Validation of the Pediatric Voice-Related Quality-of-Life Survey

OBJECTIVE

To validate the Pediatric Voice-Related Quality-of-Life (PVRQOL) survey, which was designed to assess voice changes over time in the pediatric population.

DESIGN

Prospective longitudinal study.

SETTING

Outpatient pediatric otolaryngology office practice.

PARTICIPANTS

One hundred twenty parents of children aged 2 through 18 years having a variety of otolaryngological diagnoses including disorders that affect the voice.

INTERVENTIONS

The previously validated Pediatric Voice Outcomes Survey and the PVRQOL were jointly administered to the parents of the study participants. Test-retest reliability was accomplished by having 70 caregivers repeat the instrument 2 weeks after the initial visit. The Cronbach alpha value was calculated to determine reliability. Instrument validity was determined by examining convergent and discriminant validity.

MAIN OUTCOME MEASURE

Correlation of PVRQOL scores with Pediatric Voice Outcomes Survey scores.

RESULTS

Reliability of the PVRQOL was established by evaluating the Cronbach alpha value (.96; P<.001) and by test-retest reliability (weighted kappa value, 0.8). Validity of the PVQROL was tested by evaluating its ability to show significant change in voice-related quality-of-life after adenoidectomy (discriminant validity) (P<.001). The PVQROL also proved valid when the overall score was correlated with the previously validated Pediatric Voice Outcomes Survey (r = 0.7; P<.001).

CONCLUSION

The PVRQOL is a more comprehensive survey than the previously validated Pediatric Voice Outcomes Survey and is another valid instrument to examine the health-related quality-of-life issues in pediatric voice disorders.

Validation of a pediatric voice quality-of-life instrument: the pediatric voice outcome survey

OBJECTIVE

To validate a parent proxy instrument to study the voice-related quality of life (VR-QOL) for the pediatric population.

METHODS

The voice outcome survey (VOS) was administered to 108 caregivers of children aged 2 to 18 years, who either had a tracheotomy or had achieved surgical decannulation. The VOS was altered so that each item was addressed to the parent proxy as opposed to the child. A scoring paradigm was developed to report the scores on a range of 0 to 100. Structural properties of the instrument examined include validity, reliability, and principal component analysis. The VOS was then revised to suit the results of this analysis.

RESULTS

The mean +/- SD (range) score for the pediatric VOS was 49.8 +/- 27.1 (0-100). Reliability analysis and principal component analysis supported the reduction of 1 item from the final pediatric VOS. The revised instrument demonstrated an overall Cronbach alpha value of.86. Substratification by age revealed robust Cronbach alpha values from ages 2 to 18 years. Construct validity analysis also supported statistical significance (P =.004). Principal component analysis of the revised instrument supports its internal structure and design.

CONCLUSIONS

The pediatric VOS is a simple, short, health status instrument designed to measure the VR-QOL in the pediatric population. Cross-sectional analysis suggests that children and adolescents with tracheotomies have a poorer VR-QOL than do those who have achieved decannulation.

Development and maturation of the pediatric human vocal fold lamina propria

OBJECTIVE

To identify characteristic patterns of maturation of the human vocal fold lamina propria as it develops into a mature structure.

METHODS

Histologic evaluation of sectioned true vocal folds from 34 archived larynges ages 0 to 18 years using hematoxylin-eosin, trichrome, Alcian blue pH 2.5, Weigert reticular, and Miller's elastin stain.

LOCATION

Pathology department at a tertiary care children's hospital.

RESULTS

At birth and shortly thereafter, there exists a relative hypercellular monolayer of cells throughout the lamina propria. By 2 months of age, there are the first signs of differentiation into a bilaminar structure of distinct cellular population densities. Between 11 months and 5 years, two distinct patterns are seen: 1) this bilaminar structure and 2) a lamina propria where there exists a third more hypocellular region immediately adjacent to the vocalis muscle (this region is similar to the superficial hypocellular region found just deep to the surface epithelium). By 7 years of age, all of the specimens exhibit this transition between the middle and the deeper layers according to differential density of cell populations. A lamina propria structure defined by differential fiber composition (elastin and collagen fibers) is not present until 13 years of age and then is present throughout adolescence.

CONCLUSIONS

Using the classic adult model of fiber composition and density to differentiate the layered structure of the lamina propria of the human vocal fold may not adequately allow for a thorough description of the process of maturation and development. Rather, distinct regions of cell density are seen as early as 2 months postpartum, and the model of cellular distribution may serve better to describe the lamina propria as it develops. Cell-signaling processes that shape the formation of the lamina propria appear to produce layered populations of differential cell density that in turn will later produce differential fiber compositions. Early development therefore can be followed by evaluating the maturation of these differing cell populations. Future studies are needed to quantify these cell distribution patterns, to study the cell signaling processes that trigger this maturation, and to correlate these findings with mechanical modeling.

Defective HSV-1 vector expressing BDNF in auditory ganglia elicits neurite outgrowth: model for treatment of neuron loss following cochlear degeneration

The neurotrophins are a family of growth factors that play an important role in the development and maintenance of the nervous system. Brain-derived neurotrophic factor (BDNF) is a member of the neurotrophin family that appears to participate in the maturation and function of mammalian auditory neurons. Forms of deafness due to varied injurious stimuli that are amenable to treatment with implantable prosthetic devices require the survival of these BDNF-responsive auditory neurons for effective outcome. To evaluate the feasibility of developing a gene therapy for deafness that may be used in conjunction with a prosthetic device, we constructed replication-defective herpes simplex virus (HSV) amplicon vectors that carry the human BDNF cDNA. Using these vectors, HSVbdnf and HSVbdnflac (expresses BDNF and Escherichia coli beta-galactosidase), we evaluated the expression and biological activity in established cell lines and explant cultures prepared from spiral ganglia of the murine ear. Gene transfer with HSVbdnf resulted in the efficient expression of human BDNF mRNA in murine fibroblasts. Using two BDNF-responsive cell lines, PC12trkB and MG87trkB, we demonstrate efficient secretion of biologically active BDNF. Finally, transduction of explanted spiral ganglia with HSVbdnflac elicited robust neuritic process outgrowth comparable to exogenously added BDNF. Overall, these data demonstrate that HSV vectors can efficiently transfer and express the BDNF gene in many cell types, including auditory neurons. Moreover, they suggest that similar vectors may be used to express the neurotrophin in auditory neurons in vivo and perhaps as adjunctive gene therapy for deafness.

Type 1 laryngeal cleft: establishing a functional diagnostic and management algorithm

OBJECTIVES

To report our experience with all patients diagnosed with type 1 laryngeal cleft over a period of 3 years in our referral practice and to describe a functional diagnostic and management algorithm for children with this disorder.

METHODS

A prospective longitudinal study in a tertiary care referral center. Twenty pediatric patients diagnosed with type 1 laryngeal cleft in a 3-year period (5/1/2002-5/1/2005) were included in this study. The incidence, presenting symptoms, diagnostic procedures, medical and surgical interventions performed, and clinical outcomes were evaluated.

RESULTS

The incidence of type 1 laryngeal cleft was 7.6%. Among the 20 patients in this study, aspiration with thin liquids was the most common presenting symptom (18 patients, 90%). Three patients underwent modified barium swallow (MBS) alone, 3 patients underwent functional endoscopic evaluation of swallow (FEES) alone, and 11 patients underwent both MBS and FEES prior to intraoperative endoscopic evaluation. Four patients (20%) were successfully treated with conservative therapy. Sixteen patients (80%) required endoscopic surgical repair after failing a course of conservative measures. The success rate of surgical repair was 94% (15 out of 16 patients).

CONCLUSIONS

Type 1 laryngeal cleft can be challenging diagnostically. We propose a functional diagnostic and management algorithm that includes MBS, FEES, suspension laryngoscopy with bimanual interarytenoid palpation, and a trial of conservative therapy, as a way to diagnose and manage type 1 laryngeal cleft prior to consideration of surgical repair. If conservative therapy fails, then surgical intervention is indicated.

Topical mitomycin application after laryngotracheal reconstruction: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

To explore the effect of mitomycin treatment on the pediatric airway following laryngotracheal reconstruction.

DESIGN

Randomized, double-blind, placebo-controlled trial.

PATIENTS

Children aged 2 to 17 years with subglottic or upper tracheal stenosis undergoing laryngotracheal reconstruction at a single, tertiary care, children's hospital.

INTERVENTION

At the time of extubation or stent removal, the children underwent bronchoscopy and 0.4 mg/mL (2 mL of a 0.2-mg/mL solution of either mitomycin or an equal volume of isotonic sodium chloride was directly applied to the subglottic region for a single application of 2 minutes. These children then underwent interval endoscopy at 2 weeks, 6 weeks, and 3 months postoperatively for assessment of their airways.

RESULTS

Granulation tissue was graded on a scale of 0 (none) to 4 (near-total or total occlusion). Videotapes of endoscopies were independently observed and graded by 3 pediatric otolaryngology fellows with a subsequent interobserver agreement of 91.6%. The results were then dichotomized to represent a single cohort in which further surgical intervention would be required and another separate cohort in which further surgery would not be required. At the 1-year mark, interim analysis was performed by a Data Safety and Monitoring Committee. At this time, 13 children had been randomized to the mitomycin-treated arm of the study and 11 children to the placebo-treated arm. A 2-tailed Fisher exact test revealed a value of 1.00. The Data Monitoring and Safety Committee advised that the trial should be stopped because the distributions between the 2 populations were almost identical.

CONCLUSION

We cannot reject the null hypothesis that a single topical dose of mitomycin exerts an equal benefit as does isotonic sodium chloride when applied to the pediatric airway after laryngotracheal reconstruction.

Pediatric transtracheal and cricothyrotomy airway devices for emergency use: which are appropriate for infants and children?

Cricothyrotomy or insertion of a transtracheal device is a life-saving maneuver that may be performed on an emergent or semi-elective basis as a means of bypassing an obstructed upper airway. A surgeon is trained to perform this life-saving procedure whereas most anesthesiologists are not facile with the scalpel. It is for this reason that many percutaneous devices have been developed for use by surgeons and nonsurgeons alike. Unfortunately, the majority of such devices are designed for use in adults and/or teenagers but are not appropriate for neonates and infants. The unique anatomy of the infant larynx, the small size of the cricothyroid membrane, and the technical difficulty of locating the correct anatomical structures make the use of most of these devices impractical if not outright dangerous in neonates and infants. This paper will review many (but not all) of the available devices, associated literature, pitfalls and dangers. It is emphasized that each clinician should become familiar with the advantages and disadvantages of these devices and obtain training with simulators or animal models. A strategy for management of the 'cannot ventilate, cannot oxygenate, cannot intubate' situation should be developed with age and size appropriate equipment.

Vocal Fold Medialization in Children

OBJECTIVE

To review surgical interventions for pediatric unilateral vocal fold immobility (UVFI).

DESIGN

Retrospective medical chart review.

SETTING

Two tertiary academic centers.

PATIENTS

All children who underwent vocal fold medialization for dysphonia, with or without aspiration, from January 2004 to September 2006.

INTERVENTIONS

Injection laryngoplasty, ansa cervicalis-recurrent laryngeal nerve anastomosis, or thyroplasty.

MAIN OUTCOME MEASURES

Age, sex, intervention, etiology, time from onset of UVFI to surgery, subjective success in improving voice, subjective duration of improvement, and complications.

RESULTS

Twenty-seven procedures were performed in 15 patients (mean age, 10.6 years). Nineteen injection laryngoplasties, 3 thyroplasties (1 bilateral), 2 ansa cervicalis-recurrent laryngeal nerve reinnervation procedures, 1 adduction arytenoidopexy, and 1 cricothyroid joint subluxation were performed. Causes of UVFI included thoracic surgery in 6 cases (40%), prolonged intubation in 4 (26%), central nervous system neoplasm in 3 (20%), unknown etiology in 1 (7%), and anoxic brain injury in 1 (7%). The mean duration from onset of symptoms to treatment was 47 months. There was 1 surgical complication (postoperative aspiration pneumonia following thyroplasty while the patient was under local anesthesia). Parents reported a satisfactory outcome in all cases.

CONCLUSIONS

Injection laryngoplasty, thyroplasty, and nerve reinnervation can be performed in pediatric patients with good outcomes and an acceptable safety profile. This article describes the experiences of 2 institutions with phonosurgery for UVFI in children and provides insight into the advantages and disadvantages of each procedure. Prospective studies, with validated quality-of-life measurements, are needed to greater clarify the role of different types of phonosurgery in children with UVFI.

Microdebrider Tonsillotomy vs Electrosurgical Tonsillectomy

OBJECTIVE

To examine whether microdebrider intracapsular tonsillotomy (MT) results in less postoperative pain compared with electrosurgical extracapsular tonsillectomy (ET).

DESIGN

Prospective, randomized, double-blind, matched pair, clinical trial.

SETTING

Specialty care hospital. Patients Twelve male (48%) and 13 female (52%) children aged 5 to 15 years, with obstructive tonsillar hyperplasia were randomized to have one tonsil removed by MT and the other by ET.

INTERVENTIONS

An angled endoscopic microdebrider was used to perform MT, and ET was performed by standard monopolar cautery technique. Parents and children were blinded to the side of MT and ET. Children rated the pain 0 to 5 by side using the Faces Pain Scale-Revised. Blinded data collection was via telephone daily for 2 weeks by a study nurse.

MAIN OUTCOME MEASURES

Primary: postoperative pain as recorded by Faces Pain Scale-Revised; secondary, presence or absence of otalgia and postoperative bleeding.

RESULTS

Twenty-two children (88%) had tonsillectomy and adenoidectomy, while 3 children (12%) had tonsillectomy alone. On postoperative days 1 to 9, children reported significantly less pain on the MT side compared with the ET side (paired t test; P<.01). By postoperative days 10 to 14, the difference between sides disappeared. Twenty children (80%) reported otalgia, and it was always unilateral. For those children reporting otalgia, there was a 100% correlation between the side of otalgia and the side of ET. There was no posttonsillectomy bleeding among the 25 children.

CONCLUSION

Microdebrider intracapsular tonsillotomy is significantly less painful compared with electrosurgical ET in children undergoing surgical intervention for obstructive tonsillar hypertrophy.

A pilot study to identify pre- and peri-operative risk factors for airway complications following adenotonsillectomy for treatment of severe pediatric OSA

OBJECTIVE

A pilot study to identify risk factors predicting post-operative complications in children with severe OSA undergoing adenotonsillectomy.

METHODS

Retrospective review in a tertiary care academic institution. Two-stage least squares regression analysis and instrumental variable analysis to allow for modeling of pre- and peri-operative risk factors as having significance in predicting post-operative morbidity.

RESULTS

Eighty-three children (mean age 4.88 ± 3.09 years) with apnea-hypopnea index (AHI) ≥ 10 who were observed overnight following adenotonsillectomy were evaluated for rates of major (increased level of care, CPAP/BiPAP use, pulmonary edema and reintubation) and minor (oxygen saturation <90%) airway complications as well as total observation costs. Major and minor complications occurred in 4.8% and 19.3% of children, respectively. Age <2 years (p<0.01), AHI >24 (p<0.05), intra-operative laryngospasm requiring treatment (p<0.05), oxygen saturations <90% on room air in PACU (p<0.05) and PACU stay >100 min (p<0.01) independently predicted post-operative complications. Children with any one of these factors experienced a 38% complication rate versus 4% in all others.

CONCLUSIONS

This pilot study identified pre- and peri-operative risk factors that collectively can be investigated as predictors of post-operative airway complications in a prospective study. By identifying preliminary results comparing the complication rates between those children with and without these risk factors, we will be able to calculate the sample size for a future prospective validation study. Such a study is necessary to understand the safety and potential significant cost savings of observing children without risk factors on the pediatric floor and not in an ICU setting. A best practice algorithm can be created for children with severe OSA only after completing this prospective study.

Neurotrophic effects of BDNF and CNTF, alone and in combination, on postnatal day 5 rat acoustic ganglion neurons

The neuronal survival promoting ability of brain derived neurotrophic factor (BDNF), and ciliary neurotrophic factor (CNTF), individually and in combination, was evaluated in dissociated cell cultures of postnatal day 5 (P5) rat acoustic ganglia. The neuritogenic promoting effect of these same neurotrophic factors was examined in organotypic explants of P5 rat acoustic ganglia. The results showed that BDNF was maximally effective at a concentration of 10 ng/mL in promoting both survival and neuritogenesis of these postnatal auditory neurons in vitro. CNTF was maximally effective at a concentration of 0.01 ng/mL at promoting both survival and neuritogenesis in the acoustic ganglion cultures. BDNF had its strongest effect on neuronal survival while CNTF was most effective in stimulating neurite outgrowth. These two neurotrophic factors, when added together at their respective maximally effective concentrations, behave in an additive manner for promoting both survival and neuritic outgrowth by the auditory neurons.

Surgery for pediatric vocal cord paralysis: a retrospective review

To determine the outcome of surgical procedures for bilateral vocal cord paralysis in children, we performed a retrospective review of children under 18 years of age with bilateral vocal cord paralysis and a previous tracheotomy who underwent a primary procedure at a single tertiary care institution with an aim of decannulation. The primary outcome measure was the operation-specific decannulation rate (OSDR). The overall decannulation rates, as well as morbidity rates, were also recorded. Fifty-two children met the inclusion criteria (mean age at time of primary surgery, 6.2 years; SD, 5 years). Vocal cord lateralization procedures combined with a partial arytenoidectomy achieved the highest OSDR (17/24 or 71%). This OSDR was statistically higher than the OSDRs for CO2 laser cordotomy or arytenoidectomy procedures (OSDR, 5/17 or 29%, p = .008), for isolated arytenoidopexy procedures (OSDR, 1/4 or 25%, p = .000004), or for posterior costal cartilage graft procedures (OSDR, 3/5 or 60%, p = .0004). Neither of the 2 children who underwent isolated arytenoidectomy achieved primary decannulation. The incidence of aspiration following posterior cartilage graft procedures was 15% (2/15). Subanalysis by age failed to reveal differences in OSDR. We conclude that vocal cord lateralization procedures with partial arytenoidectomy afford the highest OSDR among primary procedures for pediatric vocal cord paralysis. The CO2 laser procedures, while having limited success as a primary procedure, are effective for revision.

Surgery for pediatric subglottic stenosis: disease-specific outcomes

To set the foundation to develop a disease-based, operation-specific model to predict the outcome of pediatric airway reconstruction surgery, we performed a retrospective database review of children operated on at a single, tertiary-care children's hospital. Over the 12-year period 1988 to 2000, a total of 1,296 airway reconstruction procedures were performed. Out of these, charts were identified for 199 children who underwent laryngotracheal reconstruction for a sole diagnosis of subglottic stenosis. Children were excluded from the study if their disorder included supraglottic, glottic, or upper tracheal disease. The main outcome measures were Myer-Cotton grade-specific decannulation and extubation rates, including both operation-specific and overall results. There were 101 children who underwent double-stage laryngotracheal reconstruction. The operation-specific decannulation rates for Myer-Cotton grades 2, 3, and 4 were 85% (18/21), 37% (23/61), and 50% (7/14) (chi2 analysis, p = .0007). The overall decannulation rates were 95% (20/21), 74% (45/61), and 86% (12/14) (chi2 analysis, p = .04). There were 98 children who underwent single-stage laryngotracheal reconstruction. The operation-specific extubation rates for Myer-Cotton grades 2, 3, and 4 were 82% (37/45), 79% (34/43), and 67% (2/3) (chi2 analysis, p = .63). The overall extubation rates were 100% (45/45), 86% (37/43), and 100% (3/3) (chi2 analysis, p = .03). Logistic regression analysis showed no effect of age (less than or greater than 2 years of age) on operation-specific or overall outcome parameters. We conclude that laryngotracheal reconstruction for pediatric subglottic stenosis remains a challenging set of procedures in which multiple operations may be required to achieve eventual extubation or decannulation. Children with Myer-Cotton grade 3 or 4 disease continue to represent a significant challenge, and refinements of techniques are being examined to address this subset of children. Disease-based, operation-specific outcome statistics are the first step in the development of a meaningful predictive model.

Pediatric fiberoptic endoscopic evaluation of swallowing

Pediatric dysphagia is the presenting feature of many underlying diagnoses. Between July 1993 and July 1999, 643 fiberoptic endoscopic evaluations of swallowing (FEES) were performed on 568 patients. The median age of the population was 2.5 years (range, 3 days to 21 years). The principal medical and surgical diagnoses of the patients at the time of presentation to the FEES clinic were prospectively recorded: 36% of the patients presented with a diagnosis of structural abnormalities of the upper aerodigestive tract or airway; 26% with neurologic diagnoses; 12% with gastroenterological disorders; 8% with genetic syndromes; 7% with pulmonary dysfunction; 5% with prematurity; 3% with cardiovascular anomalies; and 2% with metabolic problems. The patients were classified according to the following feeding regimens: 9% normally fed; 38% orally fed with limitations; 13% orally fed, but with required supplemental tube feedings; and 40% prohibited from taking nutrition orally. The FEES enabled the following classification of feeding abnormalities: 15% had normal feeding; 56% exhibited behavioral abnormalities, including sensory-based feeding disorders; 15% exhibited structural abnormalities; 16% exhibited neurologic abnormalities; 1.5% exhibited metabolic abnormalities; and 0.5% exhibited cardiorespiratory abnormalities. The unique aspects of pediatric dysphagia are highlighted, and the role of FEES in the workup of this challenging aspect of pediatric otolaryngology is discussed.

Perioperative dexamethasone administration and risk of bleeding following tonsillectomy in children: a randomized controlled trial

CONTEXT

Corticosteroids are commonly given to children undergoing tonsillectomy to reduce postoperative nausea and vomiting; however, they might increase the risk of perioperative and postoperative hemorrhage.

OBJECTIVE

To determine the effect of dexamethasone on bleeding following tonsillectomy in children.

DESIGN, SETTING, AND PATIENTS

A multicenter, prospective, randomized, double-blind, placebo-controlled study at 2 tertiary medical centers of 314 children aged 3 to 18 years undergoing tonsillectomy without a history of bleeding disorder or recent corticosteroid medication use and conducted between July 15, 2010, and December 20, 2011, with 14-day follow-up. We tested the hypothesis that dexamethasone would not result in 5% more bleeding events than placebo using a noninferiority statistical design.

INTERVENTION

A single perioperative dose of dexamethasone (0.5 mg/kg; maximum dose, 20 mg), with an equivalent volume of 0.9% saline administered to the placebo group.

MAIN OUTCOME MEASURES

Rate and severity of posttonsillectomy hemorrhage in the 14-day postoperative period using a bleeding severity scale (level I, self-reported or parent-reported postoperative bleeding; level II, required inpatient admission for postoperative bleeding; or level III, required reoperation to control postoperative bleeding).

RESULTS

One hundred fifty-seven children (median [interquartile range] age, 6 [4-8] years) were randomized into each study group, with 17 patients (10.8%) in the dexamethasone group and 13 patients (8.2%) in the placebo group reporting bleeding events. In an intention-to-treat analysis, the rates of level I bleeding were 7.0% (n = 11) in the dexamethasone group and 4.5% (n = 7) in the placebo group (difference, 2.6%; upper limit 97.5% CI, 7.7%; P for noninferiority = .17); rates of level II bleeding were 1.9% (n = 3) and 3.2% (n = 5), respectively (difference, -1.3%; upper limit 97.5% CI, 2.2%; P for noninferiority < .001); and rates of level III bleeding were 1.9% (n = 3) and 0.6% (n = 1), respectively (difference, 1.3%; upper limit 97.5% CI, 3.8%; P for noninferiority = .002).

CONCLUSIONS

Perioperative dexamethasone administered during pediatric tonsillectomy was not associated with excessive, clinically significant level II or III bleeding events based on not having crossed the noninferior threshold of 5%. Increased subjective (level I) bleeding events caused by dexamethasone could not be excluded because the noninferiority threshold was crossed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01415583.

The Impact of Pediatric Tracheotomy on Parental Caregiver Burden and Health Status

OBJECTIVE

To explore the effects of the placement of a pediatric tracheotomy tube on the degree of caregiver burden and overall health status of parents using general and disease-specific instruments.

METHODS

Between January and July 2001, the Medical Outcomes Study Short Form 12 (SF-12) and the Pediatric Tracheotomy Health Status Instrument (PTHSI) were administered to 154 families of children requiring tracheotomy. Summary scores were generated for each of the 2 scales of the SF-12 (the Physical Component Score [PCS] and the Mental Component Score [MCS]) as well as for the 4 previously established domains of the PTHSI: domain 1, physical symptoms of the child (7 items); domain 2, medical visits and cost (7 items); domain 3, parental rating of the child's psychological health status (3 items); and domain 4, parental rating of their own caregiver burden (17 items). Correlations between responses from the individual domains and between domain 4 of the PTHSI (reflecting caregiver burden) and the SF-12 were performed.

RESULTS

The mean +/- SD summary scores for the 4 domains of the PTHSI were domain 1, 22.7 +/- 5.3; domain 2, 24.9 +/- 6.2; domain 3, 10.5 +/- 4.4; and domain 4, 48.3 +/- 9.5 (lower scores reflect "poorer" health status). The mean +/- SD summary scores of PCS and MCS were 50.5 +/- 11.3 and 35.8 +/- 11.4, respectively. There existed a significant correlation between parental caregiver burden (as expressed by domain 4) and the child's physical health status (domain 1) (0.32; P<.001) as well as between parental caregiver burden and increasing economic costs associated with this care (0.27; P<.001). A strong correlation was found between the domain measuring parental caregiver burden (domain 4) and the MCS-12 (r = 0.43; P<.001), while a poor correlation existed with the PCS-12 (r = -0.17; P =.14). Nevertheless, in contrast to caregiver burden, the health status of the caregivers as measured by the SF-12 did not alter according to the severity of illness for the children (P =.17).

CONCLUSIONS

Parents caring for children with tracheotomy tubes experience significant caregiver burden. These parents appear to experience increased burden with respect to the child's severity of illness and increased costs associated with caring for their children. Overall, the mental health status for an adult caring for a child with a tracheotomy tube is significantly reduced and appears to be more affected than physical health status.

Pediatric video laryngo-stroboscopy

OBJECTIVE

Laryngo-stroboscopy remains as the clinical gold standard for assessing properties of the glottal phonatory and valvular function. This includes deficits of closure as well as mucosal wave irregularities secondary to abnormal zones of pliability and symmetry. Per-oral stroboscopy has technical limitations in children due to the size of the telescope and issues of patient compliance. However, flexible laryngoscopy is readily performed in newborns and young children. This paper describes the use of a new trans-nasal, digital flexible laryngoscope, which allows for laryngo-stroboscopy in children.

METHODS AND RESULTS

A prospective longitudinal series was done on 25 children ages 19 months-13 years (mean age, 7.0 years) with this new technology. All 25 were successfully examined.

CONCLUSIONS

New technological advancements in the design of digital flexible endoscopes has allowed for laryngo-stroboscopy, and therefore, provides the potential for expanding the population of children with vocal disorders in whom stroboscopic imaging is possible. Larger studies will be necessary to determine its limitations related to age, development, and disease. As the study of pediatric voice disorders continues to evolve, accurate diagnosis is essential to apply state of the art non-operative and phonosurgical interventions. Further longitudinal studies are currently underway to continue to refine techniques of pediatric voice assessment and to define limitations of this new technology.

Recurrent laryngeal nerve monitoring during thyroidectomy and related cervical procedures in the pediatric population

OBJECTIVES

To gather data on, and assess the applicability of, intraoperative recurrent laryngeal nerve (RLN) monitoring during thyroidectomy and related cervical procedures in children and adolescents. Recurrent laryngeal nerve trauma is one of the most serious complications of surgery in the anterior neck compartment. Numerous studies have demonstrated the utility of intraoperative monitoring of the RLN in adult thyroid surgery to prevent such injury. Although the risk of RLN injury is reportedly higher in the pediatric population, little data exist regarding the use of intraoperative RLN monitoring in children and adolescents.

DESIGN

Retrospective case series review.

SETTING

A pediatric otolaryngology practice in a tertiary care hospital.

PATIENTS

Five patients undergoing surgical excision of thyroid neoplasms or branchial pouch anomalies.

INTERVENTIONS

During surgical excision, intraoperative RLN monitoring was performed with use of the Xomed NIM II monitor and Xomed RLN monitoring endotracheal tube, which allow for both passive and stimulation-evoked electromyographic monitoring of the thyroarytenoid muscle.

MAIN OUTCOME MEASURES

True vocal fold mobility as assessed by postoperative flexible laryngoscopy.

RESULTS

Intraoperative RLN monitoring was performed successfully for up to 4 hours. Such monitoring facilitated the identification of the RLN and was predictive of the subsequent presence or absence of postoperative RLN paresis.

CONCLUSIONS

Intraoperative RLN monitoring can be a useful tool during cervical procedures that place the RLN at risk in children and adolescents. As has been demonstrated in adults, it is a safe and reliable technique that can be predictive of and may lessen the risk of RLN morbidity in this younger patient population.

Surgery for pediatric vocal cord paralysis: a meta-analysis

OBJECTIVE

The study goal was to determine the impact of various surgical procedures for bilateral vocal cord paralysis in children by using established principles of meta-analysis.

STUDY DESIGN AND SETTING

We conducted a retrospective review of the literature in which a predetermined protocol was used to identify articles for meta-analysis. Six articles met inclusion criteria, and pertinent data were extracted.

RESULTS

Pooled data analysis demonstrated primary procedure-specific decannulation rates for external arytenoidopexy for 19 of 24 (79%), external arytenoidectomy for 14 of 19 (74%), CO2 laser arytenoidectomy for 4 of 10 (40%), and costal cartilage graft procedures for 2 of 2 (100%). External arytenoid procedures are more efficacious than CO2 laser procedures in terms of primary decannulation (P = 0.02).

CONCLUSION

Meta-analysis of the existing literature reveals that external arytenoidopexy and external arytenoidectomy are equivalently effective procedures and that the two combined are significantly more effective than CO2 ablative procedures.

SIGNIFICANCE

External procedures appear to be more effective as a first-line treatment in pediatric vocal cord paralysis, with arytenoidopexy with or without partial arytenoidectomy offering an attractive first-line surgical option.

Development of the Human True Vocal Fold: Depth of Cell Layers and Quantifying Cell Types within the Lamina Propria

Objectives:

We sought to further describe the development of the 3-layered human vocal fold in children and to quantify macrophage and myofibroblast concentrations in each layer.

Methods:

We used an optical analysis software package to examine 8 longitudinally sectioned human vocal folds that had been fixed in formalin (ages 2 days to 14 years).

Results:

The 2-day-old vocal fold contained only a monolayer of cells. This became a bilayer by 5 months, and a trilayer began to become evident by 7 years. The percent of total depth represented by the superficial layer of the lamina propria (SLP) gradually decreased with age. The SLP made up 22% of the total lamina propria by age 7 years; this percentage approximates that in the adult vocal fold. Macrophages and myofibroblasts were predominately found in the SLP, and began to be apparent by 11 months of age.

Conclusions:

These results help describe the development of human voice and may have implications as to when phonosurgical therapy can be considered for children.

Use of adjuvant intralesional bevacizumab for aggressive respiratory papillomatosis in children

IMPORTANCE

Juvenile recurrent respiratory papillomatosis (RRP) can be an aggressive disease process necessitating frequent trips to the operating room with multiple anesthetics for tumor debulking and airway preservation. Adjuvant therapy, such as that which is reported in this article, may help reduce the number of operative procedures affected children need each year and therefore may also affect their overall quality of life (QOL).

OBJECTIVE

To describe our experience with intralesional bevacizumab (Avastin) treatment for children with severe RRP by comparing median number of surgical procedures per year, median duration of time between procedures, Derkay staging, and voice QOL before and after bevacizumab treatment.

DESIGN

Prospective, consecutive case series.

SETTING

Tertiary care aerodigestive center.

PARTICIPANTS

Ten children, aged 18 months to 18 years, with severe RRP necessitating more than 4 operative interventions in 1 year whose parents (or legal guardians) consented to intralesional bevacizumab treatment.

INTERVENTIONS

Intralesional bevacizumab administered at concentration of 2.5 mg/mL for 3 consecutive injections (with 532-nm pulsed KTP [potassium titanyl phosphate] laser when necessary) at intervals of 2 to 3 weeks.

MAIN OUTCOME MEASURES

Time between surgical procedures, number of procedures per year, Derkay staging, total Pediatric Voice-Related Quality of Life (PVRQOL) score, Emotional PVRQOL score, and Physical PVRQOL score defined by comparing the year leading up to first of 3 bevacizumab injections with the year following the third bevacizumab injection.

RESULTS

The median duration of time between surgical procedures increased by 5.9 weeks after bevacizumab (P = .002). The median number of procedures per year decreased by 4 (P = .002). Derkay staging decreased by 6 (P = .03). The median total PVRQOL score increased by 25.5 (P = .02), the median Emotional PVRQOL score increased by 11.3 (P = .047), and the median Physical PVRQOL score increased by 14.3 (P = .047).

CONCLUSIONS AND RELEVANCE

Intralesional bevacizumab treatment may increase duration of time between surgical procedures and decrease number of procedures per year, while improving voice QOL.

Tissue-Engineered Cartilage as a Graft Source for Laryngotracheal Reconstruction

OBJECTIVE

To evaluate the feasibility of using tissue-engineered cartilage for laryngotracheal reconstruction in the pig model.

DESIGN

Auricular cartilage was harvested from 3 young swine. The cartilage was digested, processed, and suspended and a cell culture was obtained. The cells were then suspended in 3 mL of a 30% solution of a biodegradable polymer (Pluronic F-127) (polyethylene oxide/polypropylene oxide copolymer) at a cellular concentration of 50 x 10(6) cells/mL. This suspension was then implanted subcutaneously into each pig's dorsum. Eight weeks after implantation, the cartilage was harvested with the surrounding perichondrial capsule. An anterior cartilage graft laryngotracheal reconstruction was performed. Bronchoscopy was performed at 3 postoperative weeks to demonstrate airway patency. The animals were killed at 3 months, and specimens were obtained for histological analysis.

SETTING

An animal research facility.

SUBJECTS

Three young Yorkshire swine.

RESULTS

All 3 pigs survived to the 3-month postoperative interval with no evidence of stridor or airway distress. Interval bronchoscopy revealed a normal patent airway with a mucosalized graft. Histopathologic analysis revealed incorporation of the tissue-engineered cartilage graft in the cricoid area, which correlated with results of bronchoscopic evaluation.

CONCLUSION

Tissue-engineered auricular cartilage served as a viable graft in the pig model and might be an alternative cartilage source for laryngotracheal reconstruction.

Congenital laryngeal anomalies. Laryngeal atresia, stenosis, webs, and clefts

Congenital laryngeal anomalies may occur as a result of defects in normal prenatal development. They are associated with a broad spectrum of symptoms and require treatment ranging from observation alone to complex open airway surgery. The treating otolaryngologist must organize a management strategy focused on timely diagnosis, ensuring a safe airway, and maximum conservation of respiratory, phonatory, and swallowing ability.