Publications

Elizabeth DiRenzo, PhD
Assistant Professor of Otolaryngology — Head & Neck Surgery and, by courtesy, of Music

Publications

  • Impact of Electronic Cigarettes on the Upper Aerodigestive Tract: A Comprehensive Review for Otolaryngology Providers OTO OPEN Soo, J., Easwaran, M., Erickson-DiRenzo, E. 2023; 7 (1)

    View details for DOI 10.1002/oto2.25

    View details for Web of Science ID 000937521100001

  • Diagnosis and Management of Vocal Complications after Chondrolaryngoplasty. The Laryngoscope Nuyen, B., Qian, Z. J., Rakkar, M., Thomas, J. P., Erickson-DiRenzo, E., Sung, C. K. 2022

    Abstract

    OBJECTIVE: Transfeminine patients (transwomen/feminine nonbinary folks assigned male at birth) can undergo chondrolaryngoplasty ("tracheal shave") to feminize their neck appearance. While isolated cases of vocal complications have been reported following the procedure, aggregated outcomes have not been quantitatively studied. We present acoustic and stroboscopic data to describe a patient cohort with vocal complications after chondrolaryngoplasty and discuss reparative surgical technique.METHODS: Subjective and objective data, including videostroboscopy, were collected from patients with voice complaints after chondrolaryngoplasty. Dislocated anterior commissures were reconstructed with feminization laryngoplasty. Postoperative voice data were recorded and statistically compared to preoperative data using paired t-tests.RESULTS: On consecutive chart review, of the 94 transfeminine women with prior outside history of chondrolaryngoplasty, 27 (29%) reported chronic postoperative hoarseness, deepened pitch, or loss of upper register. On endoscopy, short, lax vocal folds with persistent anterior glottic gap and phase asymmetry were commonly noted; anterior commissure dislocation was confirmed in-office by using needle localization through absent thyroid cartilage. After open resuspension of the anterior commissure with feminization laryngoplasty, post-repair modal-speaking, minimum, and maximum fundamental frequencies (F0) increased on average by 7, 8, and 5 semitones, respectively (p<0.01), when compared to pre-repair values. On average, perioperative maximum phonation time did not change significantly (p=0.15). Average self-assessment of vocal femininity increased by 48% (p<0.01).CONCLUSION: Anterior commissure dislocation should be suspected with signs of vocal impairment after chondrolaryngoplasty. Following proper diagnosis, resuspension of the anterior commissure via feminization laryngoplasty approach can be an effective reparative technique.LEVEL OF EVIDENCE: This work represents a 2011 OCEBM Level 4 evidence as a case series Laryngoscope, 2022.

    View details for DOI 10.1002/lary.30518

    View details for PubMedID 36576093

  • Social Perception of External Laryngeal Anatomy Related to Gender Expression in a Web-based Survey. The Laryngoscope Kiessling, P., Balakrishnan, K., Fauer, A., Sanan, A., McDonald, D., Thomas, J., Erickson-Direnzo, E., Sung, C. K., Nuyen, B. 2022

    Abstract

    To quantify the effect of laryngeal prominence size on socially perceived attributes relating to gender expression. Chondrolaryngoplasty ("tracheal shave") is a common procedure performed for transgender women to feminize neck appearance. The extent of thyroid cartilage resection needed to convey socially-perceived feminine gender expression without destabilizing the voice is incompletely understood.Cross-sectional evaluation of a randomized allocation of images of varying laryngeal prominence to a non-repeated, random sample from November 2021 to December 2021. Photos of laryngeal prominence were isolated against a constant neck baseline with lateral, oblique, and frontal views. The images were embedded into a web-based survey with visual analog scales to capture perceived scaled gender expression (masculinity, femininity) and social traits (e.g., attractiveness, friendliness, leadership). We performed bivariate and multivariate analyses relating the laryngeal prominence to perceived gender expression and social traits.The analytic sample included 1,026 respondents. Laryngeal grades similar to the demonstrated "grade M" in this study and smaller demonstrated similar perceptions of increased femininity and decreased masculinity. Grades larger than M demonstrate significantly increased perceived masculinity and significantly decreased perceived femininity. The lateral and oblique views of the neck appear to be the most gender-informative.This crowd-sourced analysis of external laryngeal anatomy by a large population of observers provides clear, reproducible insights into social perceptions of gender identity and specifically femininity. These data will meaningfully inform patient counseling and surgical planning for gender-affirming interventions by establishing normative data representing the general public's perceptions.N/A Laryngoscope, 2022.

    View details for DOI 10.1002/lary.30498

    View details for PubMedID 36453533

  • Effects of Electronic (E)-cigarette Vapor and Cigarette Smoke in Cultured Vocal Fold Fibroblasts. The Laryngoscope Martinez, J. D., Easwaran, M., Ramirez, D., Erickson-DiRenzo, E. 2022

    Abstract

    OBJECTIVE: The public use of electronic-cigarettes (e-cigs) is rapidly growing. When heated, e-cigs produce a vapor that is inhaled. The vocal folds are among the first tissues exposed to this insult. However, the impact of e-cigs on vocal fold health is almost entirely unknown. Our objective was to evaluate the effects of e-cig vapor on cultured human vocal fold fibroblasts (hVFFs), the primary cell type of the lamina propria. We compared the cellular effects of e-cig vapor without and with nicotine and conventional cigarette smoke.STUDY DESIGN: In vitro.METHODS: E-cig vapor extract (EVE) and cigarette smoke extract (CSE) were created by bubbling vapor and smoke, respectively, into the cell culture medium. hVFFs were exposed to EVE without or with nicotine or CSE for 24hours. Untreated cells were used as a control group. Cells were harvested, and cytotoxicity, extracellular matrix and inflammatory gene expression, and DNA damage were assessed.RESULTS: Undiluted EVE without and with nicotine reduced the viability of hVFFs to a cytotoxic level. CSE reduced hVFFs viability to a greater extent than EVE and induced DNA damage as measured by DNA double-strand breaks. No changes in gene expression were observed following EVE or CSE exposure.CONCLUSION: EVE induces cytotoxicity in hVFFs. However, cellular responses were greater following exposure to CSE, suggesting cigarette smoke may induce more harm, at least in the short term. Findings from this investigation improve our understanding of responses of hVFFs to e-cigs and form the basis for an in vitro methodology to study the vocal fold responses to these products.LEVEL OF EVIDENCE: N/A Laryngoscope, 2022.

    View details for DOI 10.1002/lary.30073

    View details for PubMedID 35213064

  • Feminization Laryngoplasty: 17-Year Review on Long-Term Outcomes, Safety, and Technique. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Nuyen, B. A., Qian, Z. J., Campbell, R. D., Erickson-DiRenzo, E., Thomas, J., Sung, C. K. 2021: 1945998211036870

    Abstract

    OBJECTIVES: Transfeminine patients can experience significant gender dysphoria in vocal communication. Feminization laryngoplasty (FL) is a gender-affirming surgery developed to elevate speaking vocal range, as well as alter vocal resonance and laryngeal cosmesis. The purpose here was to appraise FL's long-term voice outcomes across a 17-year review period.STUDY DESIGN: Level III, retrospective study and description of technique.SETTING: A single-institution transfeminine voice clinic.METHODS: Voice data (speaking fundamental frequency [F0], lowest F0, highest F0, F0 range in both Hertz and semitones, and maximum phonation time [MPT]) were collected and assessed. Self-assessment of voice femininity and complications were documented.RESULTS: The 162 patients, all transfeminine women, had a mean age of 40 years with 36-month mean follow-up. There were significant increases in mean speaking F0 (Delta = 50 ± 30 Hz, Delta = 6 ± 3 semitones; P < .001) and mean change in lowest F0 (Delta = 58 ± 31 Hz, Delta = 8 ± 4 semitones; P < .001). There was no significant difference in mean change in highest F0 or MPT. There was significant improvement (Delta = 60% ± 39%; P < .001) in perceptual self-assessment of vocal femininity. There was a 1.2% rate of major postoperative complications requiring inpatient admission or operative intervention. There were no differences in vocal outcomes between those patients who had less than 1-year follow-up and those who had 5-year follow-up.CONCLUSION: FL in this cohort was a safe and effective technique for increasing mean speaking F0, mean lowest F0, and voice gender perception over a prolonged follow-up period. These findings add to the possible treatments aimed at addressing the morbid dysphoria related to voice and communication for our transfeminine patients.

    View details for DOI 10.1177/01945998211036870

    View details for PubMedID 34399638

  • The Impact of COVID-19 on Speech-Language Pathologists Engaged in Clinical Practices With Elevated Coronavirus Transmission Risk AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY Kearney, A., Searl, J., Erickson-DiRenzo, E., Doyle, P. C. 2021; 30 (4): 1673-1685

    Abstract

    Purpose This study assessed and described potential clinical practice changes secondary to COVID-19 that emerged as an early response to the pandemic for speech-language pathologists (SLPs) engaged in voice, alaryngeal, and swallowing activities that may increase the risk of virus transmission. Method SLPs from the United States and Canada (n = 665) who were engaged in clinical activities that might elevate the risk of COVID-19 exposure completed an online survey regarding their clinical practices. Topics assessed included potential clinical service modifications, COVID-19 testing and health, and potential financial impacts in the early time period of the pandemic. Results The percentage of SLPs completing the most endoscopic procedures prepandemic (≥ 10/week) was reduced from 39% of respondents to 3% due to the pandemic. Those who completed the most tracheoesophageal puncture voice prosthesis changes (≥ 5/week) reported a reduction in frequency from 24% to 6%. Twenty-five percent of SLPs reported that they were tested for COVID-19, and 6% reported a positive result. Descriptive statistics suggest that COVID-19 testing rates of SLPs, the percentage of SLPs experiencing a financial impact, and the percentage who were furloughed varied across SLP work setting. Conclusions These findings provide the first data characterizing the impact on COVID-19 on clinical practice for SLPs engaged in procedures such as endoscopy and laryngectomy care. The results indicate that, as frontline workers, SLPs were directly impacted in their practice patterns, personal health, safety, and financial security, and that these reported impacts occurred differently across SLP work settings.

    View details for DOI 10.1044/2021_AJSLP-20-00325

    View details for Web of Science ID 000683585400008

    View details for PubMedID 34161739

  • Mainstream Cigarette Smoke Impacts the Mouse Vocal Fold Epithelium and Mucus Barrier. The Laryngoscope Erickson-DiRenzo, E., Easwaran, M., Martinez, J. D., Dewan, K., Sung, C. K. 2021

    Abstract

    OBJECTIVES/HYPOTHESIS: Cigarette smoke (CS) is a primary risk factor for the development of numerous benign and malignant laryngeal diseases. The epithelium and mucus lining the vocal folds (VF) are the first barriers against CS. The primary objective of this study was to investigate epithelial and mucus barrier changes in the mouse laryngeal mucosa upon exposure to subacute CS. The secondary objective was to compare mucus barrier changes in mice and human smokers and nonsmokers. Study Design Animal model.METHODS: Mice were exposed to CS for 4weeks for 4hours (N = 12, high dose [HD]) or 1hour (N = 12, low dose [LD]) per day. Air-exposed mice were used as a control group (N = 10). Larynges were harvested and VF epithelial barrier integrity was evaluated including cellular proliferation and expression of cell junctions. We also investigated mucus production by examining mucus cell area and mucin expression in mice and human smokers and nonsmokers.RESULTS: HD CS increased VF epithelial cellular proliferation but did not alter the expression of cell junctions. HD CS also induced hypertrophy of the mucus-producing submucosal glands. However, only LD CS increased MUC5AC gene expression. MUC5AC staining appeared elevated in laryngeal specimens from smokers, but this was not significant as compared to nonsmokers.CONCLUSIONS: These findings help us identify potential adaptive mechanisms to CS exposure as well as set the foundation for further study of key aspects of epithelial and mucus barrier integrity that may be implicated in laryngeal disease development following prolonged smoking.LEVEL OF EVIDENCE: NA Laryngoscope, 2021.

    View details for DOI 10.1002/lary.29572

    View details for PubMedID 33864646

  • This Is the Voice (Book Review) SCIENCE Book Review Authored by: DiRenzo, E. 2021; 371 (6528): 471