Objectives/Hypothesis Vocal fold (VF) injury and chronic inflammation can progress to scarring, which is notoriously difficult to treat. Human amniotic fluid (AF) has potential for VF wound healing in a rabbit model, and we hypothesized that AF would demonstrate wound healing properties superior to hyaluronic acid (HA) over time. Study Design Randomized, controlled trial. Methods In this pilot study, 60 New Zealand white rabbits (10 rabbits in each of six groups) received unilateral VF biopsy and immediate injection treatment of AF, HA, or saline (SA). The contralateral VF served as an uninjured control. Rabbits were sacrificed and VFs removed at 4 or 10 weeks postinjury. Rheology and reverse transcription quantitative real-time polymerase chain reaction (RT-qPCR) were employed to assess viscoelastic properties and inflammation, respectively. Results Rheology differences were seen between four and 10 weeks postinjury in treatment groups but not in controls. Values for the AF treatment group differed from the SA and HA groups at week 10 (elastic P = 0.0002, viscous P < 0.0001). RT-qPCR: AF and HA had higher levels of inflammatory cytokines than SA at week 4 [TNFα: SA4 < HA4 (P = 0.0086), SA4 < AF4 (P = 0.0112)]. Presumptive inflammation was still present at 10 weeks in all treatment groups [IL-1β: AF control < AF (P = 0.0002), SA control < SA (P = 0.0212); IL-6: HA control < HA (P = 0.0312)]. AF demonstrated reduced inflammation at 10 weeks compared with SA [IL-6: SA > AF (P = 0.0141)]. AF was the only treatment group that had significant reductions in inflammation at 10 versus 4 weeks [IL-1β: AF4 > AF10 (P = 0.0249)]. Conclusions The main finding from this pilot study was that AF demonstrated wound healing effects over time compared with HA and SA by reducing inflammation and improving VF viscoelastic properties. Continued research to further investigate the use of AF in VF wound healing over longer periods of time is necessary before translation to human VFs.

Introduction. Vocal fold nodules (VNs) in children are benign, bilateral, callous-like lesions at the junction of the anterior third and posterior two-thirds of the true vocal folds. Chronic, repetitive, and intense vocal behavior is often cited as the primary etiology; however, difficulties with emotional adjustment may predispose some children towards extreme and possibly phonotraumatic vocal activity, thereby contributing secondarily to the development of VNs. Objectives. This case-control study examined the association between features of emotional adjustment and VNs in children. Methods. Parents of children with VNs (N = 40, Mage = 7.5, SDage = 2.03) and two medical control groups [ie, voice disordered, but not VNs (VDCs; N = 40, Mage= 7.09, SDage = 2.01) and vocally normal controls (VNCs; N = 40, Mage = 7.6, SDage = 1.54)] participated in the study. Features of emotional adjustment were assessed using two inventories: the Parent Rating scale for Reactive and Proactive Aggression and the Revised Child Anxiety and Depression Scale - Parent version. Results. As compared with the VNCs, children with VNs were significantly more aggressive (P = 0.042, Cohen's d = 0.47) whereas the VDCs were more depressed (P = 0.013, Cohen's d = 0.60). Furthermore, VDCs experienced more separation anxiety than VNs (P = 0.038, Cohen's d = 0.45) and VNCs (P = 0.021, Cohen's d = 0.55). No other significant between-group differences were identified between the VNs and VDCs. Conclusions. When present, elevated aggression may represent a risk factor for VNs formation in children, and possibly influence treatment outcomes. Therefore, the current results highlight the importance of understanding the role of emotional in the evaluation and treatment of in children.

Purpose: This pilot study systematically compared voice symptomatology across varied sensory trick conditions in those with laryngeal dystonia (LD), those with essential vocal tremor (EVT), and vocally normal controls (NCs). Sensory tricks are considered signature characteristics of dystonia and were hypothesized to reduce voice symptoms in those with LD compared to EVT and NC groups. Method: Five participants from each group (LD, EVT, and NC) completed speech recordings under control and sensory trick conditions (delayed auditory feedback [DAF], vibrotactile stimulation [VTS], and nasoendoscopic recordings with and without topical anesthesia). Comparisons between groups and conditions were made using (a) a paired-comparison paradigm (control vs. sensory condition) listener ratings of voice quality, (b) participant-perceived vocal effort ratings, and (c) average smoothed cepstral peak prominence (CPPS). Results: Participants with EVT displayed significantly worse listener ratings under most sensory trick conditions, whereas participants with LD were rated significantly worse for DAF and VTS conditions only. However, participant vocal effort ratings were similar across all sensory trick conditions. Average CPPS values generally supported listener ratings across conditions and speakers except during DAF, wherein CPPS values increased (i.e., measurably improved voice quality), whereas listener ratings indicated worsened voice quality for both voice disorder groups. Conclusions: Outcomes of this study did not support the hypothesized influences of sensory trick conditions on LD voice symptoms, with both LD and EVT groups experiencing worsened symptoms under VTS and DAF conditions. These adverse effects on voice symptoms warrant further research to further evaluate neural pathways and associated sensorimotor response patterns that distinguish individuals with LD and EVT. Supplemental Material: https://doi.org/10.23641/asha.28462292

OBJECTIVES:Idiopathic subglottic stenosis (iSGS) is a rare disease in which patients develop dyspnea from recurrent tracheal granulation scar. We present our long-term outcomes after crico-tracheal resection (CTR) for iSGS at a high-volume tertiary care center. We update our previous report in 2018 with seven additional years of follow-up. METHODS:A review was conducted with iSGS patients who underwent CTR between 1999 and 2017. Diagnosis of iSGS was based on history and bronchoscopy exam. Recurrence of iSGS was evaluated using survivability and the Kaplan-Meier curve. Management of recurrence post-CTR was investigated with Pearson correlation analysis. RESULTS:Sixty-one patients with iSGS underwent CTR. Our population was 98% female. Twenty (33%) patients developed recurrence after CTR. The mean time to recurrence was 13.8 years (range = 0.8-16.3). Seven (11%) patients had not recurred up to 21.9 years post-CTR. There was a negative correlation (-0.45, p = 0.046) between age at recurrence and number of procedures per year to treat recurrent stenosis. Six (10%) patients were deceased from unrelated causes at follow-up and on average 6 years post-CTR (range = 0.8-15.8). One patient recurred prior to her death. CONCLUSION:Our 2018 report included a mean recurrence time of 12.5 years (range = 0.8-14.3). This follow-up showed an even longer time to recurrence (average = 13.8 years). CTR is associated with a low recurrence rate of stenosis. Older patients may be better candidates for CTR than younger patients. Further research should investigate risk factors that predispose patients to recurrence after CTR. LEVEL OF EVIDENCE: 4:

Objectives Nonselective laryngeal reinnervation is an effective procedure to improve voice quality after unilateral vocal fold paralysis. Few studies have captured long‐term outcome data, and the revision rate for this operation is currently unknown. The objective of this study is to describe the long‐term outcomes and revision rates of unilateral, nonselective reinnervation in pediatric and adult patients. Methods Patients who underwent laryngeal reinnervation from 2000 to 2022 with a single surgeon were identified for inclusion. Patients who underwent bilateral, super selective, deinnervation and reinnervation, and/or concurrent arytenoid adduction procedures were excluded. Outcome measures included maximum phonation time [MPT], voice handicap index score [VHI], patient‐reported percent normal voice, revision procedures, and complications. Data were compiled and analyzed using paired t‐tests, repeated measures analysis of covariance, and binary logistic regression analysis. Results One hundred thirty‐two patients underwent unilateral, nonselective ansa‐recurrent laryngeal nerve [RLN] laryngeal reinnervation. Reinnervation significantly improved MPT and patient‐reported percentage of normal voice and significantly decreased VHI. Eleven patients underwent revision procedures, corresponding to a revision rate of 8.3%. Additional procedures included medialization laryngoplasty [ n = 3], medialization laryngoplasty with arytenoid adduction [ n = 3] and injection augmentation greater than 1 year after reinnervation [ n = 5]. The only factor associated with the need for additional surgery was time lapse from nerve injury to reinnervation. The overall complication rate was 6.8%; no patient required reintubation or tracheostomy. Conclusion Unilateral, nonselective laryngeal reinnervation can provide reliable improvement in vocal symptoms after recurrent laryngeal nerve injury. The revision rate after laryngeal reinnervation is favorable and comparable to framework surgery. Level of Evidence 4 Laryngoscope , 134:3187–3192, 2024

INTRODUCTION:Semi-occluded vocal tract exercises (SOVTEs) are widely used as a therapeutic tool to create flow resistance in the upper airway. The current study was a randomized controlled clinical trial to establish the efficacy of two SOVTE protocols, flow-resistant tube (FRT) and Lessac-Madsen Resonant Voice Therapy (LMRVT). Exploratory investigations included a noninferiority analysis of FRT to the widely adopted therapy protocol (LMRVT), as well as examining the dosing required to improve acoustic measures and subjective ratings. METHOD:Sixty-seven participants with voice disorder were randomized into one of five groups: 4-week FRT (n = 14), 8-week FRT (n = 19), 4-week LMRVT (n = 15), 8-week LMRVT (n = 5), and control (n = 14). Voice Handicap Index (VHI) and Vocal Fatigue Index scores were collected pre- and posttreatment. Acoustic analysis using the Acoustic Voice Quality Index was completed. We compared VHI between controls and 8-week FRT and LMRVT, adjusting for pre-VHI using linear regression. We examined the efficacy of 4-week protocols relative to controls and conducted a noninferiority comparison of FRT (4 and 8 weeks) to LMRVT (4 and 8 weeks) using 5- and 10-point margins. Finally, we compared the 4- versus 8-week sessions for both therapies. RESULTS:A statistically significant reduction of VHI in both 8-week FRT relative to controls (-10.60, 95% CI [-19.80, -1.40], p = .025) and 8-week LMRVT (-15.74, 95% CI [-29.40, -2.08], p = .025) was found. We also found an improvement in 4-week FRT relative to controls (-10.11, 95% CI [-20.03, -0.20], p = .046), but the 4-week LMRVT result was not statistically significant (p = .057). FRT was found to be noninferior to LMRVT in terms of VHI using a 10-point margin (FRT - LMRVT: 0.69, 95% CI [-5.76, 7.15], p = .01), but not using a 5-point margin (p = .054). There were no statistically significant differences in VHI scores between 4- and 8-week sessions for either therapy. CONCLUSIONS:Both FRT and LMRVT improved VHI scores relative to controls. FRT was noninferior to LMRVT in terms of VHI scores. There were no statistically significant differences in VHI scores between 4- and 8-week therapy sessions.

BackgroundNeonatal unilateral vocal fold paralysis may arise iatrogenically, idiopathically, or in the context of an underlying neurologic disorder. Management is often supportive, focusing on diet modification to allow for safe oral feeding. We describe the clinical course of six infants with unilateral vocal fold paralysis who developed predominantly unilateral laryngomalacia ipsilateral to the affected vocal fold with associated severe respiratory symptoms and feeding difficulty.MethodsRetrospective review of six infants with unilateral vocal fold paralysis and predominantly unilateral laryngomalacia. Charts were reviewed for etiology of vocal fold paralysis, presenting symptoms, operative details, postoperative course, and outcomes for breathing and swallowing.ResultsEtiology of vocal fold paralysis included cardiac surgery in four patients, intubation-related in one, and idiopathic in one. Presenting symptoms included increased work of breathing, stridor, feeding difficulty, respiratory failure requiring noninvasive respiratory support, and weak cry. All infants were on nasogastric tube feedings. Direct microlaryngoscopy with unilateral or predominantly unilateral (conservative contralateral aryepiglottic fold division) supraglottoplasty was performed. Stridor and work of breathing improved in all six patients within 1 week postoperatively. Oral feeding improved in three patients within 2 weeks. Three patients had persistent feeding impairment with improvement within one year.ConclusionsPredominantly unilateral laryngomalacia may arise in the context of unilateral vocal fold paralysis. Addressing the ipsilateral cuneiform collapse can improve breathing and feeding. This may be an under-described phenomenon and represents an additional reason to include the otolaryngologist early in the care of infants with suspected possible new unilateral vocal fold paralysis. Breathing and swallow can improve post-operatively, but feeding may remain limited by the vocal fold paralysis and any medical comorbidities. Ongoing follow-up and collaboration with speech-language pathology to optimize feeding are important.

Objective:Granulomatosis with polyangiitis (GPA) is a potentially fatal condition which often manifests in the head and neck. Currently, diagnosis relies on antineutrophil cytoplasmic autoantibody (c-ANCA) serology and mucosal or renal biopsy. However, a significant proportion of patients with GPA limited to the head and neck are seronegative and biopsy negative. This study evaluates the role of clinical diagnosis of GPA in the absence of positive laboratory findings.Study Design:Case series with chart review.Setting:Academic Tertiary Medical Center.Methods:This was a retrospective review of 143 patients treated in an outpatient otolaryngology clinic at a tertiary care hospital for known or suspected GPA from 1998 to 2021. Presenting symptoms, C-ANCA status at initial presentation, biopsy results, long-term serology results, and time to initiation of treatment were analyzed.Results:Twenty-six of 143 (18.2%) patients were seronegative; only 3 of these patients (12%) had positive biopsies. Seventeen (73.9%) of these patients presented with nasal and sinus disease and 12 (52.2%) presented with airway involvement. Only 4 (17.4%) patients had renal involvement. Delay in treatment of patients with negative laboratory workup ranged from 0 months to 11 years. All patients who were seronegative and/or biopsy negative at presentation responded clinically to immunosuppressive therapy.Conclusion:GPA cases are often limited to the upper respiratory tract, making diagnosis difficult, particularly in seronegative patients. These results suggest that, when GPA is suspected, despite negative serology, the diagnosis of GPA should be made on clinical grounds, and empiric therapy encouraged to prevent delay in treatment.

Vocal tics can occur in neuropsychiatric disorders and result in familial distress. Management is challenging, particularly in children with developmental delay. A 5-year-old with cerebral dysgenesis presented with a high amplitude, high-frequency vocal tic. Type II thyroplasty with bilateral cricothyroid muscle myectomy was performed after initial botulinum toxin trial. Amount, volume, and pitch of tics significantly decreased, without change in swallow. Benefits persisted at 1-year follow-up. This is the first description of combined type II thyroplasty with cricothyroid myectomy for high-frequency vocal tic. This can be done safely and provide sustained benefit for a rare, impactful voice disorder.

OBJECTIVE Determine the ideal head position to optimize visualization of the subglottis using flexible laryngoscopy. STUDY DESIGN Prospective cohort study. SETTING Outpatient multidisciplinary airway clinic at a tertiary care center. METHODS Patients presenting to a multidisciplinary airway clinic undergoing nasoendoscopic airway examination were enrolled. Three head positions were utilized to examine the subglottis during laryngoscopy: "sniffing," chin tuck, and stooping positions. In-office reviewers and blinded clinician participants evaluated views of the airway based on Cormack-Lehane (CL) scale, airway grade (AG), and visual analog scale (VAS). Demographic data were obtained. Statistical analysis compared head positions and demographic data using Student's t test, analysis of variance, and Tukey's post hoc analysis. RESULTS One hundred patients participated. No statistical differences existed among in-clinic or blinded reviewers for the CL score in any head position (p = .35, .5, respectively). For both AG and VAS, flexed and stooping positions were rated higher than the sniffing positions by both in-clinic and blinded reviewers (p < .01 for all analyses), but there was no statistical difference between these two positions (p = .28, .18, respectively). There was an inverse correlation between age and scores for AG and VAS in the flexed position for both sets of reviewers (p = .02, <.01 respectively), and a higher body mass index was significantly associated with the need to perform tracheoscopy for full airway evaluation (p < .01). CONCLUSION Both flexion and stoop postures can be implemented by an experienced endoscopist in awake, transnasal flexible laryngoscopy to enhance visualization of the subglottic airway.

The North American Airway Collaborative (NoAAC) previously published a 3-year multi-institutional prospective cohort study showing variation in treatment effectiveness between 3 primary surgical techniques for idiopathic subglottic stenosis (iSGS). In this report, we update these findings to include 5 years of data evaluating treatment effectiveness. Patients in the NoAAC cohort were re-enrolled for 2 additional years and followed using the prespecified published protocol. Consistent with prior data, prospective observation of 487 iSGS patients for 5 years showed treatment effectiveness differed by modality. Cricotracheal resection maintained the lowest rate of recurrent operation (5%), followed by endoscopic resection with adjuvant medical therapy (30%) and endoscopic dilation (50%). These data support the initial observations and continue to provide value to providers and patients navigating longitudinal decision-making. Level of evidence: 2-prospective cohort study.

ObjectiveTo explore patient‐reported outcome measures of pediatric paradoxical vocal fold motion through a multi‐institutional study of geographically diverse United States medical facilities to assess long‐term management and outcomes.MethodsEligible participants >8 years of age diagnosed with PVFM over a 10‐year period from 7 tertiary pediatric hospitals were invited to complete a survey addressing study objectives.Results65 participants completed the survey, of whom 80% were female, 75% reported a 3.5 grade point average or better, and 75% identified as competitive athletes or extremely athletic individuals. Participants rated their perceived efficacy of 13 specific treatments. Only five treatments were considered effective by a majority of the participants who tried them. The treatments that participants tried most often were breathing exercises (89.2%), bronchodilator treatments (45%), and allergy medications (35.4%). 78.8% of participants reported receiving more than one treatment and 25% reported receiving a combination of bronchodilators, anticholinergics, and steroids. At the time of PVFM diagnosis, 38% of participants had no idea when their symptoms would completely resolve. 23.3% of participants did not experience symptom resolution until greater than 1 year after diagnosis.ConclusionsTraditional management tools such as breathing exercises and biofeedback treatments may not provide the long‐term benefit that providers anticipate. In addition to these commonly used management strategies, highly efficacious techniques such as counseling and lifestyle management should be incorporated into the long‐term management of patients whose symptoms are refractory to traditional care.Level of Evidence4 Laryngoscope, 133:970–976, 2023

Objective: Retrograde cricopharyngeal dysfunction was recently described by Bastian in 2019 and is characterized by an inability to belch, abdominal or chest pressure, odd gurgling noises, and occasional difficulty vomiting. Symptoms tend to worsen with carbonated beverages. Currently, the recommended treatment is cricopharyngeus muscle botulinum toxin injections. Prior studies have included few pediatric patients within larger datasets comprised primarily of adults. We describe our preliminary experience in pediatric patients, including presenting symptoms, treatment approach, and post-treatment outcomes. Methods: Retrospective chart review of pediatric patients (aged <18 years) diagnosed with retrograde cricopharyngeal dysfunction based on clinical history by the senior author. Medical records were reviewed for presenting symptoms, prior testing and treatment, details of treatment, and postoperative outcomes. Results: Five patients with average age of 14 +/- 4 (3 females, 2 males) were included. Presenting symptoms included lifelong or nearly lifelong inability to burp (n = 5), bloating (n = 5), awkward gurgling noises (n = 3), and worsening of symptoms with carbonated beverages (n = 5). Two patients had prior normal upper endoscopy. All patients underwent cricopharyngeal botulinum toxin injection under general anesthesia, with 25-50 units of botulinum toxin injected to the posterior cricopharyngeus across 4-5 locations. All patients had resolution of symptoms with follow-up of 1.5-10 months. Conclusions: Retrograde cricopharyngeal dysfunction may be underdiagnosed due to lack of awareness of the condition. Now that the phenomenon of inability to belch has a name and is being reported in the literature, we will likely see more adult and pediatric patients with these symptoms. Pediatric patients may respond similarly to adults. Larger studies with longer-term follow-up and targeted patient-reported outcome measures are needed to characterize disease presentation and treatment outcomes.

OBJECTIVE:To compare outcomes using an open surgical incision and drainage (S-ID) versus an aspiration under interventional radiology drainage (A-ID) of pediatric neck abscesses. The primary outcome measure was successful drainage requiring one intervention, and the secondary outcome measures were readmission rates and overall cost to the healthcare system. METHODS:Retrospective data collection of all pediatric patients treated at the Primary Children's Hospital for neck abscess from 2008 to 2020. Patients who did not require drainage were not included. Comparison between S-ID and A-ID was performed according to the primary and secondary outcomes. RESULTS:Two hundred fifty nine patients were included in the study. Twenty-six patients had A-IR and 234 patients had S-ID. Patient demographics were not significantly different between both groups. Overall length of stay was greater in the A-ID group (5 vs 3.3 days) (p < 0.05). A second procedure was more frequent in the A-ID group with 11/26 (42%) versus 12/234(5%) in the S-ID group (P = 0.001) even after controlling for multiple possible confounding factors. The rate of readmission was also higher in the A-ID group with 3/26 (11%) versus 7/234 (3%) in the S-ID group (P = 0.006). Both groups showed similar overall cost (P = 0.621). CONCLUSIONS:A-ID and S-ID are both methods to treat head and neck abscess requiring drainage. However, overall results indicate a higher rate of failure requiring a second intervention and a higher rate of readmission in the A-ID group. In our study cost was noted to be similar between both methods.

In patients undergoing patent ductus arteriosus (PDA) ligation there is a significant risk of left vocal fold paralysis (LVFP) particularly in premature neonates who are small for gestational age. The objective of this study is to determine the incidence of LVFP in infants following PDA ligation and report on long‐term outcomes in patients with LVFP.

Introduction: : Vocal fold nodules (VNs) represent the most common cause of voice disorders in children. Phonotrauma related to chronic, repetitive, intense vocal activity is often cited as the proximate cause of VNs. However, diminished self-regulation (SR) may predispose some children toward extreme phonotraumatic voice use, thereby contributing secondarily to their development. This case-control study examined the association between features of SR and VNs in children. Method: : Parents of children with VNs (N = 40, Age Mean = 7.5, SD = 2.03 years) and vocally normal, medical controls (VNCs; N = 40, Age Mean = 7.6, SD = 1.54 years) completed the Behavior Rating Inventory of Executive Function, Second Edition (BRIEF2; Gioia, Isquith, Guy & Kenworthy, 2015), an inventory that evaluates components of SR in children. Results: : Children with VNs, as compared with the vocally normal control group, were described as (i) impulsive (i.e., scoring significantly worse on the Behavior Regulation Index, BRI; P < 0.001, Cohen's d = 0.86), and (ii) emotionally dysregulated (i.e., scoring significantly worse on the Emotional Regulation Index, ERI; P < 0.001, Cohen's d = 0.81). Conclusions: : Diminished SR in some children with VNs may contribute to phonotraumatic vocal behaviors and potentially attenuate the effectiveness of voice therapy.

Objective: To evaluate a case series of patients who received medically necessary botulinum toxin during pregnancy. Materials and Methods: Retrospective chart review of three patients who underwent repeated intralaryngeal injections of botulinum toxin during pregnancy. Chart reviews were also conducted on the children to further evaluate the safety. Results: No evidence of harm to the mothers or fetuses were found in our series, including data from pregnancy and birth records using standard measures of gestation, APGAR scores, neonatal intensive care unit stay, and time until discharge. Clinical data for 3–5 years were available for the children. No evidence of muscular weakness was noted and all diagnoses were listed. Conclusion: Botulinum toxin injection for functional airway issues was not associated with any adverse effects to the mother or fetus during pregnancy in any of the cases reviewed. We recommend further investigation to evaluate the current contraindication of elective botulinum toxin use in pregnancy.

Objectives: (1) To determine how pregnancy affects idiopathic subglottic stenosis (iSGS) symptoms. (2) To determine treatments utilized (including operating room (OR) and in-office procedures) for iSGS before, during, and after pregnancy. Methods: A 24-question survey was distributed to an international iSGS support group to assess the patient experience among individuals who have been pregnant with diagnosis of iSGS. Descriptive statistics and chi(2)analyses were completed. Results: A total of 413 iSGS patients participated; 84.7% (n = 350) of patients were diagnosedpriorto menopause. A total of 25.5% patients reported being pregnant when they had airway stenosis; 71.1% of those reported more severe airway symptoms during pregnancy. The proportion of patients that reported requiring >= 1 OR interventions (microlaryngoscopy and bronchoscopy, laser, balloon dilation, or steroid injection) before, during and after pregnancy was the following, respectively: 37.3%, 35.6%, 51.3%. Whereas the proportion of patients that reported requiring >= 1 in-office interventions (awake balloon dilation or steroid injection) before, during and after pregnancy was the following, respectively: 13.6%, 11.8%, 15.8%. Number of pregnancies and age of diagnosis was not related to severity of symptoms or requiring more airway interventions (P > .05). Conclusions: This survey reveals worsening of symptoms during pregnancy, however, this did not lead to increase in operative or clinic interventions to improve airway symptoms during pregnancy. Future avenues for research include optimizing management of airway symptoms during pregnancy to limit OR-based interventions.

Objective:To evaluate a case series of patients who received medically necessary botulinum toxin during pregnancy. Materials and Methods:Retrospective chart review of three patients who underwent repeated intralaryngeal injections of botulinum toxin during pregnancy. Chart reviews were also conducted on the children to further evaluate the safety. Results:No evidence of harm to the mothers or fetuses were found in our series, including data from pregnancy and birth records using standard measures of gestation, APGAR scores, neonatal intensive care unit stay, and time until discharge. Clinical data for 3-5 years were available for the children. No evidence of muscular weakness was noted and all diagnoses were listed. Conclusion:Botulinum toxin injection for functional airway issues was not associated with any adverse effects to the mother or fetus during pregnancy in any of the cases reviewed. We recommend further investigation to evaluate the current contraindication of elective botulinum toxin use in pregnancy.

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.