Festive carols, salutations, gatherings and merriment are the distinct voices—human voices—of the holiday season. As a specialty, we are privileged to offer professional care of the voice, one of the uniquely human qualities.
In this newsletter, we shine the spotlight on our laryngology division. Few concepts resonate as deeply—both scientifically and metaphorically—as the idea of "finding one's voice." Historically, this phrase originates from rhetoric and literary studies, where a "voice" signified the emergence of an author's distinctive perspective, style, and mode of expression. Over time, the notion spread to psychology, education, and social theory as a metaphor for personal empowerment, identity formation, and communication.
As physicians who specialize in the larynx, the "voice" reflects complex physiological and acoustic processes: the coordination of breathing, neurological control, and laryngeal biomechanics that enable individuals to speak, sing, and engage with the world. As an educational endeavor, it symbolizes the professional and personal journeys of our trainees, faculty, researchers, and clinical staff as they develop confidence, expertise, and purpose in this ever-evolving discipline.
In this season of reflection and gratitude, we celebrate not only the literal restoration of voice in our patients but also the figurative voices we continue to nurture as a department: voices of inquiry, collaboration, kindness, and shared mission.
Wishing you a holiday season and new year filled with warmth, hope and joy!
Tina
Konstantina Stankovic, MD, PhD
Bertarelli Foundation Professor of Otolaryngology — Head & Neck Surgery and, by courtesy, of Neurosurgery
Faculty in the Division of Laryngology continue to advance our understanding and treatment of voice and swallowing disorders, from basic science investigations in animal models to patient perceptions of surgeons based on their vocal pitch. Below, we highlight ongoing and recently published projects.
Photo Credit: Chris Gralapp
Beth DiRenzo employed a unique experimental system in mice to investigate how inhaled irritant exposure from cigarette and e-cigarette (E-cig) smoke affected upper airway mucosal physiology, illuminating the largely unknown effects of E-cigs on laryngeal health. With funding from the NIDCD, Dr. DiRenzo and her lab showed that chronic E-cig exposure significantly decreased p63-positive basal cells in the vocal folds, and vocal fold epithelial thickness, in comparison with cigarette smoke or non-exposure (Fig 1). These basal cells are the progenitors responsible for epithelial regeneration after injury. These findings suggests that E-cig aerosol may impair the tissue’s ability to repair itself after injury, potentially increasing vulnerability to vocal damage or disease, via mechanisms that differ from cigarette smoke. This work, recently published in The Laryngoscope, contributes important evidence to ongoing public health discussions about the safety of E-cigs and highlights the need to consider vocal fold health—not just lungs—when evaluating inhalation exposures.
Figure 1: Quantification of p63+ basal cells across laryngeal regions, including vocal folds (VF), in mice exposed to cigarette smoke, E-Cig smoke, or controls. From DiRenzo et al. (2025).
Dr. DiRenzo’s research is complemented by Dr. Rob Jackler’s studies, within the Stanford Research into the Impact of Tobacco Advertising (SRITA), on the advertising of emerging nicotine products such are e-cigarettes, heated tobacco, and oral pouches. His research is revealing tobacco industry’s targeting of specific market segments including: Youth, Women, Black & LatinX Americans, and chronicling the long history of cigarette advertising falsely reassuring smokers that cigarettes are safe. In an effort to better inform policy makers and the public about the practices of the tobacco industry he has made recent appearances of CBS Evening News and Fox News.
Stanford laryngologists have always been at the forefront of surgical treatment of Zenker’s diverticula. The cover of the September issue of The Laryngoscope featured Ed Damrose’s Modified Transoral Resection of Diverticulum (MTORD) technique, which has been used in over 50 patients at Stanford since 2017. Compared to traditional methods, MTORD resects a greater amount of the dysfunctional cricopharyngeus muscle and more of the diverticular sac, resulting in a far lower recurrence rate. MTORD also has a low complication rate and demonstrated utility as a salvage technique for recurrence after endoscopic stapler-assisted diverticulotomy. Our residents and fellows are among the few in the country being trained in this advanced surgery for Zenker’s diverticulum. Dr. Damrose’s article in the issue will help raise awareness about the novel surgical technique.
Figure 2: Cover of the September 2025 issue of The Laryngoscope, featuring MTORD for Zenker’s diverticulum.
Another swallowing disorder that is challenging to treat is complete esophageal stricture, which can follow radiotherapy/chemoradiotherapy for hypopharyngeal or esophageal cancer. Kwang Sung has worked with colleagues in Gastroenterology to develop a method to recanalize long-segment complete esophageal stricture using a combined antegrade-retrograde rendezvous technique with fluoroscopic guidance. A fluoroscopy C-arm unit set-up at the level of the neck is used to capture live images from a lateral view and various angles up to almost an anterior-posterior view to guide endoscopic dissection until transillumination through the stenotic segment is possible. Three patients with complete strictures of 4-8 cm in length have been successfully recanalized in this manner.
Figure 3: Recanalization of long-segment complete esophageal stricture with fluoroscopic guidance.
Leveraging a decade of national Medicare claims data, Nancy Jiang and Kwang Sung analyzed trends in vocal fold injection augmentation and medialization thyroplasty from 2012–2022. Their Laryngoscope publication shows a marked shift toward injection laryngoplasty, especially office-based flexible-scope injections, while type I thyroplasty volumes have declined. After the introduction of new HCPCS codes in 2017, office injections grew steadily and bilateral augmentation injections increased substantially, suggesting expanding procedural management of presbylarynx/presbyphonia in older adults. This work helps to quantify changing practice patterns in glottic insufficiency.
Finally, Brian Nuyen led a study co-authored by Noel Ayoub, Ann Kearney, Jennifer Alyono, and others that examined the effect of surgeons’ voice pitch and gender on patient perceptions of the surgeon. In a creative experiment, the team recruited cisgender female and cisgender male voice actors to perform a standardized informed consent for tracheostomy. The audio recordings were then up-pitch or down-pitch modulated to create “high voice” and “low voice” test recordings. Over 2,500 participants crowd-sourced through Qualtrics listened to the recordings and rated the test surgeons in various domains. The study found that test surgeons with a lower modulated pitch were perceived as more experienced, regardless of gender. On the other hand, female surgeons' voices were rated as friendlier and showing more concern than male surgeons. Despite these pitch- and gender-based perceptions, the Press-Ganey “likelihood to recommend” score was comparable across groups. While this study reaffirmed some social attribute stereotypes based on vocal gender and pitch, namely that female voices were perceived as more compassionate, it was reassuring that the patient satisfaction score was independent of these biases. This finding has important implication in today’s healthcare environment, where patient satisfaction ratings play an increasing role in how physicians and hospitals are reimbursed.