoses such as eosinophilic esophagitis, esophageal dysmotility, and medication induced esophagitis as potential causes. While flexible fiberoptic laryngoscopy is a common component of ENT training, transnasal esophagoscopy is a vital skill that can be done in clinic and can be a powerful diagnostic and therapeutic tool for addressing esophageal disorders.

This review contains 5 figures, 6 tables and 56 references

Keywords: Dysphagia, Esophagus, Reflux, Esophagram, Esophageal manometry, Esophageal Stricture, Esophageal Dysmotility