Endoscopic CO2 laser laryngofissure in pediatric laryngotracheal reconstruction

Anterior laryngofissure is often needed to provide excellent visualization of the posterior cricoid lamina during pediatric laryngotracheal reconstruction. Focus has shifted from survival and decannulation outcomes to postoperative voice outcomes as surgical techniques continue to improve. Surgeons must perform the laryngofissure extremely precisely to avoid damage to the true vocal folds and ensure proper reapproximation of the anterior commissure. Endoscopic CO2 laser laryngofissure represents a novel technique to divide the anterior commissure and facilitate its accurate reapproximation.

Chiari type I malformation: presenting as chronic cough in older children

To highlight an unusual cause of chronic cough, we present two cases of chronic cough in older children referred to a pediatric otolaryngology outpatient clinic with persistent symptoms despite extensive previous workup and treatment. Cranial neuropathy was identified in each case. As a result, magnetic resonance imaging was performed revealing Chiari type I malformation. In each case, surgical decompression provided symptom improvement. Chronic cough is a rare presenting symptom in children with Chiari type I malformation. We emphasize the significance of awareness for unusual cases of cough to aid in the correct identification and treatment in children.

Consistency of Voice Frequency and Perturbation Measures in Children

Objective

Evaluate normal pediatric voice frequency and perturbation measures with Voice Evaluation Suite (VES) and Multi Dimensional Voice Program (MDVP), determine the consistency of these measures over time, and understand which measures might be most useful for evaluating children with voice disorders.

Study Design

Prospective, longitudinal study of normal voices of 50 children aged 4 to 17 years.

Setting

Pediatric otolaryngology clinic within tertiary hospital.

Subjects and Methods

Two tests of sustained utterances from each child were evaluated by 2 computerized voice analysis programs for frequency and perturbation. Intraclass correlation coefficient (ICC) was used to assess the reliability between the samples.

Results

Children (male/female, 1.08:1) with a mean age of 8.34 years were tested on an average of 54.2 minutes apart. Each test included 4 utterances; 1 was analyzed by MDVP, and 3 grouped utterances were averaged and evaluated by VES. Fundamental frequency had excellent reliability (ICC = 0.95) in both VES and MDVP. Jitter, shimmer, and noise to harmonic ratio were poorly reliable (ICC ≤0.4) in MDVP but had good to excellent reliability (ICC 0.66-0.8) in VES.

Conclusion

Single, sustained utterances in children provide consistent measures of frequency. Perturbation is not reliably measured by such testing, but averaging multiple samples yields improved consistency. Evaluating acoustic measure stability in spontaneous speech and in sustained utterances cued by a tuning frequency can provide further insight on pediatric voice consistency.

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.

Consistency of Voice Frequency and Perturbation in Children

Objective: 1) Evaluate normal pediatric voice frequency and perturbation measures with Voice Evaluation Suite (VES) and the Multi Dimensional Voice Program (MDVP). 2) Determine consistency of these measures over time. 3) Understand which measures might be most useful for evaluating children with voice disorders.

Method: Prospective, longitudinal study of normal voices of 50 children aged 4 to 17 years. Two tests of sustained utterances from each child were evaluated by 2 computerized voice analysis programs for frequency and perturbation. Intraclass correlation coefficient (ICC) assessed the reliability between the samples.

Results: Children (M:F 1.08:1) with a mean age of 8.34 years were tested on an average of 54.2 minutes apart. Each test included 4 utterances; 1 was analyzed by MDVP and 3 grouped utterances were averaged and evaluated by VES. Fundamental frequency had excellent reliability (ICC > 0.75) in both VES and MDVP. Jitter, shimmer, and noise to harmonic ratio were poorly reliable (ICC ≤ 0.4) in MDVP but had good reliability (ICC 0.4-0.75) in VES.

Conclusion: Consistent measures of frequency can be derived from single, sustained utterances in children. Averaging multiple samples improves consistency of perturbation. Future work is needed to evaluate whether evaluating acoustic measure stability in spontaneous speech and in sustained utterances cued by tuning frequencies may provide further insight on pediatric voice consistency.

Reinnervation for Vocal Fold Paralysis: Results in Children

Objective: 1) Exhibit long-term follow-up results of patients with unilateral vocal fold immobility who underwent ANSA reinnervation of the recurrent laryngeal nerve. 2) Demonstrate the appropriate studies that should be performed at the time of follow-up.

Method: Retrospective review in a tertiary care otolaryngology practice. Four patients with symptomatic unilateral vocal fold paralysis who underwent recurrent laryngeal nerve reinnervation by a single surgeon were reviewed between September 2005 and December 2011. Postoperative measurements were obtained, both subjective (voice questionnaire) and objective (acoustic measurements and aerodynamics).

Results: The study group included 3 girls and 1 boy ages 2 to 12 years. Mean follow-up time was 4.25 years. Causes for vocal fold paralysis were cardiac surgery (3) and skull base neoplasm (1). Voice questionnaire results (0 = severely abnormal, 100 = normal) were 100 in 2 patients, 98 in 1 patient, and 96 in 1 patient indicating a high level of satisfaction postoperatively in all patients. Mean maximum phonation time was 7.7 seconds, mean s/z ratio was 2.15, and mean subglottal pressure was 8.8 cm H2O.

Conclusion: Children who undergo ANSA reinnervation of the recurrent laryngeal nerve have normal or near normal subjective voice scores. Objective scores may not reflect the same change. In this population, it may be beneficial for the practitioner to rely upon subjective measures rather than objective measures to determine treatment success.

Pediatric airway balloon dilation

Over the past decade, there has also been renewed interest in serial dilatation for the management of subglottic and tracheal stenosis with the advent of new technologies such as airway balloons designed for the pediatric airway. In this chapter, the authors describe the technique of application of airway balloons as a useful adjunct for management of airway lesions.

Behavior of poly(glycerol sebacate) plugs in chronic tympanic membrane perforations

The tympanic membrane (TM), separating the external and middle ear, consists of fibrous connective tissue sandwiched between epithelial layers. To treat chronic ear infections, tympanostomy drainage tubes are placed in surgically created holes in TMs which can become chronic perforations upon extrusion. Perforations are repaired using a variety of techniques, but are limited by morbidity, unsatisfactory closure rates, or minimal regeneration of the connective tissue. A more effective, minimally-invasive therapy is necessary to enhance the perforation closure rate. Current research utilizing decellularized or alignate materials moderately enhance closure but the native TM architecture is not restored. Poly(glycerol sebacate) (PGS) is a biocompatible elastomer which supports cell migration and enzymatically degrades in contact with vascularized tissue. PGS spool-shaped plugs were manufactured using a novel process. Using minimally invasive procedures, these elastomeric plugs were inserted into chronic chinchilla TM perforations. As previously reported, effective perforation closure occurred as both flange surfaces were covered by confluent cell layers; >90% of perforations were closed at 6-week postimplantation. This unique in vivo environment has little vascularized tissue. Consequently, PGS degradation was minimal over 16-week implantation, hindering regeneration of the TM fibrous connective tissue. PGS degradation must be enhanced to promote complete TM regeneration.

Juvenile-onset recurrent respiratory papillomatosis

Juvenile-onset recurrent respiratory papillomatosis, caused by the human papilloma virus, is the most common benign neoplasm of the larynx in children. Recurrent respiratory papillomatosis is relatively rare, but it can have a significant impact on afflicted children and their family's quality of life as dysphonia and multiple surgical procedures are hallmarks of this disease. The current standard of care is surgical therapy with a goal of complete papilloma removal and preservation of normal structures. The technique in this atlas combines both the microdebrider and the pulse KTP laser. The microdebrider allows for rapid removal of bulky lesions without the risk of thermal injury, yet it cannot provide precise removal in areas such as the anterior commissure and ventricle. The pulse KTP laser allows for removal of sessile lesions and in sensitive areas such as the vocal folds. The authors describe this technique as well as discuss adjuvant therapies and pearls for success.

Pediatric laryngeal electromyography

Vocal fold immobility (VFI) is a challenging management issue in pediatric otolaryngology. VFI is most commonly distinguished between unilateral (UVFI) and bilateral (BVFI) dysfunction. UVFI and BVFI are different pathophysiologic and clinical entities with distinct symptoms and etiologies. It has been generally accepted in the adult literature to wait at least 1 year prior to carrying out more permanent type procedures for VFI. This period has been extended out even further in children as the literature has suggested that vocal fold function may return many years later. Unfortunately, there is no simple test or procedure to help predict return of vocal fold function. In adult patients LEMG has been used to help guide management decisions, but it has not been widely investigated in children. In this chapter the authors describe a LEMG technique that has been a useful adjunct in managing children with VFI.

Pediatric lingual tonsillectomy

Tonsillectomy and adenoidectomy are an effective surgical treatment of pediatric obstructive sleep apnea; however, up to 20% of these patients can have persistent disease. In this select patient population, the lingual tonsil may be an occult source of obstruction. Lingual tonsillectomy can be a challenging procedure due to poor access and visualization, airway edema, postoperative pain and hemostasis during tissue removal. In this chapter, we describe our preferred technique for lingual tonsillectomy including surgical pearls for success.

Tracheal resection and reanastomosis

Isolated short segment tracheal stenosis occurs in a relatively rare subpopulation of patients with laryngotracheal stenosis. Etiologies include both acquired and congenital, the most common being the acquired type. Management options include observation, endoscopic balloon dilation with or without CO(2) laser, stent placement and open airway surgery. In this chapter, we will discuss tracheal resection and reanastomosis with emphasis on surgical pearls for success.

Pediatric tracheotomy

The procedure of tracheotomy dates back to ancient times. Its use has been adapted in the neonatal and pediatric population over the past half-century. Despite being a life-saving measure, tracheotomy-related mortality rates range from 0.5 to 3.6%, and this procedure is not without significant and sometimes frequent complications. Techniques regarding pediatric tracheotomy vary from surgeon to surgeon and include orientation of skin incision, removal of subcutaneous tissue, orientation of tracheotomy, maturation and stay sutures, as well postoperative care and surveillance. In this chapter, the authors detail their technique for tracheotomy. Surgical pearls for success are highlighted.

Laryngotracheal reconstruction

Laryngotracheal reconstruction (LTR) along with cricotracheal resection and thyrotracheal anastomosis has become the standard of care for symptomatic subglottic stenosis in the pediatric age group. Success rates in achieving decannulation or avoiding tracheotomy approach 90%. Fearon and Cotton introduced pediatric LTR in 1972 using cartilage interposition grafting. The procedure has evolved to include a variety of techniques for expanding the laryngotracheal complex to obtain a stable airway of sufficient size for respiration. In this chapter, the authors will describe their single and double-stage technique for LTR highlighting surgical pearls necessary for success.

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.

Interdisciplinary development and implementation of communication checklist for postoperative management of pediatric airway patients

OBJECTIVE

The authors describe their multidisciplinary experience in applying the Institute of Health Improvement methodology to develop a protocol and checklist to reduce communication error during transfer of care for postoperative pediatric surgical airway patients. Preliminary outcome data following implementation of the protocol and checklist are also presented.

STUDY DESIGN

Prospective study from July 1, 2009, to February 1, 2011.

SETTING

Tertiary care center. Subjects. One hundred twenty-six pediatric airway patients who required coordinated care between Massachusetts Eye and Ear Infirmary and Massachusetts General Hospital.

METHODS

Two sentinel events involving airway emergencies demonstrated a critical need for a standardized, comprehensive instrument that would ensure safe transfer of care. After development and implementation of the protocol and checklist, an initial pilot period on the first set of 9 pediatric airway patients was reassessed. Subsequent prospective 11-month follow-up data of 93 pediatric airway patients were collected and analyzed.

RESULTS

A multidisciplinary pediatric team developed and implemented a formalized, postoperative checklist and transfer protocol. After implementation of the checklist and transfer protocol, prospective analysis showed no adverse events from miscommunication during transfer of care over the subsequent 11-month period involving 93 pediatric airway patients.

CONCLUSION

There has been very little written in the quality and safety patient literature about coordinating effective transfer of care between the pediatric surgical and medical subspecialty realms. After design and implementation of a simple, electronically based transfer-of-care checklist and protocol, the number of postsurgical pediatric airway information transfer and communication errors decreased significantly.