“Quality, Readability, and Understandability of Online Posterior Glottic Stenosis Information”

Published:December 28, 2022DOI:



      To assess the quality, readability, and understandability of posterior glottic stenosis (PGS) information available to patients online.


      The top 50 Google search results for “posterior glottic stenosis” were categorized based on website affiliation and target audience (patient or provider). Readability was assessed using the Flesch-Kincaid Grade Level (FKGL) and the Flesch Reading Ease (FRE) scores. The DISCERN tool was used to assess quality and the Patient Education Assessment Tool for Printed Materials (PEMAT-P) was used to assess understandability and actionability. Simple descriptive statistics were used to analyze the data.


      36 of the top 50 results were eligible for scoring. 17% (6 of 36) were classified as patient-focused while 83% (30 of 36) were provider-focused. Patient-focused materials had a higher mean FRE score (36.9) than provider-focused materials (15.5) (P < 0.001). Patient-focused materials had an average reading level of 12.5 compared to 15.8 for provider-focused materials (P < 0.001). There was a significant correlation between overall PEMAT-P and DISCERN (r = 0.63, P < 0.001), PEMAT-P understandability and DISCERN (r = 0.63, P < 0.001) and FRES and FKGL (r = -0.67, P < 0.001). From this, we can infer that higher quality sites are easier to understand but not necessarily tailored to a certain reading level.


      Shared decision making in PGS management is crucial as patients must be aware of how treatment modalities affect airway, voice, and swallowing. However, this study shows that patient targeted PGS information is limited, and the readability, quality, and understandability is generally low. We suggest the development of web pages with PGS information tailored for patient education and search optimization to make this information appear earlier in Google search results. Furthermore, future studies should seek to characterize the link between online health information and socioeconomic-based health disparities.
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        • Bogdasarian RS
        • Olson NR.
        Posterior glottic laryngeal stenosis.
        Otolaryngol Head Neck Surg. 1980; 88: 765-772
        • Whited RE.
        Posterior commissure stenosis post long-term intubation.
        Laryngoscope. 1983; 93: 1314-1318
        • Gardner GM.
        Posterior glottic stenosis and bilateral vocal fold immobility: diagnosis and treatment.
        Otolaryngol Clin North Am. 2000; 33: 855-878
        • Hillel AT
        • Karatayli-Ozgursoy S
        • Samad I
        • et al.
        Predictors of Posterior glottic stenosis: a multi-institutional case-control study.
        Ann Otol Rhinol Laryngol. 2016; 125: 257-263
        • Katsantonis NG
        • Kabagambe EK
        • Wootten CT
        • et al.
        Height is an independent risk factor for postintubation laryngeal injury.
        Laryngoscope. 2018; 128: 2811-2814
        • O'Connor HH
        • Kirby KJ
        • Terrin N
        • et al.
        Decannulation following tracheostomy for prolonged mechanical ventilation.
        J Intensive Care Med. 2009; 24: 187-194
        • Shinn JR
        • Kimura KS
        • Campbell BR
        • et al.
        Incidence and outcomes of acute laryngeal injury after prolonged mechanical ventilation.
        Crit Care Med. 2019; 47: 1699-1706
        • Roh JL.
        Prevention of posterior glottic stenosis by mitomycin C.
        Ann Otol Rhinol Laryngol. 2005; 114: 558-562
        • Wald HS
        • Dube CE
        • Anthony DC.
        Untangling the Web–the impact of Internet use on health care and the physician-patient relationship.
        Patient Educ Couns. 2007; 68: 218-224
        • Kremer C
        • Jiang R
        • Singh A
        • et al.
        Factors affecting posterior glottic stenosis surgery outcomes: systematic review and meta-analysis.
        Ann Otol Rhinol Laryngol. 2021; 130: 1156-1163
        • DeHart AN
        • Richter GT.
        Posterior glottic stenosis: management and outcomes.
        Curr Opin Otolaryngol Head Neck Surg. 2020; 28: 414-424
        • Meyer TK
        • Wolf J.
        Lysis of interarytenoid synechia (Type I1 Posterior Glottic Stenosis): vocal fold mobility and airway results.
        Laryngoscope. 2011; 121: 2165-2171
        • Rosen CA
        • Wang H
        • Cates DJ
        • et al.
        The glottis is not round: teardrop-shaped glottic dilation for early posterior glottic stenosis.
        Laryngoscope. 2019; 129: 1428-1432
        • Damrose EJ
        • Beswick DM.
        Repair of posterior glottic stenosis with the modified endoscopic postcricoid advancement flap.
        Otolaryngol–Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2016; 154: 568-571
        • Dahl JP
        • Purcell PL
        • Parikh SR
        • et al.
        Endoscopic posterior cricoid split with costal cartilage graft: a15-year experience.
        Laryngoscope. 2017; 127: 252-257
        • Nouraei S a R
        • Dorman EB
        • Vokes DE
        Management of posterior glottic stenosis using the combined glottic reconstruction procedure.
        Clin Otolaryngol Off J ENT-UK Off J Neth Soc Oto-Rhino-Laryngol Cervico-Facial Surg. 2018; 43: 1415-1418
        • Duncavage JA
        • Ossoff RH
        • Toohill RJ.
        Carbon dioxide laser management of laryngeal stenosis.
        Ann Otol Rhinol Laryngol. 1985; 94: 565-569
        • Gaffney A
        • Himmelstein DU
        • Dickman S
        • et al.
        Trends and disparities in the distribution of outpatient physicians’ annual face time with patients, 1979-2018.
        J Gen Intern Med. 2022;
        • Winker MA
        • Flanagin A
        • Chi-Lum B
        • et al.
        Guidelines for medical and health information sites on the internet: principles governing AMA web sites. American Medical Association.
        JAMA. 2000; 283: 1600-1606
        • Tan SSL
        • Goonawardene N.
        Internet health information seeking and the patient-physician relationship: a systematic review.
        J Med Internet Res. 2017; 19: e9
        • Luo A
        • Qin L
        • Yuan Y
        • et al.
        The Effect of online health information seeking on physician-patient relationships: systematic review.
        J Med Internet Res. 2022; 24: e23354
      1. Health Literacy: Help your patients understand : a Continuing Medical Education (CME) program that provides tools to enhance patient care, improve office productivity, and reduce health care costs; 2003.

        • Alamoudi U
        • Hong P.
        Readability and quality assessment of websites related to microtia and aural atresia.
        Int J Pediatr Otorhinolaryngol. 2015; 79: 151-156
        • Ahmadi O
        • Wood AJ.
        The readability and reliability of online information about adenoidectomy.
        J Laryngol Otol. 2021; 135: 976-980
        • Habeeb A.
        How readable and reliable is online patient information on chronic rhinosinusitis?.
        J Laryngol Otol. 2021; 135: 644-647
        • Schwarzbach HL
        • Mady LJ
        • Kaffenberger TM
        • et al.
        Quality and readability assessment of websites on human papillomavirus and oropharyngeal cancer.
        Laryngoscope. 2021; 131: 87-94
        • Gelbard A
        • Donovan DT
        • Ongkasuwan J
        • et al.
        Disease homogeneity and treatment heterogeneity in idiopathic subglottic stenosis.
        Laryngoscope. 2016; 126: 1390-1396
        • Heffernan A
        • Hu A.
        Quality and readability of online information on idiopathic subglottic stenosis.
        Laryngoscope Investig Otolaryngol. 2021; 6: 1068-1076
        • Alwani MM
        • Campa KA
        • Svenstrup TJ
        • et al.
        An appraisal of printed online education materials on Spasmodic Dysphonia.
        J Voice Off J Voice Found. 2021; 35: 659.e1-659.e9
        • Doruk C
        • Enver N
        • Çaytemel B
        • et al.
        Understandability, and quality of online education materials for vocal fold nodules.
        J Voice Off J Voice Found. 2020; 34: 302.e15-302.e20
        • Balakrishnan V
        • Chandy Z
        • Hseih A
        • et al.
        Readability and understandability of online vocal cord paralysis materials.
        Otolaryngol–Head Neck Surg Off J Am Acad Otolaryngol-Head Neck Surg. 2016; 154: 460-464
        • Charnock D
        • Shepperd S
        • Needham G
        • et al.
        DISCERN: an instrument for judging the quality of written consumer health information on treatment choices.
        J Epidemiol Community Health. 1999; 53: 105-111
        • Shoemaker SJ
        • Wolf MS
        • Brach C.
        Development of the Patient Education Materials Assessment Tool (PEMAT): a new measure of understandability and actionability for print and audiovisual patient information.
        Patient Educ Couns. 2014; 96: 395-403
      2. Internet usage statistics: the internet big picture, world internet users and population stats. Internet World Stats. Accessed July 22, 2022.

        • JAMA patient page
        Health information on the Internet.
        JAMA. 2001; 285: 2672
        • Swire-Thompson B
        • Lazer D.
        Public health and online misinformation: challenges and recommendations.
        Annu Rev Public Health. 2020; 41: 433-451
        • Lambert SD
        • Loiselle CG.
        Health information seeking behavior.
        Qual Health Res. 2007; 17: 1006-1019
        • Zimmerman MS
        • Shaw G.
        Health information seeking behavior: a concept analysis.
        Health Inf Libr J. 2020; 37: 173-191
        • Tonsaker T
        • Bartlett G
        • Trpkov C.
        Health information on the Internet: gold mine or minefield?.
        Can Fam Physician Med Fam Can. 2014; 60: 407-408
        • Dang S
        • Shinn JR
        • Campbell BR
        • et al.
        The impact of social determinants of health on laryngotracheal stenosis development and outcomes.
        Laryngoscope. 2020; 130: 1000-1006
        • Gelbard A
        • Anderson C
        • Berry LD
        • et al.
        Comparative treatment outcomes for patients with idiopathic subglottic stenosis.
        JAMA Otolaryngol– Head Neck Surg. 2020; 146: 20-29
      3. Anderson C. Idiopathic subglottic stenosis arough uide for beginners. living idiopathic subglottic stenosis. Published online January 2018.

        • Diviani N
        • van den Putte B
        • Giani S
        • et al.
        Low health literacy and evaluation of online health information: a systematic review of the literature.
        J Med Internet Res. 2015; 17: e112
        • Tichenor PJ
        • Donohue GA
        • Olien CN.
        Mass media flow and differential growth in knowledge.
        Public Opin Q. 1970; 34: 159
        • Viswanath K
        • Kreuter MW.
        Health disparities, communication inequalities, and health.
        Am J Prev Med. 2007; 32: S131-S133
        • Cutilli CC
        • Bennett IM.
        Understanding the health literacy of America: results of the National Assessment of adult literacy.
        Orthop Nurs. 2009; 28: 27-32
        • Health literacy: report of the Council on Scientific Affairs
        Ad hoc committee on health literacy for the council on scientific affairs.
        Am Med Assoc. JAMA. 1999; 281: 552-557
        • D'Alessandro DM
        • Kingsley P
        • Johnson-West J
        The readability of pediatric patient education materials on the World Wide Web.
        Arch Pediatr Adolesc Med. 2001; 155: 807-812
        • Wolf MS
        • Davis TC
        • Shrank W
        • et al.
        To err is human: patient misinterpretations of prescription drug label instructions.
        Patient Educ Couns. 2007; 67: 293-300
        • Yermilov I
        • Chow W
        • Devgan L
        • et al.
        What is the quality of surgery-related information on the internet? Lessons learned from a standardized evaluation of 10 common operations.
        J Am Coll Surg. 2008; 207: 580-586